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ON LITHOTRITY AND LITHOTOMY.
1220
cyanide in acute rheumatism and in all the febrile diseases sulphocyanide was in the cases in which the average hitherto examined be due to the increased temperature of the temperature was 98° to 99°, and that it lessened as the body, and be therefore merely an indication of the augmen- average amount of heat increased, so that there is no contation of the destructive processes by the fever, or of the nexion between the quantity of the salivary salt and the inspissation of the saliva accompanying it? Table IX. increased retrograde processes that are believed to occur TABLE
VIII.—oMtM
the
Depth of Colour in each Week of Residence in Hospital of Cases of Rheumatic Fever.
prepared to test the truth of this objection, and iu fever. In acute rheumatism the saliva is always calculating the average evening temperature abundant, so that there is no reason to suppose the of each case during its residence in the hospital; the whole augmentation in the amount of the sulphocyanide is the of the cases being then grouped according to the tempera- result of an inspissation of the secretion. tures thus obtained. But it may be said, Is not the temperature a measure of the intensity of the disease, and ought not, therefore, the TABLE IX.-Shozoinq the Cases of Rheumatic Fever grouped elevation of the thermometer to correspond with an augmenaccording to their average Evemng Temperature. tation of the sulphouyanide? But the average evening temperature does not represent the severity of the illness, for the highest temperature m each cameusually occurs during the first four days after the patient’a admission, and in short cases, where there is no recurrence of the fever, the patients are quickly dismissed, and consequently the average temperature is high. But where there is a frequent succession of attacks, attended with a moderate rise of temperature, the patients remain, long in the hospital, and the average height of the thermo-
has been was
formed by
meter is not much above the normal.
Now it is in thes& that the syphocyanide is in the greatest excess, and consequently the saliva furnishes us with a most valuable indication in respect to the prognosis of the disease. of thei (To be concluded.)
protracted
It will be remarked that the
highest quantity
cases
fore postponed for a few days until the vesical irritability had been allayed by rest and recumbency in bed. On March 12th lithotrity was performed. The patient BY F. J. GANT, F.R.C.S., having been ansesthetised, and the bladder moderately disSENIOR SURGEON TO THE ROYAL FREE HOSPITAL. tended with warm water, the calculus was readily caught by the lithotrite, and measured nearly one inch and a half in HAVING recently had occasion to operate on two patients its long diameter. It broke readily into pieces, and the in succession for stone in the bladder-the one by lithotrity fragments were successively crushed. In the process of and the other by the lateral operation of lithotomy,-this pulverisation, the pieces were not sought by any exploration in the unusual coincidence led me to reconsider the relative merits with the instrument; but, by fixing the female blade fundus of the bladder, and gently sliding the male blade of these two operations, and that of the suprapubic method, backwards and forwards, the disturbance of the water for the removal of vesical calculus; at the same time re- sufficed to bring some fragment between the blades. By a viewing the various accidents which may befall each such half-rotatory movement of the instrument from side to side, fragments were readily caught, lying beyond the operation, the difficulties which may have to be encountered other middle area. When a quantity of detritus had accumulated, in their performance, and the dangers which may follow the it was evacuated by a No. 15 evacuating catheter, the orifice footsteps of these procedures. I will first briefly narrate of the urethral meatus having been incised to admit of the the two cases which suggested this critical survey. introduction of this instrument. Crushing and evacuation CASE 1. Lithotrity.- Joseph D-, aged twenty-eight, were repeated a second and a third time, the operation had suffered from symptoms of stone in the bladder for lasting an hour and a half, when I deemed it advisable to about eight months previously to his admission to the Royal leave the remainder for another sitting. But it is worthy Free Hospital on March 4th, 1887. On sounding him, I of note, that the water in the receiver of the aspirator found a calculus lying in the fundus of the bladder, which is scarcely blood-stained throughout the operation. A gave a dull sound, and was attended with an alkaline and gentle use of the lithotrite, in the manner explained, even mucous state of the urine. The diagnosis pointed to the for a long period, is better tolerated, and especially by an presence of a phosphatic calculus, and that, judging from irritable bladder, than that by a more active use of the the extent of surface over which the convexity of the sound instrument, lithotrity should be finished in half the time. traversed, it seemed to be of large size, while the resistance The patient suffered not the slightest after-symptom of any offered to movement by the sound gave some estimate of its kind, feeling as comfortable as if nothing had been done, weight. The act of sounding was painful, and excited and passing urine only three or four times daily. The man some spasmodic expulsion of urine. Operation was there- was kept in bed only on account of the acute east winds.
ON LITHOTRITY AND LITHOTOMY.
,
1221 an ounce of phosphatic calculus had been thus removed without any inconvenience. In a few days the operation was completed ; with a final exploration of the bladder, which still remained irritable, even under the influence of anaesthesia. Two days afterwards, the patient being quite well, he got up at his He continued under observation for a fortown request.
