Clinical
Records.
i
INTERESTING
SOME
THE
BLADDER.
t.K.S.E., Surgeon (Read
at a
meeting of
REMOVAL OF A THE
to
METHOD
NEPHRITIS AND
58,
was
ON
THE
His
IN
Greig Smith, M.A.,
Royal lnhrmary.
OVER
NINE
OUNCES
BY
IN A PATIENT WITH DISCHARGING
TENTH
EMPYEMA.
DAY.
sent to me with what
be caries of the ribs.
STONE
Medico-Chirurgical Society.)
STONE WEIGHING
DEATH
yet.
By J.
OF
to the Bristol
the Bristol
SUPRA-PUBIC
SUPPURATIVE
J. T.,
CASES
history
was
supposed
was, that for ten
years he had been more or less of an invalid, but that six months previously he had been taken seriously ill
being very ill for some weeks, with great pain 011 the right side and difficult breathing, he suddenly coughed up large quantities of pus, and then he improved a little. Soon after, an abscess burst between the 7th and 8th ribs in the axillary line; and the sinus had continued open ever since, discharging large quantities of thick pus. When I first saw him, he was so much exhausted after a long journey that a minute examination was impossible. However, the existence of dulness, hardness, and some oedema in the right loin, between the crest of with
a
pulmonary
trouble.
After
/
178
STONE
the ilium and the
BLADDER.
IN THE
made
ribs,
me
look to the
kidney.
I diagnosed suppurative nephritis the pus having from the kidney-capsule, burrowed its way upwards :
diaphragm into the pleura, and through the lung. This diagnosis the
medical attendant.
of which he
turition,
questioning, way. For
Pus in the
a
I
few
days
I communicated to his
urine,
informed
thought might
escaped through ultimately having burst
be
me
and
frequent after
only
mic-
direct
accounted for in this
further examination
was
impossible,
he continued very weak and ill. A probe entered the sinus upwards for eight inches, and could be moved freely as
pleural cavity. I inserted a drainage tube, and put the patient on stimulating diet. Questioned as to the possibility of stone in the bladder, in all directions in the
he told
me
that he had had what his medical advisers
(and he had had many) called he had been that
frequently sounded,
quite recently one of his
habit of was no
an
washing
medical
out his bladder.
stone, and he
begged pain. me
it gave him so much blood in the urine.
as
irritable bladder; that
and
no
stone
men
He
found; and
had been in the
was
not to pass
He had
certain there
an
instrument,
never
noticed
The
finger in the rectum soon settled the diagnosis. thing felt was a large stone, lying almost like a polypus in the rectum, and blocking its calibre. The bladder was evidently drawn out like a Florence flask, the stone occupying its fundus. A short-beaked sound, introduced point backwards and tilted upwards?in the directions reverse to the ordinary method?came in conThe first
tact
with the stone, but could
not measure its
size,
on
account of the contracted state of the bladder. The
diagnosis
was
now, that the stone had set up the
STONE
IN
trouble?that it
kidney
under all the
THE
was a
BLADDER.
backward I
And, operate. I
nephritis.
refused to
circumstances, lithotomy
to him that the
explained
179
alone would be
a
very serious operation for a man in fair condition, but that in his case it would almost certainly be fatal. And when the stone would
further
require
that also
was
a
were
The
suppurating kidney
while
operation ; an
the empyema,
as to
I further
serious condition.
that the administration of
lungs
the
removed,
was
anaesthetic to
explained
a man
whose
not sound was attended with risk.
patient was not strong enough to
return to his
home,
He had little
and he continued under my care. sleep, and less to waked half-hour or micturate, being up every which the for some time awake pain by being kept At every visit he urged me to if were only to relieve him of his agony and it operate, give him a few hours' consecutive sleep. His medical followed micturition.
man
advised
gave
me
colleague who opinion thought it right to October 12th, I therefore operated by the
operation,
On
operate.
supra-pubic by
was
means
of
attached to the
in,
then
inserted,
dissection near
was
first washed out with an
irrigator,
irrigator
rapidly made,
irrigation-reservoir was rapidly distended, seen to
The
tube.
being left rectal bag was The ordinary
partially divided was exposed, the
and the recti
elevated
a
while the
be carried
boro-glyceride
the catheter
When the bladder
was
few
feet,
and the bladder
peritoneal
upwards.
fold could be
When distension placed on the level
sufficient, the irrigator simply bladder, ligation of the penis being quite unnecessary. Lister's sinus-forceps was gently insinuated through the
was
of the A
friend and
and distended with water.
their insertion.
felt and
a
method.
