- Email: [email protected]
ON LITHOTRITIC INSTRUMENTS IN CASES OF ENLARGED PROSTATE.
has occupied a great portion of the vesical cavity. In all the cases now alluded to, the effect of this extension of the middle lobe of the prostate backwards is to form a reser. voir or sac behind the enlarged gland. The floor of the bladder is here greatly depressed; the urine remains as in a sac; and here a calculus may be lodged, the detection of which is often extremely difficult. I have, at the present time, under treatment, a patient who has a stone concealed behind an enlarged prostate, the existence of which had escaped the notice of those surgeons by whom he had been previously examined. The necessity of employing special sounds and catheters in ON cas s of enlarged prostate is well known to all practitioners. The LITHOTRITIC INSTRUMENTS IN CASES increased length of the urethra, and the encroachment of the enlarged lobe on the floor of the bladder compel the surgeon to. OF ENLARGED PROSTATE. In prostatic enlargeuse a much longer catheter than usual. ment the ordinary catheter will not penetrate into the bladder; BY WILLIAM COULSON, ESQ., SURGEON TO, AND LECTURER ON SURGERY AT, ST. MARY’S HOSPITAL. and the experienced practitioner at once suspects the existence of the complaint from this circumstance. To enter the cavity IN the following remarks, I propose to explain the necessity of the bladder he takes a catheter from two to four inches than the one in ordinary use, and with an instrument of ’which exists for employing a peculiar lithotrite in patients longer this kind he succeedsafter having passed it about twelveinches who have stone and enlargement of the prostate. It is now beyond the orifice of the urethra. The same holds good with more than three years since this necessity was impressed upon regard to the sound. Thus the stem of the ordinary sound: I had a case of vesical calculus in a stout man, seventy measures seven inches and a half; the stem of a moderatelyme. sized prostatic sound measures nine inches and a half. An vears of age, whose prostate was enlarged; although the ordiordinary catheter, now before me, measures nine inches and was I found it lithotrite introduced without nary difficulty, three quarters to the point. A prostatic catheter measures impossible to seize the stone, in consequence of the lithotrite thirteen inches and a half. From fourteen to sixteen inches being too short. The operation was deferred until a new in- is the length recommended in standard works. In cases of enlarged prostate, then, the surgeon requires 3. strument was made. Since the period just mentioned, four similar cases have occurred in my practice. In each case the long catheter of peculiar shape to draw off the urine. For the same reason-viz., the increased length of the urethra, and patient laboured under enlargement of the prostate, and in the depression in the floor of the bladder-he will require a, each I should have been unable to terminate the operation lithotrite of peculiar shape, in order to catch and crushlong without the use of the instrument which I shall presently de- the stone with ease to himself and safety to his patient. scribe. Indeed, at the present moment I have under treatment If the long prostatic catheter be expedient, the long prostatic lithotrite is, & fortiori, indispensable. The necessity of ema similar case, sent to me by Mr. James, surgeon, of Uxbridge. This patient’s prostate is not greatly enlarged, yet with the ploying a longer instrument than usual in such cases will, I imagine, be generally admitted; and if I insist on it here, it is ordinary instruments I cannot well reach the stone. because our standard works do not allude to the point-an The changes in the genito-urinary organs produced by en- omission of which I have been no less guilty than others, and largement of the prostate, and requiring the use of peculiar which I would now repair. The ordinary lithotrite of Charriere lithotritic instruments, may be explained in a few words. measures ten inches from the root of the stem to the eye ; the Many men who have passed the middle period of life labour chord of the curve, from the eye to the point, is one inch and under some enlargement of the prostate; and such a condition three-eighths. The long lithotrite, manufactured expressly for of the gland seriously interferes with the functions of the me by Charriere, measures twelve inches in the stem, and one bladder; but for my present purpose it will suffice to consider inch and three-eighths in the curve. The stem of Weiss’s ordithe effects produced on the urethra and floor of the bladder by nary lithotrite measures nine inches; the stem of the long inany