LITHOTOMY IN THE FEMALE.

34 16.

Strongylus bronchialis, Cobbold. (Filaria bronclaicalis, Rudolphi. ) 17. Eastrongylus gigas, Diesing, (Lumbricus in renibus, Blasius.)) 18. Sclerostoma duodenale, Siebold. Anchylostoma duo, denale, Dubini.) 19. 20.

Spiroptera hominis, Rudolphi. (Spiroptera Rudolphii, Chiaje.) Owyuris vermicularis, Bremser. (Ascaris ver2niculctris, Linnæus. )

21. Tœnia solium, Linnæus, (Tœnia humana armata, Brera. ) 22. Tœnia 1ni’diocanellata, Küchenmeister. Tœnia cucurbitina grandis, saginata, Goeze.) 23. Tœnia acanthotrias, Weinland. 24. Tœnia flavopuncta, Weinland. 25. Tœnia marginata, Batsch. (Tcmtia ex cysticerci te?t2ti-

colli, Kiiclmnmeister.) ’

2f?. Tœnia echinococcus, Siebold. (Tœnia granulosa, Grnelin.) 27. Tœnia nana, Siebold. (Tcenia Ægyptica, Bilharz.) 28. Tœnia elliptica, Batsch. (7’a,,tiia cariina, I’rallas.) 29. Bothryocephalus latus, Bremser, (Tœnia humana

inermis, Brera.) 30.

Leuckart. the above thirty species I do not now propose to enter; but I may be permitted to remark, that I have recently given elsewhere a resumé of most of the more important facts which have lately been brought to light by the combined researches of modern investigators. and in this memoir (which will shortly be published in the Zoological Society’s Proceedings’) I have also given a complete synonymy of every species, allocating all the larval forms ntider their respective adult titles. The novelty and utility of this plan will, it is conceived, render it useful as a medium of reference, whilst at the same time it will, in some measure, explain the reasons of our altered nomenclature. In regard to one of the above-named species, however, it is incumbent upon me to say a few words. I allude to the little Oxyuris vermicularis, respecting which an astounding statement not long sgo appeared in the pages of the very same journal to which we are so deeply indebted for Dr. Beltingham’s communication. The passage to which I refer (Dublin Medical Press for Jan. 15th, 1862, 76) is headed" Ascarides in Children," and runs as follows :"Dr. Kidd, firm(ing chloroform useful in destroying these pests of infant life, was led to examine them and give his opinion, held for several years, that they are the larve of house flies. Dr. Brinton and Dr. Lionel Beale, on continuing the subject, have microscopically examined the worms, and have discovered that Dr. Kidd’s opinion is correct." The absurdity of the view here promulgated is so gross that I am at a loss to understand how any member of the profession could advance it, especially since iu his been known for ages that these so-callecl ascarides are sexually mature animals, the females displaying in their interior multitudes of characteristic nematoid ova-a feature certainly not exhibited by any dipterous larva. I am happy, however, to be able to add that Prof. Beale, F.R.S. has informed me that the above statement has been published without his knowledge or concurrence. In conclusion, I may perhaps be permitted to tender my thanks to those members of the profession and others who, by Ithe transmission of specimens and works, have materially aided me in my investigations, the results of wh’ch have been recorded in the "Linnæan Transactions" and elsewhere. In particular I may mention Prof. Leuckart, of Giessen ; Dr. Diesing, of Vienna; Dr. Weinland, of Frankfort; Dr. Claparede, of Geneva; Dr. Pagenstecher, of Heidelberg; Professor Lawson, of Kingston, Canada; Pruf. Busk; Dr. Baird; Prof. Simonds, of the Veterinary College; Mr. Canton; Dr. Leared; Mr. Flower; Dr. Sanderson; Mr. Hulke; Mr. F. Buckland; Dr. Hughlings Jackson ; Dt’s. Haldane and W. Turner, of Edinburgh; Mr. Frederick Turner, of Sheffield ; Mr. Murray, of Brighton; Dr. Lowe, of Lynn; Dr. M’lntosh, of Perth; Mr. Bartlett, of the Zoulogical Gardens; and especially Dr. Lankester, and Mr. Scattergood of Leeds who by their valuable contribution have most kindly enabled me not only to establish the truth of certain previously recorded facts (which Dr. Kiichemneister and others almost, if not entirely, regarded as mere myths), but also to extend in some degree the borders, of

Bothryocephalus cordatuts, Into details regarding any of

p.

helminthological

science.