The bladder solution
and
the benefit of his
was
l8o
IN
STONE
THE
BLADDER.
bladder, and separated them ; while by pulling forward, they gave easy opportunity for the placing of two catch forceps at the sides of the opening. The opening was then enlarged, chiefly downwards, by scissors. The stone was first tilted on its side by the finger, and then extracted by long flat-bladed lithotomy forceps. coats of the
the bladder-walls
The wound in the bladder
extremity
and fascia
skin,
It
sutures.
friability
was
attached to the upper
of the abdominal wound ;
was
bladder-wall, muscles, being gathered together in the same
not
possible,
of the vesical
on
tissue,
account of the extreme
to
satisfactorily
unite the
wall of the viscus to the abdominal wound in its lower
portion.
A
and the
patient
bladder
edges
large drainage
was
laid
rubbed
was
his side.
on
placed
in the
bladder,
The interior of the
boro-glyceride, and the neighbouring skin freely smeared
over
of the wound and
tube
with
with the pure material. When the patient was first seen, a few hours afterwards, he was breathing with great difficulty, bronchial rales
being
twenty-four and
more
audible all hours his
cedematous.
over
seemed to get steadily more Then, with the help of strong
lungs
stimulating expectorants,
he
mucus, and for the first four
sleeping
almost
the room, and for the first
constantly,
began to get up a little days he greatly improved, and
expressing
himself
as
being delighted with the relief afforded. But about the sixth day the expectoration somewhat suddenly became more abundant and quite purulent. I judged that the old communication with the lung had re-opened. He could In spite of every breathe only in the sitting position.
therapeutic means, his lungs got more and more with purulent material, and he died asphyxiated.
laden
STONE
IN
THE
l8l
BLADDER.
The wound had
progressed most satisfactorily, never showing a sign of redness, and healing perfectly, all except a small sinus, through which clear urine trickled. He had begun to pass a little through the penis. It him at even his fits all, during scarcely pained prolonged of coughing. A better result, so far as the operation was concerned, could scarcely have been wished for; it certainly was not expected. After the less
freely,
favour of the
post-mortem This
operation,
in
spite re-opening
examination
was
drainage;
of the old was
discharged
this also
pulmonary
was
fistula.
in A
not held.
the fifth occasion
supra-pubic lithotomy; so
the sinus in the side
of free
and
on
which I had
nothing
has
performed impressed me
much with the excellence of this method
as
the local
result in this Considering the size of the stone, and the nature of the enormously thickened and noncase.
distensile bladder
walls,
the
proceeding
was
peculiarly
rapid. In any case, it was the only feasible Crushing was out of the question, and perineal
easy and method.
lithotomy,
without
crushing,
Remarks.?I dare
would have been
now to
say in
impossible.
what I have
public, private, that perineal lithotomy is, in my opinion, a grand surgical error. Ever since I have had an opportunity of performing a major operation, I have spoken against perineal lithoalways
said in
A surgeon to a large general hospital for seven years, I have never operated for stone by perineal section. In every case where crushing was out of the question?
tomy.
and such
cases are
pubic operation.
very few?I have performed the supraThis opinion I held before Bigelow
the field: his advent has confirmed my practice. I have often heard an excellent surgeon, now dead,
came on
182
stone
and much
respected
in
the
bladder.
and admired
he had often to finish
a
by many of us, say that colleague's lithotomies by curing
Such sequences of lithoor their fistulse. somehow seemed to gravitate towards him : he put tomy it down to the mode of operating by the median
their strictures
method. his
Very possibly some one else will done by the lateral method. each case the operations were
cases
in
that
and the
immediate
results
have to treat It
is certain
as
brilliantly
as performed, good, art could and about. science And yet as surgical bring only a few months ago, in our Infirmary, a colleague had to treat a case of perineal fistula (fortunately with success) for a patient on whom lithotomy had been performed by
were
of these surgeons some ten years ago. In my own comparatively limited experience, I have seen three cases
one
fistula, and four of urethral stricture, all following perineal lithotomy. It is undoubtedly true that stricture, fistula, and sexual incompetence are by no means rare sequences of A London hospital surgeon has perineal lithotomy. said that in 200 cases in which he had perrecently
of
formed
known any of I would venture to affirm that a
perineal lithotomy,
these results follow.
he had
never
written statement from each of these
patients
would
give
very different information. That the seminal ducts may be divided, and the urethra be cut, bruised, or torn, with impunity, is dead against all that we know of pathology,
and
physiology
as
well.
however, a consideration of these remote weighed so much with me, as the plain, palpable, straightforward fact, that in lateral lithotomy we sought a devious and dubious, not to say hap-hazard, It
was
not,
results which
mode of entrance into the
bladder,
when
we
had
provided
STONE
IN
THE
183
BLADDER.
and
straightforward one over the pubes. If the results from the high operation were worse than the results from the low, then I felt certain that this was because of some error in technique. If only one tithe of the anatomical study and description which has been spent on the perineum had been spent on the supra-pubic It was terror space, the result might have been different. of the peritoneum, probably, which drove surgeons from In respect of the operation the supra-pubic operation. in question, Lister was the first to dispel this terror; to him, without a doubt, must be awarded the merit of a
simple
having re-introduced the supra-pubic
method of
One of my most treasured possessions is 1722, of Cheselden's Treatise on the High
a
lithotomy.
copy, dated
Operation for operation, I trace of the lateral method the resumption by others. Cutting on the Gripe," as the old Roman and Greek operation was called; dignified into a surgical procedure by the major operation of Marian in 1524; degenerated into semi-quackery by Frere Jacques in 1697, was, in its anaStone.