considerable swelling of the prostate. A consideration of strument which he has made for me measures ten inches and a these effects will at once show in what manner the modified half; the beak is the same length in both, about an inch and a instruments that I employ in such cases are, of necessity, half. required. A constant effect of prostatic enlargement is I need hardly occupy much space in dwelling on the neceselongation of the urethra. This lengthening of the canal sity of the surgeon being provided with a long instrument of may be connected with several conditions of the enlarged gland; this kind, and of the many advantages which he will derive it is, however, mainly confined to the prostatic portion of the from its use. I can only say that I havehad cases which, I urethra, and occurs in one of two ways. As the enlargement feel convinced, I could never have conducted to a successfur pushes up the neck of the bladder under the arch of the pubes, termination without it. It should be remembered, that with an it necessarily draws up and elongates the vesical end of the elongated urethra, the distance between the external and inurethra; or, while the gland is slowly enlarging from before ternal orifices of the canal is increased by at least an inch. backwards, that portion of the urethra which traverses it must The enlarged prostate, again, occupies the front part of the necessarily follow the abnormal development of the prostate,* floor of the bladder, on which it encroaches another inch or. and become elongated. In his recent work on the Prostate,* more. The calculus lies concealed in a sort of pouch behind Mr. Thompson observes "that in some preparations which he the enlarged lobe, which rises like a barrier before it. Under examined, the urethra measured three inches from the orifice these circumstances, it is evident that the surgeon will require of the bladder to the membranous portion, instead of an inch an instrument longer than that in ordinary use by two or three and a half, which is the normal length." In all cases of this inches; the common lithotrite will either not pass into the kind, more especially when the middle lobe is chiefly affected, cavity of the bladder, or, if it does, after having been forced the orifice of the bladder is thrown backwards in proportion up to the handle, the motion of its curved part will still be, to the development of the enlarged lobe: and hence the point greatly impeded by the prostate. of any instrument used is apt to catch against the superior In some of my cases the common instruments were not suffiwall of the canal before it enters the bladder. This is an ob- ciently long, and it became necessary to push them up to the stacle which the surgeon is very likely to meet with; and I may shoulder before I could turn the point in the necessary direcadd, the shorter the instrument he employs the more likely tion. With the long lithotrite, on the other hand, the surgeon is the obstacle to occur. gets readily into the bladder; but to overcome the impediments The effects of the morbid growth on the cavity of the bladder likely to arise from an enlarged middle lobe, a peculiarly also require some notice. These effects, so far as regards my formed beak is necessary, and the pelvis must be raised. present subject, will depend on the degree of prostatic enlargeThe beak or curved part of the lithotrite must be short, and ment, and on the lobe principally affected. Whentbeenlarge- the curve sharp. With an instrument of this kind the surgeon ment is chiefly confined to the middle lobe of the prostate, will often be able to "fish up the stone from the depression which encroaches on the floor of the bladder, the capacity of behind the in the manner described in the enlarged prostate," that viscus at its lower part is proportionably diminished. I last edition of my work on the Bladder.* By turning the have seen a considerable part of the bladder occupied by the point down, and elevating the handle of the instrument, the enlarged prostate; and, in extreme cases, preparations of stone will commonly be found in the position already men’which IU’P rracervarl in our Truseums. the morbidlv cleve* The Diseases of the Bladder and Prostate Gland, p. 463. Fifth Edition. * The EnlargedProstate, p. 23. 1858. London, 1857.
often attributed to it by the patient. Neither have I yet found any obstacle to its use, nor that it has stood in the way of any other remedy which might appear to be wanted, such as leeches, mercury, wine, bark, or food of any kind. When it begins to fail in my hands, I shall let you know. Having spoken so much about general treatment, I will now make a few remarks on the individual cases. (To be concluded.)