Three-quarters of
thus explained, more than by circumstances incident to the individual skill of the operator. Bigelow’s method of rapid lithotrity has done much to place the crushing operation on equal terms with the cutting operation of lithotomy for the complete removal of stone from the bladder; but, if rightly interpreted in its full bearings on the question, this method has done even more should determine night, daily taking exercise; then, no fragments having to demonstrate the circumstances which The complete evacuation of stone been found on carefully sounding the bladder, and being the surgeon’s choice. .entirely free from stone symptoms, he left the hospital from the bladder by a single operation of crushing, proin ,good health. The total amount of phosphatic detritus, longed perhaps for an hour or more, as compared with thea so far as it could be collected, was over an ounce in former method, by repeated crushings, each lasting only experiweight, and the original size of the calculus one inch and few minutes, may be read in the light of a crucial for the ment to test the tolerance of the urinary bladder ,a half. CASE 2. Lithotomy (perineal) by the lateral operation.- free use of instruments or for the continued presence of ’William P-, aged eighteen, had experienced symptoms of stone fragments. The evidence in favour of prolonged vesical calculus for a period of ten years. When admitted instrumentation has not only reversed thejudgment to the hospital (March 7th, 1887), sounding at once touched a formerly held as to the supposed intolerance of the bladder stone, lying in the fundus of the bladder; it rang with a sound for this kind of irritation, but has elicited the equally as if metallic, and was distinctly tuberculated under the point significant fact that stone chips remaining in the bladder, of the instrument, the stone measuring about one inch from followed speedily by cystitis or aggravating the previous before backwards, as indicated by the passage of the sound vesical inflammation, is the immediate cause of death I concluded that there was a hard mul- after lithotrity. The choice of operation for the removal over its surface. berry calculus, and of more than average size. The bladder of stone must, therefore, be centralised in the kind and urine were quite healthy. In this case the operation of calculus with which the surgeon has to deal. In of lithotomy, and by the lateral method in the perineum, lithotrity, a hard calculus, ringing as if metallic when leaving the suprapubic operation out of the question, would sounded, yields fragments more angular and irritative than those of a soft calculus-more provocative of cystibe far more suitable than lithotrity. On March 1Zth, after the previous case of lithotrity, I tis. Unless the bladder can be most assuredly emptied of performed lateral lithotomy in the usual manner. But, all such fragments, a hard calculus of uric acid or oxalate having made the prostatic incision and seized the stone with of lime had far better be removed by lithotomy. Of course some little trouble, as it slipped from the grasp of the the size of the stone is also an important consideration, but forceps, I experienced a real difficulty in extracting the quite subordinate, I should say, to that of density, as a stone without bruising the neck of the bladder. Accord- factor in lithotrity. According to my judgment, the crushing tingly, I had recourse to an expedient which I strongly of an earthy phosphatic calculus, measuring by the lithoadvocate in such cases. Passing a blunt-pointed scalpel trite an inch and a half, would entail less bladder liabilities along the inner blade of the forceps, held in the prostatic than the crushing of a flinty mulberry calculus of only half incision, I made a second rectangular or transverse incision that size. The one squashes readily into grit as the operaoutwards in the right half of the prostate, sufficiently to tion proceeds; the other gives way with a sort of bang, extract the stone with ease. This modification of the falls into angular pieces, and then breaks into similar fragoperation was seen to be necessary, not only from the size of ments. Any remaining chips which had perchance escaped the calculus, but owing to the projection of its rough evacuation would induce cystitis more surely than the surface beyond the blades of the forceps. whole amount of pulverulent matter into which the phosThe after course of this case was noteworthy only on phatic stone had crumbled, mixing with the water into a account of the absence of any unfavourable symptoms. No mortar-like puddle in the bladder. With relation to lithotomy, the size of the calculus is the suprapubic pain ensued as from pelvic cellulitis, and the urine passed freely through the wound about six times in the element in the question which mainly determines the claims twenty-four hours for the first two days. Thus, on the in favour of lithotrity. The dimensions of a stone may second day-usually a critical time-The report states : render it ill-fitted for extraction by any cutting operation. April 14th: urine from wound at 10 A.M., 2 P.M., 6 P.M., In lateral lithotomy, the extraction of a stone beyond a 8.30 P.M., 10 PM., and 6 A.M. On the following (third) day certain size, is attended with such bruising of the neck of urine was passed through the urethra and through the the bladder as will almost inevitably be followed by spreadwound, and so on, alternating until the fifth day. Subse- ing cellulitis around. On the other hand, a more than quently the urine again passed more and more through the limited prostatic incision backwards might trespass beyond wound; but from the eighth day onwards entirely per the fascial investment of the prostate, and lead to urinary urethram. The perineal incision healed up from within, infiltration, with the same result. But contusion of the without any tenderness or fulness, and had completely vesical neck is more frequently responsible for a fatal issue. ’closed in a fortnight. Recumbency still