LITHOTOMY BY JAMES R.

IN

THE

FEMALE.

LANE, ESQ., F.R.C.S.,

SURGEON TO ST.

MARY’S HOSPITAL.

CALCULUS in the bladder is a complaint concerning which so much has been written, and to the treatment of which so much attention has been devoted by the leading surgical authorities, from the earliest times down to the present period, that there ought, perhaps, to be little room for further dissertation on the subject. Such, however, is far from being the case. It is not so even as regards the male subject, in whom the greater of the disease, and the greater anatomical complicaof the parts implicated, have always caused the operation of lithotomy to be regarded as one of the most important in the whole range of surgery. But still less is it the case as regards the female, in whom, I think, no one will assert that anything approaching to finality in the treatment of this complaint has yet been reached. Various plans of operation have been at different times proposed, have been adopted with more or less unanimity, have after a time been laid aside, and again after a time been reintroduced. But there has been hitherto, and there is now, no consent on the part of authorities as to which of these various methods is the best, or which of them may be best adapted to one, and which to another class of

frequency tion

cases.

My object

in the

present communication is, in the first in-

attention to what I believe to be, in appropriate cases, a greatly improved plan of operation ; and, in addition to this, to inquire how far we can determine--1st, whether some of the various operations proposed may not now with adstance,

to c--tlt

vantage be discarded altogether; 2nd, which of them are worthy of being retained ; and 3rd, whether, amongst these

find good grounds for allotting to each its own class of cases. If we can advance a step in the determination of these questions, I cannot help thinking that something will have been gained. With these objects in view, I set aside the question of the comparative merits of lithutomy and lithotrity, although freely admitting the superior excellence of the crushing operation in appropriate cases, and believing it to be, to say the least, quite as applicable to the female as to the male, and probably in children considerably more so. Nevertheless, cases will occur in which the bladder will not tolerate the irritation of the lithotriptic instruments and of the prolonged presence of the sharp fragments of stone which result from their employment ; and I believe this intolerance will be met with more frequently in the female than in the male, in consequence of the later period at which, as a general rule, they can be brought to submit themselves to examination and treatment. Furthermore, there need not be the same hesitation in advising a resort to a cutting operation in the female as in the male, inasmuch as the greater accessibility of the female bladder much diminishes the immediate risk of the proceeding. I have been led to consider the subject of lithotomy in the female in consequence of a case which was under my care in St. Mary’s Hospital about a year ago, in which I adopted a plan which, though I cannot claim for it any originality of idea, is nevertheless not altogether devoid of interest and novelty. The operation to which r allude consisted in the extraction of the stone by means of an incision into the base of the bladder through the vesico-vaginal septum, immediately followed by closure of the wound with metallic sutures. I will not now eater upon the detai!s of this case, as they have recently been recorded in THE LANCET (the Mirror," Oct. 4th, 1862). I will merely state briefly that the patient, whose age was thirtyeight, had suffered from stone for many years, and that an attempt which I made to crush it so greatly aggravated her symptoms that its immediate removal became a matter of im.

latter,

we can

appropriate

perative necessity. The operation was performed in the following manner :-The patient being placed in the lithotomy position, Bozeman’s speculum was introduced into the vagina, and held so as to expose its anterior wall, and a straight grooved staff was passed

into the bladder by the urethra. An iucision was then made into the groove of the staff, commencing just behind the neck of the bladder, and extending backwards in the median line * Part ii:. for 1862, Vol. xxc., which will nppear in February next, and many for about an inch and three quarters-to within a short disbe had of Longmans and Co., or of Mr. Fage, Assistant-Secretary of the tance, in fact, of the attachment of the vagina to the cervix Zoological Society, 11, Hanover-square.