was
110
loped gland
indistinct fleshy vascular mass. It is to intra-uterine masses of this description, the true origin of which was long unknown, that the term mole has been given. Their presence in the uterus, and progressive development, sometimes for many months, gives rise to many, if not most, of the symptoms of pregnancy, and is attended, all but invariably, with repeated irregular haemorrhage. Sometimes the haemorrhage is constant; sometimes it is irregularly periodical, simulating morbid menstruation. When these symptoms are present, the state of the patient is necessarily one of doubt and uncertainty, until the mole is expelled. The morbid product to which the name of hydatids of the uterus has been given, is probably generated under the same circumstances, and its presence is attended with identically the same symptoms-viz., irregular, constantly recurring haemorrhage, and the more or less perfect reproduction of the ordinary signs of pregnancy. The above are the generally recognised causes and forms of haemorrhage during the erly stage of pregnancy, and with them we may group chronic inflammation of the body of the uterus. The cause to which I wish specially to draw attention -viz., inflammatory lesions of the cervix uteri, although overlooked as yet by most accoucheurs, is most certainly the one which is by far the most frequently met with in practice, and the one also over which we have the greatest therapeutical HÆMORRHAGE IN EARLY PREGNANCY control. PRACTICALLY CONSIDERED. Inflammation and ulceration of the mucous membrane coverBY J. HENRY BENNET, M.D., ing the cervix uteri, and lining the cervical canal, is now generally admitted to be a lesion of frequent occurrence in childPHYSICIAN-ACCOUCHEUR TO THE ROYAL FREE HOSPITAL. bearing women. Such being the case, and the presence of these morbid conditions, although a cause of sterility in HAEMORRHAGE during the early stages of pregnancy is gene- some, not preventing pregnancy in many, the two conditions, and inflammatory ulceration, must and do often rally, if not always, a source of anxiety and doubt both to the pregnancy exist. Whenever their co-existence takes place, occasional patient and to the medical attendant. Of anxiety, because it haemorrhage, slight or severe, may be said to generally occur, is the constant forerunner of abortion ; of doubt, because its and the more readily as all ulcerative lesions of the uterina assume in pregnancy a very irritable fungoid character. repeated appearance, simulating irregular menstruation, often neck Thus may occur spontaneously, or it may depend haemorrhage throws a doubt on the reality of the pregnancy. on accidental causes, such as over-exertion, marital intertoo under these circumstances is still Haemorrhage occurring It may be irregular or it may be periodical, course, &c. exclusively considered by accoucheurs in connexion with dis- simulating menstruation. In any case, its existence is not eased conditions of the ovum and of its membranes. The imso much, in most instances, a danger as a relief to the conportant fact, that it is frequently the result of chronic inflam- gested and inflamed uterus. The real danger is the existence inflammatory disease of the uterine cervix, which matory conditions of the body and neck of the uterus and of of the the haemorrhage, and unfits the uterus for the functhe cervical canal-a fact to which I drew attention many causes which it is performing. The pressing therapeutical intions years ago-is still generally ignored and overlooked : and yet dication is to subdue the uterine disease, to heal the ulcerated the additional experience I have since acquired has completely surfaces from which the blood so readily oozes, and thus to put an end to the danger which threatens the life of the foetus. confirmed the truth of the views I then brought forward. Itwill be perceived that valuable rules may be deduced from occur to Haemorrhage may during early pregnancy, owing the partial separation of the ovum from its uterine connexions; what precedes, for our guidance in practice. If a healthy female is suddenly attacked with haemorrhage in the owing to the existence of a blighted ovum or mole ; or owing early stages of her pregnancy, we are warranted in considering to the above-mentioned inflammatory conditions. the haemorrhage the forerunner of abortion, and we must treat When the connexion between the ovum and the uterus is it accordingly. The patient must be kept in the recumbent modified, under the influence of the maternal, foetal, or acci- position, mineral acids and sedatives should be given internally, dental causes, which are generally recognised as the causes of and laudanum injected per