seemed advisable, The median operation can offer only a limited access to the to render the perineum firm and unyielding, the wound bladder, and allowing the extraction of a proportionately having been known to reopen in consequence of the patient small stone, this method of cutting is out of the running, in being allowed to get up at too early a period; but the young comparison with lithotrity. Looking at lithotomy only from man took gentle walking exercise in the quadrangle of the a stone-extraction point of view, it is here assumed that in hospital for a few days, and then left quite well. The stone, either the lateral or the median way of approaching the bladder the path is well known, with its relations, and the a fine specimen of black mulberry oxalate of lime calculus, looked like a round rough piece of iron slag, and weighed operation skilfully performed. Suprapubic lithotomy provides for the removal of a large stone, of such size as could nearly an ounce. Choice of operation lithotrity or lithotomy.. ; lateral, not be removed by lithotrity, however prolonged or repeated. median, or suprapubic.-Before proceeding to remove a stone But, having regard to the pathway of operation, experience from the bladder, certain clear and definite views must be has shown, and quite recently, that the bladder cannot held as to the conditions which should determine the kind of be entered above the pubes always, without wounding the operation, seeing that the circumstances which lead to this peritoneal reflexion, even when the bladder is raised by the selection will obviously affect, for better or worse, all the fullest distension, almost to the point of bursting, and contingencies of difficulty and adverse consequences which propped up from below by an equally distended Petersen’s are associated with the particular method, but which are rectal bag. Then, again, the known risk of urinary infiltrareferable rather to the questionable fitness of the case, and tion has proved to be a not uncommon after-consequence of thence the prior judgment of the operator. In connexion the suprapubic incision, and certainly should not be an with the relative merits of lithotrity and lithotomy, what- after-thought in the mind of the surgeon who is about to ever method be adopted, no question can have more practical operate by this route. significance than with regard to the size and the density of Apart from the kind of calculus, as determining the choice the calculus, coupled with the state of the bladder and urinary of operation, of less direct importance may be reckoned the tract throughout-the combination of factors which shall state of the bladder and kidneys, cystitis depending far oe more favourable for the performance and after safety of more on the continued presence of stone fragments after the one or the other of these operations. The wide difference lithotrity than arising from this operation. The complete of results in the hands of experienced operators may be evacuation of the bladder would place the rapid method on
1222
operation of lithotomy. So, likewise, and oxalate of lime, each weighing more than three ounces. nephritis pyelitis, whether due to the extension of vesical But these are quite exceptional cases, and in the hands inflammation up the ureters, or occurring from reflex vaso- of an exceptional lithotritist. Success in crushing and motor influence on the kidney, is alikethe expression of vesical evacuating such calculi might well place some other operairritation. The symptoms betokening renal irritation, by tors in mourning. The average lithotritist, tackling either rigors, lumbar pain, with ureamic blood-poisoning, proceed of those hardened sinners, would certainly have left some from the bladder, and all the significance of kidney mischief portion of the enemy in the bladder; ay, and even aftera is lost in the prior question of entire removal of the calculus second attack, an angular fragment or two might still be from the organ below. lodged. When the surgeon, who is about equally apt in But when, in any case, the hardness of a calculus would crushing or cutting, has to encounter a big, brazen mulberry be adverse to lithotrity-unless the operation can be com- calculus, or its almost as formidable uric acid rival, instead pleted, and the bladder be certainly emptied of all frag- of spending an hour and a half or longer in lithotrity, ments, and when the size of the calculus places it beyond without then clearing out the bladder, I would recom. lithotomy, otherwise than through the perils of the supra- mend him to try lateral lithotomy, with the additional pubic adventure,-can the old lateral operation of lithotomy rectangular incision of the prostate to the right side, and be modified and adapted for the removal of a stone, whose capture the enemy in a few minutes. dimensions may require further space than usual for its I may take another opportunity of referring to the diffiextraction, without any untoward consequences? The culties and dangers pertaining to lithotrity and lithotomy perineal incision itsalf will, of course, be sufficient ; and in the various methods of operation. the prostatic incision may be safely extended backwards to Connaught-square, W. the very neck of the bladder, notching the elastic ring, but within the boundary of the fascial investment of the A MEDIAN LITHOTOMY. prostate; the incision, thus limited, admitting readily of a dilatation with the enlargement, by tunneling finger, BY REGINALD HARRISON, F.R.C.S, without dividing or rupturing the elastic ring. But the SURGEON TO THE LIVERPOOL ROYAL INFIRMAEY. opening thus formed by this well-defined incision and dilatation may be further enlarged to twice the size THE recent movement to revive the suprapubic operation by a rectangular incision from the middle of the first towards the other side of the prostate. In a prostate of for stone in the bladder, under somewhat altered circum. average dimensions the usual lateral incision may be one has been doubtless prompted with the view of inch, admitting