To his abandonment of this
"
tomical outcome, lateral
lithotomy.
Cheselden's fresh
young ideas were theoretically correct; where he failed in practice, from ignorance of now ascertained principles of surgery, he took the intelligible course of following on a sound anatomical basis the palpably successful practice of ancients and
tion,
quacks. The real inventor of the opera(1561), successful as he was, did not
Pierre Franco
Cheselden himself even, advise any one to follow him. after writing such a treatise, and with his (for those days) of anatomy, abandoned it for the And herein he followed his lights: he
complete knowledge
lateral method. knew nothing of the germ theory; his vulnerary decoctions were aseptic, but not antiseptic; he did not know
STONE
184
IN
THE
BLADDER.
how to avoid the
peritoneum in operating; protect the supra-pubic wound
and he knew
not how to
in the after-
treatment.
Had he known these
things,
he would
never
practice of those years when his at its best, and his hands were most skilful.
have abandoned the intellect
was
Anatomy
rose
in the
schools,
and the
perineum was muscles,
dissected and described in all its intricacies of
fascise, arteries,
description
and
could
nerves.
never
But all this dissection and
make lateral
lithotomy
more
than
dark, or at best a cutting by rule of thumb if ?or, you like, by guidance of staff and forefinger. Now this is fortuitous surgery. True, in children at least, the chances have been highly favourable, the recoveries a
stab in the
have been numerous, and the immediate results favourable. But we ought to take congnisance of remote results. And
being done. Incompetence, stricture, and even perineal fistula, must be counted among the possible results of lateral lithotomy. In the supra-pubic operation, the recovering patient is well, not only after the operation, but for ever afterwards. He has nothing to dread. The seminal ducts are intact, this is
now
the membranous urethra is undivided. is in it
an area
The bladder-scar
remote from urethra and seminal
harm whatever.
duct,
and
If its immediate
mortality closely approaches that of the perineal operation, the supra-pubic is the preferable. At present it is quite In the as good, and the rapidity of recovery is greater. have no I doubt whatever that, where crushing and future causes no
at all
immediate evacuation of the will
pubic lithotomy perineal operation. In the operation
of
stone is out of court, supra-
uniformly
take the
place
supra-pubic lithotomy,
of
I think
the
we
have made in the last few years of its revival several
STONE
IN
THE
185
BLADDER.
*
notable advances.
Foremost among these I would place of the bladder in children. In quite a consider-
suturing
able number of
union has been
primary
cases
obtained,
and in the great majority union has been complete within three weeks. In old people, and in cases of very large I
drainage is, these, healing will be
stones, supra-pubic in
even
suturing the opening; bladder-opening
and
the
in
more
the
think,
advisable.
But, by partially particularly by suturing
accelerated
stitches which
the
close
abdominal wound. The second advance is the in the urethra.
placed patients
of mine
I
primary
distension of the
am
rejection
sure
union
bladder, catheter during the night. was small, and healed up
was
caused
of the catheter
that twice in young
prevented by overby blocking of the
But the fistula which formed
quickly than does the lithotomy. I had several times perineal discussed the advisability of doing without the catheter, and had decided to try the experiment, when Mr. Barker's success solved its feasibility. Other cases have proved the more
wound in lateral
wisdom of his recommendation?one of them in my
own
practice. As to the rectal removal of
again
use
a
it,
bag, my mind large stone I
very but should
prefer
is not made up. In the do not think I should
instead the
fingers
of
an
assistant in the rectum, which would push the stone up to, or out of, the wound. And in such cases the bladder
tissues or
are
even
so
tear
friable that rectal distension them.
might damage
In children the bladder lies natu-
rally high, and I doubt if the rectal bag does much good. It steadies the parts, and, when the bladder is opened, it keeps forward the posterior wall, and brings it within easy reach of the finger. In the removal of 14
l86
STONE
IN
THE
bladder-tumours I have found
BLADDER.
that,
bag is very useful. What has usually been claimed
on
these
the
grounds,
rectal
the chief
advantage bag, namely, increasing of the supra-pubic interval, I should regard as the least. A little experience of peritoneal surgery soon teaches us how to recognise and push up that membrane in epicystotomy. The advantage of increasing this interval, at least, is only momentary: when the bladder collapses, after being opened, the increase of the interval is lost. Then the whole end may be attained by pushing the peritoneum as
of the rectal
inwards
CASE
on
the abdominal
OF CALCULUS BLADDER IN
The was
patient,
URETHRA WITH
GIRL
CALCULUS
EIGHT YEARS
IN
OLD.
eight, but small for her years, Bristol Royal Infirmary on Jan. 8th, of
from incontinence of urine.