anum if there are uterine tormina abortion, haemorrhage is the usual result, In a case of this or contractions present. Of course no examination should be kind, if the cervix uteri is brought into view, it is found quite made, as it might prove an additional source of irritation. If, healthy, merely presenting the size and colour that pertain to however, the treatment resorted to, at first successful, subsethe stage of pregnancy which the patient has reached. The quently fails, the haemorrhage again appearing; or if even on blood is seen gently oozing from the orifice of the cervical canal. the first attack there are decided antecedents of uterine sufferThese are the cases iu which rest and constitutional treatment ing in the history of the patient, a careful instrumental exaalone are required, and often succeed, especially when the mination of the uterus and of its cervix should be made as soon haemorrhage has followed some accidental cause. As long as as possible. If no inflammator3 lesions are discovered, we may the foetus is alive, there is reason to hope that any mischief prepare for the doubts and uncertainties connected with that may have occurred may be repaired, the haemorrhage blighted ova. ; but if, on the contrary, inflammatory lesions are arrested, and the pregnancy saved. Moreover as we cannot recognised, they should be at once treated and removed. In tell positively, at fitst, whether the fcetus has died or not, it is the latter case, we may hope that the haemorrhage merely proour duty to continue our efforts to preserve it, until the violence ceeds from the inflamed or ulcerated mucous surface, and that of the haemorrhage has destroyed all hope, or until the abortion the integrity of the ovum and of its attachments to the uterus has actually taken place. has not suffered. Generally speaking, in such cases, if the The haemorrhage which is occasioned by the conditions that haemorrhage has not been allowed to too long, the lead to abortion is, generally speaking, either subdued, or it pregnancy is saved by the cure of the local disease. I may continues, notwithstanding treatment, until the abortion has safely say that I have saved very many pregnancies by applyoccurred. It may be arrested, and then break out again and ing the above rules of practice, and that many children now of these imagain, but this is the exception. When uterine haemorrhage alive and well owe their lives to the recognition 0 occurs irregularly in the early months of pregnancy, the cervix portant facts. uteri being free from inflammatory lesions, stopping and returnIn some instances, where the cervix is diseased, inflamed, ing repeatedly, without uterine contractions, it is generally and ulcerated, and the blood is seen, on examination, to ooze occasioned by the presence in the uterus of a blighted ovum or from the ulcerative surface, the feetus is dead, and the ovum mole; and, in some rare instances, by that of partly detached, when the examination is made; or these acciThe fcetal germ may die soon after conception, and become dents occur before the practitioner has had time to modify the atrophied, absorbed, or lost, whilst the membranes and pla- cervical inflammation. In such cases, the treatment of the centa may continue to grow, like moss on a wall, deriving latter disease does not, of course, save the pregnancy. As, nourishment from the inner surface of the uterus, and forming therefore, we never can be sure that the foetus is still sound
tioned. When the middle lobe of the prostate is much enlarged,
an
and extends some way into the bladder, the point of the instrument cannot be turned downwards in such a way as to reach the stone. The plan from which I have derived most benefit in such cases is that of raising the pelvis of the patient in such a way that the calculus shall be displaced towards the posterior wall of the bladder. Especial care must be taken that the pelvis itself is raised, and not merely the lower extremities. By adopting this plan, I have, on several occasions, immediately caught the calculi, which lay concealed behind the prostate as long as the patient retained the ordinary position. Every lithotrity couch should be provided with some mechanical contrivance for executing this proceeding quickly. The sufferings occasioned by the attempt to seize a stone behind an enlarged prostate, in the ordinary way, and after strong elevation of the handle, are often of the most distressing kind, and cannot certainly contribute to the well-doing of the patient. On the other hand, the ease with which the reversed beak falls on the stone is remarkable; but the manipulation requires a cautious and practised hand.
pregnant
’
continue
hydatids.