of the extraction of a calculus which stances, shall weigh an ounce and a half ; and the rectangular diminishing the mortality connected with the removal of incision, in the middle of the right half of the pros- those stones from the bladder which cannot be effected by tate, having nearly the same extent-another inch,- crushing, and of substituting an operation which is free will provide the additional space for the extraction of a from the difficulties and risks which, either rightly or stone double the size, should the necessity arise in this have been with lateral lithotomy. That associated wrongly, stage of the_operation. The valvular opening thus formed there 1 are grounds for possessing an alternative is evident for of a room the calculus as passage gives, therefore, ample I a study of some statistics and records of the latter large as may be met with. This rectangular incision is notfrom the incision which was practised occasionally by Martineau4operation. That the lateral method for stone in adults has and Liston, who divided the right side of the prostate down-been found to be a proceeding attended with a considerable towards the right ischial tuberosity, forming, with the wards of in some instances, it is stated, degree fatality, reaching similar section of the left side, a double lateral section of the to a 35 death-rate of cent., there can be no doubt. per prostate. Theobjectionto that direction of the secondincision to the right is the liability of wounding the rectum, now Further, records of this operation show that the mortality that the prostate is not held up by the staff, and has arisen very largely out of complications having an the bowel protected also by the finger, as when in the act of evident relation to the difficulties with which the operation making the ordinary lateral incision alone in the left half was performed. For instance, a well-executed lateral of the prostate. The semilunar prostatic incision, by the operation where everything is straightforward is about "bilateral operation" of Dupuytren, has obviously a different the safest operation of- any magnitude in surgery; shape, and the downward direction of the section on either and in proportion with the degree of deviation from the side, in using the covered double-bladed lithotome, is very standard that circumstances render inevitable may its liable to touch the vasa deferentia or the seminal vesicles, fatality be measured. In proof of this let me mention the and emasculate the patient. Notching the margins of the chief early causes of death after lithotomy. Hemorrhage, ordinary left lateral incision, obliquely, above and below the primary and secondary; cellulitis and peritonitis arising " quadrilateral section" of the prostate, advocated by Vidal from damage done by the knife, as when the latter is de Cassis, is a procedure which involves no such risk; but allowed to miss or leave the staff and to pass behind or nickings with the knife in those situations, to ease the for- through the bladder, not mentioning the rectum; rupture ceps for the extraction of a large stone, might readily cut the of the urethra and failure to enter the bladder, as when fascial investment of the prostate above or the rectum below. these parts are telescoped by the finger of the operator; The additional space afforded by the rectangular section and, lastly, sepsis. With the exception of the last-mentioned passing transversely across the right half of the prostate cause, which is largely determined by the nature of the is fully equivalent to that which is given in either of these incisions made, probably all the others are avoidable, and ways, and is entirely free from any danger. It is easily seldom occur save in connexion with an operation the accomplished. When, in the extraction of a large stone, doing of which might be improved upon. Apart, however, the forceps is found to be fixed somewhat firmly in the from these difficulties and contingencies, there is a necessity ordinary lateral opening in the prostate, the second cut for carefully considering our means of removing stones from the bladder by the frequency with which recurrences take can be made by sliding a blunt-pointed knife along the the it not of inner and outwards, blade, place after lithotrity, even when the operation has been convexity carrying downwards, in the middle of the right half of the prostate. practised by experienced hands. Such recurrences bave If there be any doubt as to the bearing of the blade, a little been recentlv stated as amounting to about 13 per cent. traction with the forceps will make the prostate bulge When we consider the rarity of stone relapses after lithoforwards sufficiently to bring that part actually into view tomy, as compared with lithotrity, we have the best reason in a perineum of the ordinary depth. By this second for critically studying the former operation with the riev transverse incision bruising of the vesical neck is prevented, of rendering it simple and efficient. I think it will be the risk of urinary infiltration from a too free left lateral generally admitted that the easiest and simplest method of incision in the backward direction is avoided, and the entering the bladder, say for the purpose of exploring i’ extraction of the stone is effected without fracture and with the finger, is that known as median perineal urethrosplintering in the bladder, or in drawing it through the tomy, or incorrectly as median cystotomy. By this pitf the finger may be readily passed into the bladder withoat prostate. By the operation of lithotrity large stones of the hardest risk. As I have now practised this operation for the relief kind have been pulverised, and the bladder completely of cystitis, for the exploration of tumours of the bladder emptied. That operation may be credited in Freyer’s prac- and prostate, for prostatotomy and prostatectomy, a very tice with having thus got rid of calculi formed of uric acid considerable number of times, I think my experience ha: a
level with any or
1
I
.