Every quarter
she tried to pass water, but most of it dribbled away in the intervals. There was considerable pain, with marked tenesmus. The urine was often stained an
hour
A
girl
admitted to the
1887, suffering of
a
IN
cavity.
or so
with
blood, and blood was seen in the evacuations. Jan. 14th the child was put under the influence of chloroform. A probe passed into the bladder struck a On
stone of
considerable dimensions.
time that the urethra
coated with
was
phosphates,
long
It and
was
noted at the
rough, apparently
but urethral calculus
was
not
diagnosed. On
through
Jan. 17th
I
the urethra.
proceeded A
to
remove
small incision
the calculus
was
made
by
STONE
scissors
on
THE
IN
187
BLADDER.
the under surface of the urethral
the canal behind
was
dilated with
a
Lister's
During dilatation I was surprised to tiguity with the forceps, which was I concluded that this
extracted.
find
a
orifice, and sinus-forceps. stone in con-
at once and
was
easily
the stone in the
bladder, and that the urethra was very short. Its curious shape (as shown in the drawing, made to scale) and the existence of a facet on its surface suggested the existence of another stone. I pushed my little finger, which was as large as the parts would admit without risk of laceration, and was able to feel at its tip a small opening: a probe pushed through this opening at once came upon a stone which was evidently closely embraced by the walls of the bladder, as in a saccule. I cautiously' dilated this opening with the finger sufficiently to admit the introduction of a polypus-forceps, and by conjoined manipulation through rectum and over pubes endeavoured to place the between
stone
the
blades.
After
several
ineffectual
attempts the stone was caught, but it could not be tracted through the small opening without tearing it. therefore crushed it with
a
reality
piecemeal. This proceeding. The sac
the contracted
I
small
to remove it
delicate
ex-
lithotrite, and proceeded proved to be a difficult and in which the stone lay (in
bladder)
was not
in
a
line with the
it; no instrument could be sharp enough to enter it through the urethra. Washing out the fragments with a Bigelow's apparatus was also found impracticable. Most of the fragments were removed between the tip of the little finger and a small scoop, while a finger in the rectum pushed the bladder forwards. The smallest fragments urethra,
but behind and below
found with
were
a
finally
curve
The very small size of the and friability, made it imperative
washed out.
parts, and their delicacy
14
*
l88
proceedings gentleness.
took the anaesthetic very
patient
after the commencement of the marked
epileptic
The
patient
uneventful recovery. complete control over the
an
later she
days
carefully
discharged well. operation was over
examined did it strike
of combined
case
well-
By Feb. bladder, and the
that this
me
was a
urethral and vesical calculus.
of the calculus first
shape
a
was
Remarks.?Not till the calculi
operation
badly; shortly she had
fit. made
2nd she had recovered and three
BLADDER.
should be carried out with extreme
that all The
THE
IN
STONE
and the
removed,
The
polished
the knob which sprang from its inner extremity, showed that' it had been partly encapsuled, and that a facet
on
second stone rubbed from the saccule
on
against
the knob which
in the urethra I have
no
now
protruded
That this stone
which it rested.
It
doubt.
lay quite
lay
close to
the orifice of the urethra ; and the urethral canal had gradually distended and elongated by the growing
been
stone,
so
that the neck of the bladder
distance backwards.
It
and mucus, and the
probe
glided easily
over
first used in
it without
pushed epithelial
was
coated with
was
sounding
some
debris
the stone
the characteristic
producing
sensation. So
firmly
was
the
bladder
second stone that sacculation stone could be
readily palpated
rectum and the hand
over
contracted
was at
the
first
The
diagnosed.
between the
pubes,
around the
finger
in the
but from the
con-
tinued straining and struggling of the child (profound anaesthesia at once induced alarming symptoms) it from the grasp And when forceps had
slipped sible
to
pull
it
through
in the most
gripped it,
the
narrow
it
aggravating way. simply impos-
was
orifice at the neck of
--WALL OF
hJ J
vesical'^ +
calculus]
WALL
OF^j
'\\'
ft
URETHRA
CALCULUS^ IN
URETHRA)
BLADDER
\
\\ix|
'?!
TUMOUR IN
the
bladder,
dilated
as
189
THE ORBIT.
it had been
by
the
finger.
It
was
necessary to crush ; and to remove the fragments one by through the narrow opening without causing injury
one
to the delicate
difficult
tissues,
surgical operations
Much time
was
symptoms aris.ing tion
was one
occupied
the
of the most tedious and
in which I have been
wasted in
attending
from the
anaesthesia;
greater part
of
an
(To be continued.)
to the
engaged,
dangerous
the whole opera-
hour.