Norland-square, Notting-hill,

Jan. 1863.

35 uteri. Through this incision the stone, which was nearly two The edges of the inches in length, was readily extracted. wound were then brought into apposition by twelve silver- wire sutures.

closure belongs, I believe, to M. Vallet, of Orleans, who published a paper on the subject in the " M6rnoires cte la Société d’Agric, Science, &c., d’Orleans," t. ii., 1856. I havenot seen this memoir, but it is referred to by M. N61aton,* from whom I gather that M. Vallet operated in two cases, the second of which required a reapplication of sutures for the closure of a portion of the wound. I presume from this that, in the first M. Vallet made case, the whole of the wound united at once. a transverse instead of a 1 mgitudmal incision, thinking he could select a part of the base of the bladder where the septum was thicker than elsewhere. The septum, however, appears to me so nearly uniform in thickness throughout, that I do notbelieveany advantage worth mentioning is to be gained by a, transverse incision, which might injure the entrance of theureters, and would be more likely to be attended with hsemorrhage, and also to implicate the loose cellular tissue surrounding the pelvic viscera. Mr. Baker Brown is strongly in favour of the vaginal incision, intending, of course, that it should be immediately closed by suture. He mentions a case in which Dr. Marion Sims adopted it, but does not state with what result. Vaginal lithotomy, immediately followed by suture, possesses, in my opinion, many and great advantages. Perhaps there is no part of the vesical parietes which may be incised with so little risk. The incision being in the median line, no. vessels of any magnitude are likely to be wounded. The vesicovaginal septum is composed of dense tissue, little, if at all, liable to urinary infiltration, and the free outlet provided for the urine would, even under other circumstances, render such an occurrence improbable. The chance of pelvic cellulitis is, therefore, remote. The peritoneum is not likely to be injured, for even if the incision required to be carried as far back as the attachment of the vagina to the cervix uteri, the vesico-uterine reflection of the- peritoneum is situated nearly an inch higher up. Velpeau, in his inquiry into the history of this operation, seems to have been struck with its great immunity from danger, and with the slight degree of constitutional disturbance which it entails; in fact, he did not meet with the record of a single fatal case. The favourable progress of my own case was certainly remarkable. Almost from the moment of the operation the pain began to subside, and by the next day had completely disappeared. The slight feverish excitement which had resulted from the attempt at lithotrity also rapidly passed away. The urine, which had been muoo-purulent and phosphatic, in a day or two became clear. There was never any pain worthy of rernark in the region of the wound, even though a small portion it sloughed. What uneasiness existed, was caused, after a few days, by the continued presence of a catheter in the urethra. The effect of the removal of the foreign body, and of the draining away of the urine through the catheter, afforded an excellent exemplification of what " physiological rest" is capable of doing for the relief of an inflamed and irritated.