cyanide in acute rheumatism and in all the febrile diseases sulphocyanide was in the cases in which the average hitherto examined be due to the increased temperature of the temperature was 98° to 99°, and that it lessened as the body, and be therefore merely an indication of the augmen- average amount of heat increased, so that there is no contation of the destructive processes by the fever, or of the nexion between the quantity of the salivary salt and the inspissation of the saliva accompanying it? Table IX. increased retrograde processes that are believed to occur TABLE
VIII.—oMtM
the
Depth of Colour in each Week of Residence in Hospital of Cases of Rheumatic Fever.
prepared to test the truth of this objection, and iu fever. In acute rheumatism the saliva is always calculating the average evening temperature abundant, so that there is no reason to suppose the of each case during its residence in the hospital; the whole augmentation in the amount of the sulphocyanide is the of the cases being then grouped according to the tempera- result of an inspissation of the secretion. tures thus obtained. But it may be said, Is not the temperature a measure of the intensity of the disease, and ought not, therefore, the TABLE IX.-Shozoinq the Cases of Rheumatic Fever grouped elevation of the thermometer to correspond with an augmenaccording to their average Evemng Temperature. tation of the sulphouyanide? But the average evening temperature does not represent the severity of the illness, for the highest temperature m each cameusually occurs during the first four days after the patient’a admission, and in short cases, where there is no recurrence of the fever, the patients are quickly dismissed, and consequently the average temperature is high. But where there is a frequent succession of attacks, attended with a moderate rise of temperature, the patients remain, long in the hospital, and the average height of the thermo-
has been was
formed by
meter is not much above the normal.
Now it is in thes& that the syphocyanide is in the greatest excess, and consequently the saliva furnishes us with a most valuable indication in respect to the prognosis of the disease. of thei (To be concluded.)
protracted
It will be remarked that the
highest quantity
cases
fore postponed for a few days until the vesical irritability had been allayed by rest and recumbency in bed. On March 12th lithotrity was performed. The patient BY F. J. GANT, F.R.C.S., having been ansesthetised, and the bladder moderately disSENIOR SURGEON TO THE ROYAL FREE HOSPITAL. tended with warm water, the calculus was readily caught by the lithotrite, and measured nearly one inch and a half in HAVING recently had occasion to operate on two patients its long diameter. It broke readily into pieces, and the in succession for stone in the bladder-the one by lithotrity fragments were successively crushed. In the process of and the other by the lateral operation of lithotomy,-this pulverisation, the pieces were not sought by any exploration in the unusual coincidence led me to reconsider the relative merits with the instrument; but, by fixing the female blade fundus of the bladder, and gently sliding the male blade of these two operations, and that of the suprapubic method, backwards and forwards, the disturbance of the water for the removal of vesical calculus; at the same time re- sufficed to bring some fragment between the blades. By a viewing the various accidents which may befall each such half-rotatory movement of the instrument from side to side, fragments were readily caught, lying beyond the operation, the difficulties which may have to be encountered other middle area. When a quantity of detritus had accumulated, in their performance, and the dangers which may follow the it was evacuated by a No. 15 evacuating catheter, the orifice footsteps of these procedures. I will first briefly narrate of the urethral meatus having been incised to admit of the the two cases which suggested this critical survey. introduction of this instrument. Crushing and evacuation CASE 1. Lithotrity.- Joseph D-, aged twenty-eight, were repeated a second and a third time, the operation had suffered from symptoms of stone in the bladder for lasting an hour and a half, when I deemed it advisable to about eight months previously to his admission to the Royal leave the remainder for another sitting. But it is worthy Free Hospital on March 4th, 1887. On sounding him, I of note, that the water in the receiver of the aspirator found a calculus lying in the fundus of the bladder, which is scarcely blood-stained throughout the operation. A gave a dull sound, and was attended with an alkaline and gentle use of the lithotrite, in the manner explained, even mucous state of the urine. The diagnosis pointed to the for a long period, is better tolerated, and especially by an presence of a phosphatic calculus, and that, judging from irritable bladder, than that by a more active use of the the extent of surface over which the convexity of the sound instrument, lithotrity should be finished in half the time. traversed, it seemed to be of large size, while the resistance The patient suffered not the slightest after-symptom of any offered to movement by the sound gave some estimate of its kind, feeling as comfortable as if nothing had been done, weight. The act of sounding was painful, and excited and passing urine only three or four times daily. The man some spasmodic expulsion of urine. Operation was there- was kept in bed only on account of the acute east winds.
ON LITHOTRITY AND LITHOTOMY.
,
1221 an ounce of phosphatic calculus had been thus removed without any inconvenience. In a few days the operation was completed ; with a final exploration of the bladder, which still remained irritable, even under the influence of anaesthesia. Two days afterwards, the patient being quite well, he got up at his He continued under observation for a fortown request.