Records.
i
INTERESTING
SOME
THE
BLADDER.
t.K.S.E., Surgeon (Read
at a
meeting of
REMOVAL OF A THE
to
METHOD
NEPHRITIS AND
58,
was
ON
THE
His
IN
Greig Smith, M.A.,
Royal lnhrmary.
OVER
NINE
OUNCES
BY
IN A PATIENT WITH DISCHARGING
TENTH
EMPYEMA.
DAY.
sent to me with what
be caries of the ribs.
STONE
Medico-Chirurgical Society.)
STONE WEIGHING
DEATH
yet.
By J.
OF
to the Bristol
the Bristol
SUPRA-PUBIC
SUPPURATIVE
J. T.,
CASES
history
was
supposed
was, that for ten
years he had been more or less of an invalid, but that six months previously he had been taken seriously ill
being very ill for some weeks, with great pain 011 the right side and difficult breathing, he suddenly coughed up large quantities of pus, and then he improved a little. Soon after, an abscess burst between the 7th and 8th ribs in the axillary line; and the sinus had continued open ever since, discharging large quantities of thick pus. When I first saw him, he was so much exhausted after a long journey that a minute examination was impossible. However, the existence of dulness, hardness, and some oedema in the right loin, between the crest of with
a
pulmonary
trouble.
After
/
178
STONE
the ilium and the
BLADDER.
IN THE
made
ribs,
me
look to the
kidney.
I diagnosed suppurative nephritis the pus having from the kidney-capsule, burrowed its way upwards :
diaphragm into the pleura, and through the lung. This diagnosis the
medical attendant.
of which he
turition,
questioning, way. For
Pus in the
a
I
few
days
I communicated to his
urine,
informed
thought might
escaped through ultimately having burst
be
me
and
frequent after
only
mic-
direct
accounted for in this
further examination
was
impossible,
he continued very weak and ill. A probe entered the sinus upwards for eight inches, and could be moved freely as
pleural cavity. I inserted a drainage tube, and put the patient on stimulating diet. Questioned as to the possibility of stone in the bladder, in all directions in the
he told
me
that he had had what his medical advisers
(and he had had many) called he had been that
frequently sounded,
quite recently one of his
habit of was no
an
washing
medical
out his bladder.
stone, and he
begged pain. me
it gave him so much blood in the urine.
as
irritable bladder; that
and
no
stone
men
He
found; and
had been in the
was
not to pass
He had
certain there
an
instrument,
never
noticed
The
finger in the rectum soon settled the diagnosis. thing felt was a large stone, lying almost like a polypus in the rectum, and blocking its calibre. The bladder was evidently drawn out like a Florence flask, the stone occupying its fundus. A short-beaked sound, introduced point backwards and tilted upwards?in the directions reverse to the ordinary method?came in conThe first
tact
with the stone, but could
not measure its
size,
on
account of the contracted state of the bladder. The
diagnosis
was
now, that the stone had set up the
STONE
IN
trouble?that it
kidney
under all the
THE
was a
BLADDER.
backward I
And, operate. I
nephritis.
refused to
circumstances, lithotomy
to him that the
explained
179
alone would be
a
very serious operation for a man in fair condition, but that in his case it would almost certainly be fatal. And when the stone would
further
require
that also
was
a
were
The
suppurating kidney
while
operation ; an
the empyema,
as to
I further
serious condition.
that the administration of
lungs
the
removed,
was
anaesthetic to
explained
a man
whose
not sound was attended with risk.
patient was not strong enough to
return to his
home,
He had little
and he continued under my care. sleep, and less to waked half-hour or micturate, being up every which the for some time awake pain by being kept At every visit he urged me to if were only to relieve him of his agony and it operate, give him a few hours' consecutive sleep. His medical followed micturition.
man
advised
gave
me
colleague who opinion thought it right to October 12th, I therefore operated by the
operation,
On
operate.
supra-pubic by
was
means
of
attached to the
in,
then
inserted,
dissection near
was
first washed out with an
irrigator,
irrigator
rapidly made,
irrigation-reservoir was rapidly distended, seen to
The
tube.
being left rectal bag was The ordinary
partially divided was exposed, the
and the recti
elevated
a
while the
be carried
boro-glyceride
the catheter
When the bladder
was
few
feet,
and the bladder
peritoneal
upwards.
fold could be
When distension placed on the level
sufficient, the irrigator simply bladder, ligation of the penis being quite unnecessary. Lister's sinus-forceps was gently insinuated through the
was
of the A
friend and
and distended with water.
their insertion.
felt and
a
method.