immediate relief of all the painful symptoms followed the greater part of the incison united, by tirst intention, but, unfortunately, a small portion of its edges at theanterior part sloughed, and when the slough separated the urir.e made its way into the vaginal. This opening, however, heated by granulation, the granulating surfaces being held together by the insertion of two wire sutures. It remained closed for a fortnight, the patient being able to retain half a pint of urine without difficulty; but at the end of this time, the uniting medium, which was at one point very thin, gave way, and an opening was formed just large enough to admit a probe. Failing to close this by repeated applications of caustic, I pared its edges, and again applied sutures, this time with complete success, and the patient shortly afterwards left the hospital quite well, having perfect control over her urine, and all inflammation and irritability of the bladder having subsided, the vesico-vaginal septum remaining as thick and strong along the line of the incision as elsewhere. Veaioo vaginal lithotomy is no new thing, but it has never taken its place as an approved and recognised operation, in consequence of the great difficulty of securing the closure of the wound, and its being consequently so often followed by the distressing condition of a vesico-vaginal fistula. A French surgeon named Rousset has the credit of beinc, the first to perform it, in a case in which the bladder, pushing before it the upper wall of the vagina, protruded through the vulva, Fabricius Hildanus, following the example of Rousset, practised it in two cases, in one of which the stone had partially perforated the vesico-vaginal septum, while in the other there was a vesico-vaginal fistula following parturition. In 1740, Gooch extracteda calculus through the vagina weighing three ounces, which had caused ulceration through the septum. M. Velpeau has given the names of various operators who have since, at different times, adopted the vesico- vaginal method of performing lithotomy ; and, amongst others, M. Faure,* who made his incision in the median line, but very obliquely through the septum ; that is to say, directing the of his knife towards either the right or the left side, so as to produce a broader cut surface, and to give the wound somewhat ofa valvular arrangement. He thus, in lbOR. succeeded in curing his patient without the formation of a fistula. Most of the earlier operators speak only of the removal of the stone, and sa.y nothing about the result as regards the formation of a fistula. Chelius even, as recently as years ago, says that " the production of a vesico-vaginal fistula, which has been objected to this operation, cannot be considered as the usual consequence." He advocates it as causing no bleeding and no incontinence of urine, while it affords facilities for the removal of very large stones Velpeau’s conclusion, after looking into the cases recorded by different operators, was organAs far as I have been able to ascertain, this is the first case not so favourable as this ; he thinks that a fistula is met with in at least one case out of four. Both statements, however, 111 which the operation by vaginal incision, with immediate there can be no doubt, are far too favourable ; and if no steps ensure by suture, has been practised in this country. I find, however, that its expediency had some time previously been are taken for the immediate closure of the wound, I fear a fistula must alwaysbe reckoned upon as the rnle, and its fully recognised by Mr. Paget, of Leicester, as shown by a. absence the exception. Indeed, the general conviction that paper reacl to the British Medical Association in June, l862 q this is the truth has caused the vesico vaginal method to be but the mode of procedure adopted was, in my opinion, faulty several important particulars, and was not likely to be folalways regarded with disfavour, and to be-reser%,ed as a kind in of last report, for exceptional cases, and where the stone was lowed by very satisfactory results. Mr. Pa.get’s first operation was performed in Sept., 1859, on a child, aged three years and very large. Velpeau, even with his too favourable estimate, is so impressed with the dread of fistula, that he recommends a half-an, age but ill adapted for manipulation in the interior in preference the high or supra, pubic operation, notwitbsta,nd- of the vagina, the size of which must render it almost imposto apply the necessary sutures. Again, the incision was ing its greater danger. M. Coste, many years ago, suggested sible the reunion of the wound by suture immediately after the ex- tnacie through the whole length of the urethra, beginning at the traction of the stone, but appears to have b en deterred from meatus. On attempting to seize the edges of the divided urethra, had so completely collapsed, and the bladder itself had so. attempting it by the then almost invariably unfavourable ter- they retracted within the small vagina, that after several trials the mination of operations for vesico-vaginal fistula. Now, however, all this is changed. The experience of the operator wis compelled to desist, and leave the result to Nature s last ten years has abundantly shown that almost every case of unaided powers of repair. That result wasa permanent inconof urine. Mr. Paget operated a second time, in January, vesico vaginal fistula, even when attended with great loss of tinence 1861, on a patient aged eighteen, making the same incision, inbe firmly and permanently closed by the substance. length of the urethra. The edges were proved plastic procedures now in use. We may therefore very volving the wholewith five wire sutures. The wound healed fairly feel confidence in our ability to close the clean longi- brought together tudinal incision m,1de for the extraction of a stone, which is excepting at its anterior parts, which circumstance gave the attended by no loss of substance, and with no cicatricial con- meatus the appeara.nce of being larger than natural. This patient appears to have ultimately recovered the control over traction or induration. into effect the idea of immediate her urine, hut was troubled with more or less of incontinence The merit of first some months. for some months. of Oper. See Velpean, * *See Velpeau, Elem. Elem. of Oper.Surg., Surg., Mott’s Mott’stranslation, translation, vol. vol.iii., iii.,p.p:967; 967 for * See Nelaton, Elém. de Patho. et Chir., t. v., p. 243. also Bourgéry, Medicine Oper., t. ii., p. 289. ; of Second Edition, p. 225. Diseases of 617. Women, translated vol. ii., p. by South, t See System Surgery,