Three-quarters of
thus explained, more than by circumstances incident to the individual skill of the operator. Bigelow’s method of rapid lithotrity has done much to place the crushing operation on equal terms with the cutting operation of lithotomy for the complete removal of stone from the bladder; but, if rightly interpreted in its full bearings on the question, this method has done even more should determine night, daily taking exercise; then, no fragments having to demonstrate the circumstances which The complete evacuation of stone been found on carefully sounding the bladder, and being the surgeon’s choice. .entirely free from stone symptoms, he left the hospital from the bladder by a single operation of crushing, proin ,good health. The total amount of phosphatic detritus, longed perhaps for an hour or more, as compared with thea so far as it could be collected, was over an ounce in former method, by repeated crushings, each lasting only experiweight, and the original size of the calculus one inch and few minutes, may be read in the light of a crucial for the ment to test the tolerance of the urinary bladder ,a half. CASE 2. Lithotomy (perineal) by the lateral operation.- free use of instruments or for the continued presence of ’William P-, aged eighteen, had experienced symptoms of stone fragments. The evidence in favour of prolonged vesical calculus for a period of ten years. When admitted instrumentation has not only reversed thejudgment to the hospital (March 7th, 1887), sounding at once touched a formerly held as to the supposed intolerance of the bladder stone, lying in the fundus of the bladder; it rang with a sound for this kind of irritation, but has elicited the equally as if metallic, and was distinctly tuberculated under the point significant fact that stone chips remaining in the bladder, of the instrument, the stone measuring about one inch from followed speedily by cystitis or aggravating the previous before backwards, as indicated by the passage of the sound vesical inflammation, is the immediate cause of death I concluded that there was a hard mul- after lithotrity. The choice of operation for the removal over its surface. berry calculus, and of more than average size. The bladder of stone must, therefore, be centralised in the kind and urine were quite healthy. In this case the operation of calculus with which the surgeon has to deal. In of lithotomy, and by the lateral method in the perineum, lithotrity, a hard calculus, ringing as if metallic when leaving the suprapubic operation out of the question, would sounded, yields fragments more angular and irritative than those of a soft calculus-more provocative of cystibe far more suitable than lithotrity. On March 1Zth, after the previous case of lithotrity, I tis. Unless the bladder can be most assuredly emptied of performed lateral lithotomy in the usual manner. But, all such fragments, a hard calculus of uric acid or oxalate having made the prostatic incision and seized the stone with of lime had far better be removed by lithotomy. Of course some little trouble, as it slipped from the grasp of the the size of the stone is also an important consideration, but forceps, I experienced a real difficulty in extracting the quite subordinate, I should say, to that of density, as a stone without bruising the neck of the bladder. Accord- factor in lithotrity. According to my judgment, the crushing tingly, I had recourse to an expedient which I strongly of an earthy phosphatic calculus, measuring by the lithoadvocate in such cases. Passing a blunt-pointed scalpel trite an inch and a half, would entail less bladder liabilities along the inner blade of the forceps, held in the prostatic than the crushing of a flinty mulberry calculus of only half incision, I made a second rectangular or transverse incision that size. The one squashes readily into grit as the operaoutwards in the right half of the prostate, sufficiently to tion proceeds; the other gives way with a sort of bang, extract the stone with ease. This modification of the falls into angular pieces, and then breaks into similar fragoperation was seen to be necessary, not only from the size of ments. Any remaining chips which had perchance escaped the calculus, but owing to the projection of its rough evacuation would induce cystitis more surely than the surface beyond the blades of the forceps. whole amount of pulverulent matter into which the phosThe after course of this case was noteworthy only on phatic stone had crumbled, mixing with the water into a account of the absence of any unfavourable symptoms. No mortar-like puddle in the bladder. With relation to lithotomy, the size of the calculus is the suprapubic pain ensued as from pelvic cellulitis, and the urine passed freely through the wound about six times in the element in the question which mainly determines the claims twenty-four hours for the first two days. Thus, on the in favour of lithotrity. The dimensions of a stone may second day-usually a critical time-The report states : render it ill-fitted for extraction by any cutting operation. April 14th: urine from wound at 10 A.M., 2 P.M., 6 P.M., In lateral lithotomy, the extraction of a stone beyond a 8.30 P.M., 10 PM., and 6 A.M. On the following (third) day certain size, is attended with such bruising of the neck of urine was passed through the urethra and through the the bladder as will almost inevitably be followed by spreadwound, and so on, alternating until the fifth day. Subse- ing cellulitis around. On the other hand, a more than quently the urine again passed more and more through the limited prostatic incision backwards might trespass beyond wound; but from the eighth day onwards entirely per the fascial investment of the prostate, and lead to urinary urethram. The perineal incision healed up from within, infiltration, with the same result. But contusion of the without any tenderness or fulness, and had completely vesical neck is more frequently responsible for a fatal issue. ’closed in a fortnight. Recumbency still seemed advisable, The median