The bladder solution
and
the benefit of his
was
l8o
IN
STONE
THE
BLADDER.
bladder, and separated them ; while by pulling forward, they gave easy opportunity for the placing of two catch forceps at the sides of the opening. The opening was then enlarged, chiefly downwards, by scissors. The stone was first tilted on its side by the finger, and then extracted by long flat-bladed lithotomy forceps. coats of the
the bladder-walls
The wound in the bladder
extremity
and fascia
skin,
It
sutures.
friability
was
attached to the upper
of the abdominal wound ;
was
bladder-wall, muscles, being gathered together in the same
not
possible,
of the vesical
on
tissue,
account of the extreme
to
satisfactorily
unite the
wall of the viscus to the abdominal wound in its lower
portion.
A
and the
patient
bladder
edges
large drainage
was
laid
rubbed
was
his side.
on
placed
in the
bladder,
The interior of the
boro-glyceride, and the neighbouring skin freely smeared
over
of the wound and
tube
with
with the pure material. When the patient was first seen, a few hours afterwards, he was breathing with great difficulty, bronchial rales
being
twenty-four and
more
audible all hours his
cedematous.
over
seemed to get steadily more Then, with the help of strong
lungs
stimulating expectorants,
he
mucus, and for the first four
sleeping
almost
the room, and for the first
constantly,
began to get up a little days he greatly improved, and
expressing
himself
as
being delighted with the relief afforded. But about the sixth day the expectoration somewhat suddenly became more abundant and quite purulent. I judged that the old communication with the lung had re-opened. He could In spite of every breathe only in the sitting position.
therapeutic means, his lungs got more and more with purulent material, and he died asphyxiated.
laden
STONE
IN
THE
l8l
BLADDER.
The wound had
progressed most satisfactorily, never showing a sign of redness, and healing perfectly, all except a small sinus, through which clear urine trickled. He had begun to pass a little through the penis. It him at even his fits all, during scarcely pained prolonged of coughing. A better result, so far as the operation was concerned, could scarcely have been wished for; it certainly was not expected. After the less
freely,
favour of the
post-mortem This
operation,
in
spite re-opening
examination
was
drainage;
of the old was
discharged
this also
pulmonary
was
fistula.
in A
not held.
the fifth occasion
supra-pubic lithotomy; so
the sinus in the side
of free
and
on
which I had
nothing
has
performed impressed me
much with the excellence of this method
as
the local
result in this Considering the size of the stone, and the nature of the enormously thickened and noncase.
distensile bladder
walls,
the
proceeding
was
peculiarly
rapid. In any case, it was the only feasible Crushing was out of the question, and perineal
easy and method.
lithotomy,
without
crushing,
Remarks.?I dare
would have been
now to
say in
impossible.
what I have
public, private, that perineal lithotomy is, in my opinion, a grand surgical error. Ever since I have had an opportunity of performing a major operation, I have spoken against perineal lithoalways
said in
A surgeon to a large general hospital for seven years, I have never operated for stone by perineal section. In every case where crushing was out of the question?
tomy.
and such
cases are
pubic operation.
very few?I have performed the supraThis opinion I held before Bigelow
the field: his advent has confirmed my practice. I have often heard an excellent surgeon, now dead,
came on
182
stone
and much
respected
in
the
bladder.
and admired
he had often to finish
a
by many of us, say that colleague's lithotomies by curing
Such sequences of lithoor their fistulse. somehow seemed to gravitate towards him : he put tomy it down to the mode of operating by the median
their strictures
method. his
Very possibly some one else will done by the lateral method. each case the operations were
cases
in
that
and the
immediate
results
have to treat It
is certain
as
brilliantly
as performed, good, art could and about. science And yet as surgical bring only a few months ago, in our Infirmary, a colleague had to treat a case of perineal fistula (fortunately with success) for a patient on whom lithotomy had been performed by
were
of these surgeons some ten years ago. In my own comparatively limited experience, I have seen three cases
one
fistula, and four of urethral stricture, all following perineal lithotomy. It is undoubtedly true that stricture, fistula, and sexual incompetence are by no means rare sequences of A London hospital surgeon has perineal lithotomy. said that in 200 cases in which he had perrecently
of
formed
known any of I would venture to affirm that a
perineal lithotomy,
these results follow.
he had
never
written statement from each of these
patients
would
give
very different information. That the seminal ducts may be divided, and the urethra be cut, bruised, or torn, with impunity, is dead against all that we know of pathology,
and
physiology
as
well.
however, a consideration of these remote weighed so much with me, as the plain, palpable, straightforward fact, that in lateral lithotomy we sought a devious and dubious, not to say hap-hazard, It
was
not,
results which
mode of entrance into the
bladder,
when
we
had
provided
STONE
IN
THE
183
BLADDER.
and
straightforward one over the pubes. If the results from the high operation were worse than the results from the low, then I felt certain that this was because of some error in technique. If only one tithe of the anatomical study and description which has been spent on the perineum had been spent on the supra-pubic It was terror space, the result might have been different. of the peritoneum, probably, which drove surgeons from In respect of the operation the supra-pubic operation. in question, Lister was the first to dispel this terror; to him, without a doubt, must be awarded the merit of a
simple
having re-introduced the supra-pubic
method of
One of my most treasured possessions is 1722, of Cheselden's Treatise on the High
a
lithotomy.
copy, dated
Operation for operation, I trace of the lateral method the resumption by others. Cutting on the Gripe," as the old Roman and Greek operation was called; dignified into a surgical procedure by the major operation of Marian in 1524; degenerated into semi-quackery by Frere Jacques in 1697, was, in its anaStone.
