No. 1743.

JANUARY 24, 1857.

Clinical LectureON THE

SEVERAL FORMS OF LITHOTOMY,Delivered in the Toronto General Hospital, Canada West,

during the winter of 1855-56,

BY W. R. BEAUMONT, F.R.C.S. ENG.,LATE PROFESSOR OF SURGERY IN THE UNIVERSITY OF TORONTO.

Extraction from the Bladder of Foreign Bodies which are notCalculous Form]ations; " Allarton’s Operation performed forthe Extraction frozn the Bladder of a piece of Glass Tube,2 3/10 inches long. Rapid Recovery.GENTLMEN,-For about ten years preceding the last two or

three, I was in the habit of delivering, once a week, in theToronto General Hospital, a clinical lecture on Surgery, and Ishall again take much pleasure in doing so, by which I shallbring before you the most important surgical cases which

may come under my care. And first I propose to speak to youof a series of cases of lithotomy and lithotrit,y, and of a fewother cases of operations on the urethra. Lithotomy is thename which for more than twenty centuries has been appliedto all forms of operations for the removal of vesical calculi byincision. It is the operation of " cutting for the stone." Li-

thotrity, which is of very recent invention, is the breaking ofa stone into fragments small enough to be expelled, or extractedffom the bladder through the unencised urethra. Lithotomy,at different periods, and by different operators, has been per-formed in many different ways :-

1st, and oldest of all, we have the method described byCelsus, called the Celsian, or lithotomy by the ’’ apparatusminor," which latter designation it acquired from the few in-struments used-viz., a scalpel and a hook. It is also called"cutting on the grip." The index and middle-fingers of theleft hand are passed into the rectum, the stone is felt, andpressed by the fingers into the neck of the bladder, and towardsthe surface of the perinseum, and then, without a staff- an in-cision is made through the perinæum and neck of the bladderupon the stone itself, by which opening the stone escapes, or isextracted by a hook. This method of operating was practisedby Ammonius, of Alexandria, 250 years or more before theChristian era.

2nd. In contradistinction to this we have the Marian ope-ration, invented by Johannis de Romanis about the year 1520,and shortly afterwards published by Marianus Sanctus, andwhich, from the number of instruments used, was called cuttingwith the "apparatus major." Allan, in his work on litho-tomy, calls this " the cruellest and most bloody operation that ever was performed on the human body." It might be cruel,but not the most bloody. A grooved staff was passed into thebladder, its convexity turned towards the left side of the peri-næum. An incision was then commenced immediatly behindthe scrotum, on the left side of the raphe, and carried back-wards to within two fingers’ breadtlz of the anus. Next, theaccelerator urinæ was cut, and the bulbous part of the urethraopened, the incision being continued through the adjoining partof the membranous portion of the canal. The rest of the ure-thra towards the bladder, and the neck of this viscus, werethen dilated by instruments to an extent sufficient to extractthe stone. It was, no doubt, a cruel operation for the extrac-tion of a large stone, and ill devised for the extraction of any,but with Allarton’s modifications, I believe it is neither cruelnor injudicious, for the removal of small stones.

3rd. There is the lateral operation ; that which has beenand still is, the most frequently performed. It has been sonamed from the incisions being made on one side of the peri-næum, prostate, and neck of the bladder, the left side, for con-venience, being chosen. Some say that it originated withFrere Jacques, a French ecclesiastic, who first operated inParis, in 16’97, and afterwards, upon an immense number ofpatients, it is said, nearly five thousand, at first with an enor-mous loss of life, but afterwards, when he had studied the ana- Itomy of the parts, with the most extraordinary success. Carpuestates, and it appears, correctly, that we are indebted for this ! operation, not to Frcre Jacques, but to Pierre Franco, of Pro- vence, who lived about 150 years before the former.

4th. There is the bilateral, in which both the lateral lobes othe prostate are cut. This operation was sometimes perfomeiby the late Baron Dupuytren, the greatest French surgeon of hiday, and, I believe, devised by him also. It has the advantageof making a larger opening in the prostate than that which imade in the lateral operation, and may, therefore, be desirablein cases where an unusually large stone is to be extracted.

5th. There is the supra-pubic, or high operation, which, iiis said, was first performed in Paris, in 1475, by Collot, and a:an experiment on a criminal, who recovered from the operationThe first account of this mode of operating was published b3Pierre Franco, about the year 1560. Franco first performed itand successfully, on a child, in whose bladder he found, afterperforming the lateral operation, a stone too large to be extracted by the wound in the neck of the bladder and perinmun.It would seem from this, that Franco had performed the lateraloperation long before the time of Frere Jacques. In the higloperation, an incision is made between the pyramidales abdominis, and then the anterior aspect of the body of the bladdeIis opened above the pubes, and in the mesial plane. It is onlyjustifiable in cases of enormously large calculi, and has veryrarely been performed since the lateral operation was improvedby Raw. Cheselden, and others, about 120 or 130 years ago.