operation can offer only a limited access to the to render the perineum firm and unyielding, the wound bladder, and allowing the extraction of a proportionately having been known to reopen in consequence of the patient small stone, this method of cutting is out of the running, in being allowed to get up at too early a period; but the young comparison with lithotrity. Looking at lithotomy only from man took gentle walking exercise in the quadrangle of the a stone-extraction point of view, it is here assumed that in hospital for a few days, and then left quite well. The stone, either the lateral or the median way of approaching the bladder the path is well known, with its relations, and the a fine specimen of black mulberry oxalate of lime calculus, looked like a round rough piece of iron slag, and weighed operation skilfully performed. Suprapubic lithotomy provides for the removal of a large stone, of such size as could nearly an ounce. Choice of operation lithotrity or lithotomy.. ; lateral, not be removed by lithotrity, however prolonged or repeated. median, or suprapubic.-Before proceeding to remove a stone But, having regard to the pathway of operation, experience from the bladder, certain clear and definite views must be has shown, and quite recently, that the bladder cannot held as to the conditions which should determine the kind of be entered above the pubes always, without wounding the operation, seeing that the circumstances which lead to this peritoneal reflexion, even when the bladder is raised by the selection will obviously affect, for better or worse, all the fullest distension, almost to the point of bursting, and contingencies of difficulty and adverse consequences which propped up from below by an equally distended Petersen’s are associated with the particular method, but which are rectal bag. Then, again, the known risk of urinary infiltrareferable rather to the questionable fitness of the case, and tion has proved to be a not uncommon after-consequence of thence the prior judgment of the operator. In connexion the suprapubic incision, and certainly should not be an with the relative merits of lithotrity and lithotomy, what- after-thought in the mind of the surgeon who is about to ever method be adopted, no question can have more practical operate by this route. significance than with regard to the size and the density of Apart from the kind of calculus, as determining the choice the calculus, coupled with the state of the bladder and urinary of operation, of less direct importance may be reckoned the tract throughout-the combination of factors which shall state of the bladder and kidneys, cystitis depending far oe more favourable for the performance and after safety of more on the continued presence of stone fragments after the one or the other of these operations. The wide difference lithotrity than arising from this operation. The complete of results in the hands of experienced operators may be evacuation of the bladder would place the rapid method on
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operation of lithotomy. So, likewise, and oxalate of lime, each weighing more than three ounces. nephritis pyelitis, whether due to the extension of vesical But these are quite exceptional cases, and in the hands inflammation up the ureters, or occurring from reflex vaso- of an exceptional lithotritist. Success in crushing and motor influence on the kidney, is alikethe expression of vesical evacuating such calculi might well place some other operairritation. The symptoms betokening renal irritation, by tors in mourning. The average lithotritist, tackling either rigors, lumbar pain, with ureamic blood-poisoning, proceed of those hardened sinners, would certainly have left some from the bladder, and all the significance of kidney mischief portion of the enemy in the bladder; ay, and even aftera is lost in the prior question of entire removal of the calculus second attack, an angular fragment or two might still be from the organ below. lodged. When the surgeon, who is about equally apt in But when, in any case, the hardness of a calculus would crushing or cutting, has to encounter a big, brazen mulberry be adverse to lithotrity-unless the operation can be com- calculus, or its almost as formidable uric acid rival, instead pleted, and the bladder be certainly emptied of all frag- of spending an hour and a half or longer in lithotrity, ments, and when the size of the calculus places it beyond without then clearing out the bladder, I would recom. lithotomy, otherwise than through the perils of the supra- mend him to try lateral lithotomy, with the additional pubic adventure,-can the old lateral operation of lithotomy rectangular incision of the prostate to the right side, and be modified and adapted for the removal of a stone, whose capture the enemy in a few minutes. dimensions may require further space than usual for its I may take another opportunity of referring to the diffiextraction, without any untoward consequences? The culties and dangers pertaining to lithotrity and lithotomy perineal incision itsalf will, of course, be sufficient ; and in the various methods of operation. the prostatic incision may be safely extended backwards to Connaught-square, W. the very neck of the bladder, notching the elastic ring, but within the boundary of the fascial investment of the A MEDIAN LITHOTOMY. prostate; the incision, thus limited, admitting readily of a dilatation with the enlargement, by tunneling finger, BY REGINALD HARRISON, F.R.C.S, without dividing or rupturing the elastic ring. But the SURGEON TO THE LIVERPOOL ROYAL INFIRMAEY. opening thus formed by this well-defined incision and dilatation may be further enlarged to twice the size THE recent movement to revive the suprapubic operation by a rectangular incision from the middle of the first towards the other side of the prostate. In a prostate of for stone in the bladder, under somewhat altered circum. average dimensions the usual lateral incision may be one has been doubtless prompted with the view of inch, admitting