111
often attributed to it by the patient. Neither have I yet found any obstacle to its use, nor that it has stood in the way of any other remedy which might appear to be wanted, such as leeches, mercury, wine, bark, or food of any kind. When it begins to fail in my hands, I shall let you know. Having spoken so much about general treatment, I will now make a few remarks on the individual cases. (To be concluded.)
was
110
loped gland
indistinct fleshy vascular mass. It is to intra-uterine masses of this description, the true origin of which was long unknown, that the term mole has been given. Their presence in the uterus, and progressive development, sometimes for many months, gives rise to many, if not most, of the symptoms of pregnancy, and is attended, all but invariably, with repeated irregular haemorrhage. Sometimes the haemorrhage is constant; sometimes it is irregularly periodical, simulating morbid menstruation. When these symptoms are present, the state of the patient is necessarily one of doubt and uncertainty, until the mole is expelled. The morbid product to which the name of hydatids of the uterus has been given, is probably generated under the same circumstances, and its presence is attended with identically the same symptoms-viz., irregular, constantly recurring haemorrhage, and the more or less perfect reproduction of the ordinary signs of pregnancy. The above are the generally recognised causes and forms of haemorrhage during the erly stage of pregnancy, and with them we may group chronic inflammation of the body of the uterus. The cause to which I wish specially to draw attention -viz., inflammatory lesions of the cervix uteri, although overlooked as yet by most accoucheurs, is most certainly the one which is by far the most frequently met with in practice, and the one also over which we have the greatest therapeutical HÆMORRHAGE IN EARLY PREGNANCY control. PRACTICALLY CONSIDERED. Inflammation and ulceration of the mucous membrane coverBY J. HENRY BENNET, M.D., ing the cervix uteri, and lining the cervical canal, is now generally admitted to be a lesion of frequent occurrence in childPHYSICIAN-ACCOUCHEUR TO THE ROYAL FREE HOSPITAL. bearing women. Such being the case, and the presence of these morbid conditions, although a cause of sterility in HAEMORRHAGE during the early stages of pregnancy is gene- some, not preventing pregnancy in many, the two conditions, and inflammatory ulceration, must and do often rally, if not always, a source of anxiety and doubt both to the pregnancy exist. Whenever their co-existence takes place, occasional patient and to the medical attendant. Of anxiety, because it haemorrhage, slight or severe, may be said to generally occur, is the constant forerunner of abortion ; of doubt, because its and the more readily as all ulcerative lesions of the uterina assume in pregnancy a very irritable fungoid character. repeated appearance, simulating irregular menstruation, often neck Thus may occur spontaneously, or it may depend haemorrhage throws a doubt on the reality of the pregnancy. on accidental causes, such as over-exertion, marital intertoo under these circumstances is still Haemorrhage occurring It may be irregular or it may be periodical, course, &c. exclusively considered by accoucheurs in connexion with dis- simulating menstruation. In any case, its existence is not eased conditions of the ovum and of its membranes. The imso much, in most instances, a danger as a relief to the conportant fact, that it is frequently the result of chronic inflam- gested and inflamed uterus. The real danger is the existence inflammatory disease of the uterine cervix, which matory conditions of the body and neck of the uterus and of of the the haemorrhage, and unfits the uterus for the functhe cervical canal-a fact to which I drew attention many causes which it is performing. The pressing therapeutical intions years ago-is still generally ignored and overlooked : and yet dication is to subdue the uterine disease, to heal the ulcerated the additional experience I have since acquired has completely surfaces from which the blood so readily oozes, and thus to put an end to the danger which threatens the life of the foetus. confirmed the truth of the views I then brought forward. Itwill be perceived that valuable rules may be deduced from occur to Haemorrhage may during early pregnancy, owing the partial separation of the ovum from its uterine connexions; what precedes, for our guidance in practice. If a healthy female is suddenly attacked with haemorrhage in the owing to the existence of a blighted ovum or mole ; or owing early stages of her pregnancy, we are warranted in considering to the above-mentioned inflammatory conditions. the haemorrhage the forerunner of abortion, and we must treat When the connexion between the ovum and the uterus is it accordingly. The patient must be kept in the recumbent modified, under