theoperation ;

edge

twenty of

im-

may

carrying

tOnSurgical

36

quick,

I do not understand the object of commencing the incision irregular, 110; skin hot and dry; complains of front:! at the external orifice of the urethra; indeed, I think it cannotheadaehe, and of great pain in the larger joints, increased ty be too strongly urged that this canal should on no account be movement ; there is also nausea, but no vomiting; the bowds interfered with. The incision should commence just behind the are inclined to be relaxed; the appetite is gone, but thirst pt3neck of the bladder; that is to say, iu an adult person at least sent, and she has a desire for acid drink; a mulberry-colourel, an inch and a quarter behind the external orifice of the urethra. spotted (not mottled) rash making its appearance over the Incision of the urethra gives no additional room, but increases abdomen, trunk, and upper extremities. The previous histoy the length of wound without any compensating advantage of the patient is as follows :-She is a tailoress, of temperaa whatever, and the urethral portion of the wound is incom- habits, and of good general health. On the Thursday before parably more difficult to close than that which is deeper in the admission she began to feel ill ; she had pains of the head aad aching of the back, occasionally feeling alternations of heat aad vagina. Mr. Fergusson, in March, 1862, (see THE LANCET, Oct. llth, cold. She quickly became unable to follow her employment. p. 388,) operated in King’s College Hospital on a child, aged She applied to the hospital, and was afterwards visited at nine years and a half. He commenced his incision immediately home, in Bedfordbury, as an out-patient, by the clinical clerk behind the neck of the bladder, and extracted the stone with- of Dr. Headland. As the pains in the joints and prostration out difficulty. The wound was three-quarters of an inch in became greater, her friends desired her admission into the hos. leng h, and its edges were brought together with one silver-wire pital. Up to this time, however, she was considered to have auture, which was removed the next day. The wound did not been suffering from acute rheumatism, but Dr. Willshire was close.

In April, 1862, Mr. Fergusson operated on a patient requested by the clinical assistant to see her, to clear up some aged twenty.one, by slitting up the urethra in a direction ) doubts about the matter previous to her admission. downwards and outwards, and dilating the neck of the bladder Upon going to a narrow and densely populated street at the with his finger. No sutures were applied in this case. Incon- back of the hospital-viz., Bedfordbury, and entering one of

tinence of urine was the result. Dr. Lyon, of Glasgow, in Sept., 1862. (vide THE LANCET Nov. 1st,) removed a stone by vaginal incision in a patient aged forty-two, immediately closing the wound by sutures, and taking all the precautions necessary to ensure success. A small portion of the wound did not immediately heal, but closed in a few days by granulation. In this case some haemorrhage took place into the bladder the evening after the operation, and was not suppressed until a saturated solution of alum had been in-

the

houses,

a

strong smell of chloride of lime

was

perceived.