To his abandonment of this
"
tomical outcome, lateral
lithotomy.
Cheselden's fresh
young ideas were theoretically correct; where he failed in practice, from ignorance of now ascertained principles of surgery, he took the intelligible course of following on a sound anatomical basis the palpably successful practice of ancients and
tion,
quacks. The real inventor of the opera(1561), successful as he was, did not
Pierre Franco
Cheselden himself even, advise any one to follow him. after writing such a treatise, and with his (for those days) of anatomy, abandoned it for the And herein he followed his lights: he
complete knowledge
lateral method. knew nothing of the germ theory; his vulnerary decoctions were aseptic, but not antiseptic; he did not know
STONE
184
IN
THE
BLADDER.
how to avoid the
peritoneum in operating; protect the supra-pubic wound
and he knew
not how to
in the after-
treatment.
Had he known these
things,
he would
never
practice of those years when his at its best, and his hands were most skilful.
have abandoned the intellect
was
Anatomy
rose
in the
schools,
and the
perineum was muscles,
dissected and described in all its intricacies of
fascise, arteries,
description
and
could
nerves.
never
But all this dissection and
make lateral
lithotomy
more
than
dark, or at best a cutting by rule of thumb if ?or, you like, by guidance of staff and forefinger. Now this is fortuitous surgery. True, in children at least, the chances have been highly favourable, the recoveries a
stab in the
have been numerous, and the immediate results favourable. But we ought to take congnisance of remote results. And
being done. Incompetence, stricture, and even perineal fistula, must be counted among the possible results of lateral lithotomy. In the supra-pubic operation, the recovering patient is well, not only after the operation, but for ever afterwards. He has nothing to dread. The seminal ducts are intact, this is
now
the membranous urethra is undivided. is in it
an area
The bladder-scar
remote from urethra and seminal
harm whatever.
duct,
and
If its immediate
mortality closely approaches that of the perineal operation, the supra-pubic is the preferable. At present it is quite In the as good, and the rapidity of recovery is greater. have no I doubt whatever that, where crushing and future causes no
at all
immediate evacuation of the will
pubic lithotomy perineal operation. In the operation
of
stone is out of court, supra-
uniformly
take the
place
supra-pubic lithotomy,
of
I think
the
we
have made in the last few years of its revival several
STONE
IN
THE
185
BLADDER.
*
notable advances.
Foremost among these I would place of the bladder in children. In quite a consider-
suturing
able number of
union has been
primary
cases
obtained,
and in the great majority union has been complete within three weeks. In old people, and in cases of very large I
drainage is, these, healing will be
stones, supra-pubic in
even
suturing the opening; bladder-opening
and
the
in
more
the
think,
advisable.
But, by partially particularly by suturing
accelerated
stitches which
the
close
abdominal wound. The second advance is the in the urethra.
placed patients
of mine
I
primary
distension of the
am
rejection
sure
union
bladder, catheter during the night. was small, and healed up
was
caused
of the catheter
that twice in young
prevented by overby blocking of the
But the fistula which formed
quickly than does the lithotomy. I had several times perineal discussed the advisability of doing without the catheter, and had decided to try the experiment, when Mr. Barker's success solved its feasibility. Other cases have proved the more
wound in lateral
wisdom of his recommendation?one of them in my
own
practice. As to the rectal removal of
again
use
a
it,
bag, my mind large stone I
very but should
prefer
is not made up. In the do not think I should
instead the
fingers
of
an
assistant in the rectum, which would push the stone up to, or out of, the wound. And in such cases the bladder
tissues or
are
even
so
tear
friable that rectal distension them.
might damage
In children the bladder lies natu-
rally high, and I doubt if the rectal bag does much good. It steadies the parts, and, when the bladder is opened, it keeps forward the posterior wall, and brings it within easy reach of the finger. In the removal of 14
l86
STONE
IN
THE
bladder-tumours I have found
BLADDER.
that,
bag is very useful. What has usually been claimed
on
these
the
grounds,
rectal
the chief
advantage bag, namely, increasing of the supra-pubic interval, I should regard as the least. A little experience of peritoneal surgery soon teaches us how to recognise and push up that membrane in epicystotomy. The advantage of increasing this interval, at least, is only momentary: when the bladder collapses, after being opened, the increase of the interval is lost. Then the whole end may be attained by pushing the peritoneum as
of the rectal
inwards
CASE
on
the abdominal
OF CALCULUS BLADDER IN
The was
patient,
URETHRA WITH
GIRL
CALCULUS
EIGHT YEARS
IN
OLD.
eight, but small for her years, Bristol Royal Infirmary on Jan. 8th, of
from incontinence of urine.