the influence of the maternal, foetal, or acci- position, mineral acids and sedatives should be given internally, dental causes, which are generally recognised as the causes of and laudanum injected per anum if there are uterine tormina abortion, haemorrhage is the usual result, In a case of this or contractions present. Of course no examination should be kind, if the cervix uteri is brought into view, it is found quite made, as it might prove an additional source of irritation. If, healthy, merely presenting the size and colour that pertain to however, the treatment resorted to, at first successful, subsethe stage of pregnancy which the patient has reached. The quently fails, the haemorrhage again appearing; or if even on blood is seen gently oozing from the orifice of the cervical canal. the first attack there are decided antecedents of uterine sufferThese are the cases iu which rest and constitutional treatment ing in the history of the patient, a careful instrumental exaalone are required, and often succeed, especially when the mination of the uterus and of its cervix should be made as soon haemorrhage has followed some accidental cause. As long as as possible. If no inflammator3 lesions are discovered, we may the foetus is alive, there is reason to hope that any mischief prepare for the doubts and uncertainties connected with that may have occurred may be repaired, the haemorrhage blighted ova. ; but if, on the contrary, inflammatory lesions are arrested, and the pregnancy saved. Moreover as we cannot recognised, they should be at once treated and removed. In tell positively, at fitst, whether the fcetus has died or not, it is the latter case, we may hope that the haemorrhage merely proour duty to continue our efforts to preserve it, until the violence ceeds from the inflamed or ulcerated mucous surface, and that of the haemorrhage has destroyed all hope, or until the abortion the integrity of the ovum and of its attachments to the uterus has actually taken place. has not suffered. Generally speaking, in such cases, if the The haemorrhage which is occasioned by the conditions that haemorrhage has not been allowed to too long, the lead to abortion is, generally speaking, either subdued, or it pregnancy is saved by the cure of the local disease. I may continues, notwithstanding treatment, until the abortion has safely say that I have saved very many pregnancies by applyoccurred. It may be arrested, and then break out again and ing the above rules of practice, and that many children now of these imagain, but this is the exception. When uterine haemorrhage alive and well owe their lives to the recognition 0 occurs irregularly in the early months of pregnancy, the cervix portant facts. uteri being free from inflammatory lesions, stopping and returnIn some instances, where the cervix is diseased, inflamed, ing repeatedly, without uterine contractions, it is generally and ulcerated, and the blood is seen, on examination, to ooze occasioned by the presence in the uterus of a blighted ovum or from the ulcerative surface, the feetus is dead, and the ovum mole; and, in some rare instances, by that of partly detached, when the examination is made; or these acciThe fcetal germ may die soon after conception, and become dents occur before the practitioner has had time to modify the atrophied, absorbed, or lost, whilst the membranes and pla- cervical inflammation. In such cases, the treatment of the centa may continue to grow, like moss on a wall, deriving latter disease does not, of course, save the pregnancy. As, nourishment from the inner surface of the uterus, and forming therefore, we never can be sure that the foetus is still sound
tioned. When the middle lobe of the prostate is much enlarged,
an
and extends some way into the bladder, the point of the instrument cannot be turned downwards in such a way as to reach the stone. The plan from which I have derived most benefit in such cases is that of raising the pelvis of the patient in such a way that the calculus shall be displaced towards the posterior wall of the bladder. Especial care must be taken that the pelvis itself is raised, and not merely the lower extremities. By adopting this plan, I have, on several occasions, immediately caught the calculi, which lay concealed behind the prostate as long as the patient retained the ordinary position. Every lithotrity couch should be provided with some mechanical contrivance for executing this proceeding quickly. The sufferings occasioned by the attempt to seize a stone behind an enlarged prostate, in the ordinary way, and after strong elevation of the handle, are often of the most distressing kind, and cannot certainly contribute to the well-doing of the patient. On the other hand, the ease with which the reversed beak falls on the stone is remarkable; but the manipulation requires a cautious and practised hand.
pregnant
’
continue
hydatids.
111