of the extraction of a calculus which stances, shall weigh an ounce and a half ; and the rectangular diminishing the mortality connected with the removal of incision, in the middle of the right half of the pros- those stones from the bladder which cannot be effected by tate, having nearly the same extent-another inch,- crushing, and of substituting an operation which is free will provide the additional space for the extraction of a from the difficulties and risks which, either rightly or stone double the size, should the necessity arise in this have been with lateral lithotomy. That associated wrongly, stage of the_operation. The valvular opening thus formed there 1 are grounds for possessing an alternative is evident for of a room the calculus as passage gives, therefore, ample I a study of some statistics and records of the latter large as may be met with. This rectangular incision is notfrom the incision which was practised occasionally by Martineau4operation. That the lateral method for stone in adults has and Liston, who divided the right side of the prostate down-been found to be a proceeding attended with a considerable towards the right ischial tuberosity, forming, with the wards of in some instances, it is stated, degree fatality, reaching similar section of the left side, a double lateral section of the to a 35 death-rate of cent., there can be no doubt. per prostate. Theobjectionto that direction of the secondincision to the right is the liability of wounding the rectum, now Further, records of this operation show that the mortality that the prostate is not held up by the staff, and has arisen very largely out of complications having an the bowel protected also by the finger, as when in the act of evident relation to the difficulties with which the operation making the ordinary lateral incision alone in the left half was performed. For instance, a well-executed lateral of the prostate. The semilunar prostatic incision, by the operation where everything is straightforward is about "bilateral operation" of Dupuytren, has obviously a different the safest operation of- any magnitude in surgery; shape, and the downward direction of the section on either and in proportion with the degree of deviation from the side, in using the covered double-bladed lithotome, is very standard that circumstances render inevitable may its liable to touch the vasa deferentia or the seminal vesicles, fatality be measured. In proof of this let me mention the and emasculate the patient. Notching the margins of the chief early causes of death after lithotomy. Hemorrhage, ordinary left lateral incision, obliquely, above and below the primary and secondary; cellulitis and peritonitis arising " quadrilateral section" of the prostate, advocated by Vidal from damage done by the knife, as when the latter is de Cassis, is a procedure which involves no such risk; but allowed to miss or leave the staff and to pass behind or nickings with the knife in those situations, to ease the for- through the bladder, not mentioning the rectum; rupture ceps for the extraction of a large stone, might readily cut the of the urethra and failure to enter the bladder, as when fascial investment of the prostate above or the rectum below. these parts are telescoped by the finger of the operator; The additional space afforded by the rectangular section and, lastly, sepsis. With the exception of the last-mentioned passing transversely across the right half of the prostate cause, which is largely determined by the nature of the is fully equivalent to that which is given in either of these incisions made, probably all the others are avoidable, and ways, and is entirely free from any danger. It is easily seldom occur save in connexion with an operation the accomplished. When, in the extraction of a large stone, doing of which might be improved upon. Apart, however, the forceps is found to be fixed somewhat firmly in the from these difficulties and contingencies, there is a necessity ordinary lateral opening in the prostate, the second cut for carefully considering our means of removing stones from the bladder by the frequency with which recurrences take can be made by sliding a blunt-pointed knife along the the it not of inner and outwards, blade, place after lithotrity, even when the operation has been convexity carrying downwards, in the middle of the right half of the prostate. practised by experienced hands. Such recurrences bave If there be any doubt as to the bearing of the blade, a little been recentlv stated as amounting to about 13 per cent. traction with the forceps will make the prostate bulge When we consider the rarity of stone relapses after lithoforwards sufficiently to bring that part actually into view tomy, as compared with lithotrity, we have the best reason in a perineum of the ordinary depth. By this second for critically studying the former operation with the riev transverse incision bruising of the vesical neck is prevented, of rendering it simple and efficient. I think it will be the risk of urinary infiltration from a too free left lateral generally admitted that the easiest and simplest method of incision in the backward direction is avoided, and the entering the bladder, say for the purpose of exploring i’ extraction of the stone is effected without fracture and with the finger, is that known as median perineal urethrosplintering in the bladder, or in drawing it through the tomy, or incorrectly as median cystotomy. By this pitf the finger may be readily passed into the bladder withoat prostate. By the operation of lithotrity large stones of the hardest risk. As I have now practised this operation for the relief kind have been pulverised, and the bladder completely of cystitis, for the exploration of tumours of the bladder emptied. That operation may be credited in Freyer’s prac- and prostate, for prostatotomy and prostatectomy, a very tice with having thus got rid of calculi formed of uric acid considerable number of times, I think my experience ha: a
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