Every quarter
she tried to pass water, but most of it dribbled away in the intervals. There was considerable pain, with marked tenesmus. The urine was often stained an
hour
A
girl
admitted to the
1887, suffering of
a
IN
cavity.
or so
with
blood, and blood was seen in the evacuations. Jan. 14th the child was put under the influence of chloroform. A probe passed into the bladder struck a On
stone of
considerable dimensions.
time that the urethra
coated with
was
phosphates,
long
It and
was
noted at the
rough, apparently
but urethral calculus
was
not
diagnosed. On
through
Jan. 17th
I
the urethra.
proceeded A
to
remove
small incision
the calculus
was
made
by
STONE
scissors
on
THE
IN
187
BLADDER.
the under surface of the urethral
the canal behind
was
dilated with
a
Lister's
During dilatation I was surprised to tiguity with the forceps, which was I concluded that this
extracted.
find
a
orifice, and sinus-forceps. stone in con-
at once and
was
easily
the stone in the
bladder, and that the urethra was very short. Its curious shape (as shown in the drawing, made to scale) and the existence of a facet on its surface suggested the existence of another stone. I pushed my little finger, which was as large as the parts would admit without risk of laceration, and was able to feel at its tip a small opening: a probe pushed through this opening at once came upon a stone which was evidently closely embraced by the walls of the bladder, as in a saccule. I cautiously' dilated this opening with the finger sufficiently to admit the introduction of a polypus-forceps, and by conjoined manipulation through rectum and over pubes endeavoured to place the between
stone
the
blades.
After
several
ineffectual
attempts the stone was caught, but it could not be tracted through the small opening without tearing it. therefore crushed it with
a
reality
piecemeal. This proceeding. The sac
the contracted
I
small
to remove it
delicate
ex-
lithotrite, and proceeded proved to be a difficult and in which the stone lay (in
bladder)
was not
in
a
line with the
it; no instrument could be sharp enough to enter it through the urethra. Washing out the fragments with a Bigelow's apparatus was also found impracticable. Most of the fragments were removed between the tip of the little finger and a small scoop, while a finger in the rectum pushed the bladder forwards. The smallest fragments urethra,
but behind and below
found with
were
a
finally
curve
The very small size of the and friability, made it imperative
washed out.
parts, and their delicacy
14
*
l88
proceedings gentleness.
took the anaesthetic very
patient
after the commencement of the marked
epileptic
The
patient
uneventful recovery. complete control over the
an
later she
days
carefully
discharged well. operation was over
examined did it strike
of combined
case
well-
By Feb. bladder, and the
that this
me
was a
urethral and vesical calculus.
of the calculus first
shape
a
was
Remarks.?Not till the calculi
operation
badly; shortly she had
fit. made
2nd she had recovered and three
BLADDER.
should be carried out with extreme
that all The
THE
IN
STONE
and the
removed,
The
polished
the knob which sprang from its inner extremity, showed that' it had been partly encapsuled, and that a facet
on
second stone rubbed from the saccule
on
against
the knob which
in the urethra I have
no
now
protruded
That this stone
which it rested.
It
doubt.
lay quite
lay
close to
the orifice of the urethra ; and the urethral canal had gradually distended and elongated by the growing
been
stone,
so
that the neck of the bladder
distance backwards.
It
and mucus, and the
probe
glided easily
over
first used in
it without
pushed epithelial
was
coated with
was
sounding
some
debris
the stone
the characteristic
producing
sensation. So
firmly
was
the
bladder
second stone that sacculation stone could be
readily palpated
rectum and the hand
over
contracted
was at
the
first
The
diagnosed.
between the
pubes,
around the
finger
in the
but from the
con-
tinued straining and struggling of the child (profound anaesthesia at once induced alarming symptoms) it from the grasp And when forceps had
slipped sible
to
pull
it
through
in the most
gripped it,
the
narrow
it
aggravating way. simply impos-
was
orifice at the neck of
--WALL OF
hJ J
vesical'^ +
calculus]
WALL
OF^j
'\\'
ft
URETHRA
CALCULUS^ IN
URETHRA)
BLADDER
\
\\ix|
'?!
TUMOUR IN
the
bladder,
dilated
as
189
THE ORBIT.
it had been
by
the
finger.
It
was
necessary to crush ; and to remove the fragments one by through the narrow opening without causing injury
one
to the delicate
difficult
tissues,
surgical operations
Much time
was
symptoms aris.ing tion
was one
occupied
the
of the most tedious and
in which I have been
wasted in
attending
from the
anaesthesia;
greater part
of
an
(To be continued.)
to the
engaged,
dangerous
the whole opera-
hour.