found that typhus was prevailing in the street and its adjacent courts, and that the parish authorities had ordered the free use of the agent in question. Upon the examination of the patient, it became clear to Dr. Willshire that the pains of the joints so much complained of were not those of acute rheumatism, and that they meant something else more dangerous to the patient. The general appearance of the latter was such as to lead to the inference that she was attacked by the prevailing fever of the district. She was ad. jected. In August, 1862, Dr. Robert Nelson performed a similar mitted the same day into the hospital. The next day she preoperation, and with perfect success. (See A merican Medical sented the symptoms before described. From this time the general debility became greater, and some delirium was present Monthly Journal, Sept., 1862.)] These are the principal facts relating to this operation that at night. The general symptoms of pyrexia increased, as was I have been able to collect. They are not numerous, but I to be expected. The bowels were moved twice or more in the cannot help thinking that they are very suggestive. Each day, and there was some slight tenderness upon pressure over time that the operation was performed in an appropriate case, the right iliac fossae. On the 5th of November a decided and conducted upon proper principles. complete snccess was change took place for the better, the report being: "tongue obtained ; while in every instance of failure, the result may, I moist, of a more natural appearance; skin cool; passed a com. think, fairly be attributed either to the injudicious selection fortable night; pulse 9 ." The patient was discharged conof the case, or to the manner in which the details of the opera. valescent on the Jst of December. The treatment consisted in tion were carried out. The conclusion which I have formed is the administration of ammonia, eight ounces of wine daily, and that in an adult female, and especially in the case of a large beef-tea, and whatever the patient could be got to take. Alice S--, aged twenty seven, admitted November 6th, stone, lithotomy through the vagina, conducted on proper principles, and followed by immediate closure of the wound, with phthisis, and occupying the next bed to Eliza N--, is the safest en i best procedure that has as yet been devised, was seized on the 25th of November with vomiting, diarrhoea,, and deserves to be accepted as a recognised operation in sur frontal headache, and pain of the back. The tongue soon begery. It should be understood, however, that it is not applic- came furred, and the skin hot and dry. In two days’ time the able to children; neither is it well adapted for young un. pulse rose to 110, and a spotted typhus rash made its appearThe pyrexial symptoms continued to married women, in whom the difficulties of this operation ance over the body. must necessarily be greatly increased. increase; marked pulmonary congestion ensued; the delirium became violent, with almost maniacal symptoms, but subsided (To be concluded.) into a tremulous low form as the debility increased ; and the evacuations were passed frequently and involuntarily. The patient died on the 15th of December. Ellen E-, aged twenty-one, was admitted on the Ilth of Oct. last, sun’ering from erysipelas of the lower extremity, and a bed in the adjacent ward communicating with that OF THE PRACTICE OF in which lay Ehza N and Alice S-. On the 26th of November she complained of feeling very weak, and unable to MEDICINE AND SURGERY walk about. On the 27th she was attacked by great pain of the head and back, and rigors ; the tongne became furred and IN THE dry ; the nights were passed with much restlessness. Soon HOSPITALS OF LONDON. vomiting came on, with some relaxation of the bowels. On the third day after the attack, a deep coloured, spotted typhus rash appeared over the arms and trunk of the body. The musNulla est alia pro certo noscendi via, nisi quam plurimas et morborum et cular prostration was considerable, there was some delirium at dissectionum historias, tam aliorum proprias, collectas habere et inter se corn night, and the tongne became dry and brown. The typhus parare.-MORGAGNI. De Sed. et Cau8, Morb., lib.14. Procemium. symptoms continued until the 6th of December, so as to render the prognosis a little anxious; after which time they diminished CHARING-CROSS HOSPITAL. in severity, and the patient progressed favourably. M. C--, aged thirty three, the sister of the ward in which SUBSTANCE OF A CLINICAL LECTURE UPON A NUMBER lay Eliza N and Alice S-, complained on the 26th OF CASES OF TYPHUS FEVER. of November last of feeling weak and "out of sorts." The next day she was sl1drJeu]y seized by rigors, vomiting, and (Under the care of Dr. WILLSHIRE.) ; the pulse became quick, the skin hot and dry, the FoR the following notes we are indebted to Mr. Thos. Lang- diarrhoeacoated tongue by a thick fur, and great pain of the head and ston, clioical clerk :back was complained of. The second day of the attack a ElizN , aged twenty, was admitted into the hospital on typhus mottling was observed in the upper part of the trunk; Oct. 28th, 1862. Her condition was as follows : General pros- and on the third day the patient herself drew attention to the tration of the-whole system; countenance and expression heavy "Rpots,"which now made their appearance freely over the body. and sluggish, but intellect clear; tongue dry and furred; pulse The prostration increased, and delirium supervened, under the

Upon inquiry

,

A Mirror

occupied

it

was