6th. There is the recto-vesical operation, which was proposed in the sixteenth century, in a work published at Bâle,under the assumed name of Vegetius, of whom Haller writes:" Jubet per vulnus intestini recti et vesicæ aculeo lapidemejicere." About forty years ago, M. Sanson revived this ope-ration in France, and it was performed by him, and also byBaron Dupuytren, but not with an average satisfactory result,a large proportion of patients dying soon after the operation,or else recovering with a recto-vesical fistula. In this operationSanson, by his first method, cut the sphincter ani, and the ad-joining part of the rectum, after which he incised the bladderimmediately behind the prostate. Another method which heproposed was, after dividing the sphincter ani, to incise themembranous and prostatic portions of the urethra and the neckof the bladder, in the mesial plane, carrying his knife alongthe groove of a staff held exactly in this plane, which must beby far the best procedure of the two. This operation, like thesupra-pubic, seems only desirable in cases of very large calculi.For the extraction of such, Sir Benjamin Brodie expressed a

preference for this form of lithotomy over the high operation.7th. There is Allarton’s operation, which he first performed

in 1840, and twice since. It is a modification of the Marianmethod. These three cases were highly successful, the patientsbeing convalescent in a few days. The mode of operating Iwill detail to you in a case I am about to relate. It is saidthat M. de Borsft and Manzoni, in Italy, have lost only onepatient out of a hundred after a nearly similar operation.

Sth. There is the recto-urethral operation, which differs verylittle from Allarton’s-merely in the division of the sphincterani, which part is not cut in Mr. Allarton’s mode of operating.Mr. Lloyd, about eight months ago, performed the recto-urethral operation, at St. Bartholomew’s Hospital, in London,on a man, aged twenty, and without a bad symptom resulting.Some other methods of performing lithotomy have, no doubt,occasionally been adopted, but those which I have mentioned,are the only modes of operating which have obtained any con-sideration in the profession.The case to which I am about to call your attention is, I

believe, unique, as the patient is probably the first into whosebladder a glass catheter has been passed. I am glad to saythat the idea was his own. and not that of a member of ourprofession. Mr. Richard N-, aged twenty-six, a muscularhealthy man, residing in Brampton, near Toronto, was admittedinto the Toronto Hospital as a patient on the 8th of November,1855, having a piece of glass tube in his bladder, which he sup-posed was about an inch and a half in length. For a year be-fore he had been in the habit of passing for himself an elasticcatheter, having, or supposing that he had, stricture of theurethra. A glass-blower being in Brampton, my patient hadthe misfortune to conceive the idea of a glass catheter, and toget one made. This instrument he had used for a month safely,but at last broke it, in the act of withdrawing it from hisbladder, which happened the night before his admission intathe hospital, the piece being, he believed, at the time of frac-ture, partly in the urethra, as he could touch it with a wire notlong enough to reach the bladder. From the time of the acci-dent, micturition had been frequent, and caused him much painas he finished emptying his bladder, and some blood followedthe urine at each act of micturition. The broken end of the

glass was, no deabt, pressed by the contracting bladder againstits mucous membrane, and scratched it at each evacuation. He

82

had, therefore, some of the prominent symptoms of stone- viz.,frequent and painful micturition, and a slight discharge of bloodimmediately after each act. On admission, I passed very slowlyand gently, a No. 11 silver catheter, but did not touch theglass, so that I was sure it was not, as the patient supposed,partly in the urethra. In two or three days, by continuedrecumbence, and by voiding his urine as he lay on his back, hebecame much more free from pain, and blood ceased to flowafter micturition. This relief probably resulted from the pieceof glass falling from the neck of the bladder into its posteriorfundus, where its broken extremity would be less liable to bepressed during micturition against the mucous membrane. Idirected him to send for the remainder of the tube, in order tocompare it with the piece I might extract from his bladder, butit could not then be found.With the exception of urinary calculi, surgeons are very

rarely called on to extract foreign bodies from the bladder, andwhen thi3 does happen, such bodies are usually the nuclei ofstones. Sir Benjamin Brodie, in his work, " On Diseases ofthe Urinary Organs," says that he once assisted Mr. Keate inan operation for the removal from the bladder of a cylindricalpiece of sealing-wax, several inches long, which operation wasperformed soon after the wax had been passed into the bladder.South, in his translation of Chelius, states that Mr. Cline, sen.,operated at St. Thomas’s Hospital, in London, in February,1812, for the removal of a bullet from the bladder of a sailor,who had been shot in action in the July preceding. The ballwas found encysted on the left side of the bladder, much flat-tened, having passed through the ilium, and a small piece ofbone adhering to it. The patient recovered quickly. Myfriend and colleague, Staff-surgeon Widmer, has also told meof a gentleman of our profession, Dr. P--, who many yearsago lived in Toronto, and who, long before this time, when en-gaged in the Excise service in Ireland, was shot, the bulletlodging in the bladder, from which it was extracted by theusual operation for stone, I believe, by Sir Philip Crampton.Of all kinds of foreign bodies lodged in the bladder, I cannotconceive of any so fearful as a long and broken piece of glass,not only as regards the injury it may do to the bladder, butalso as regards the difficulty of its extraction.

For the removal of the piece of glass tube, in Nichol’s case,I performed, on Nov. 15th, Allarton’s operation-i. e., the

patient being placed in the usual position for lithotomy, andchloroform having been administered, I passed a large staffinto the bladder, and with it felt the glass. The staff (groovedon the convex side) was held in the mesial plane and hooked-up towards the symphisis pubis. Whilst pressing from therectum with the point of the left index-finger on the apex ofthe prostate, and against the staff, I pierced the raphe of theperinæum, close to the anterior margin of the anus, and carriedthe point of the knife, its back being towards the rectum, intothe groove of the staff, as nearly as I could guess, close to thefront of the prostate, to hit which part with the point of theknife, is in my opinion, the most difficult step of the operation.I next, in withdrawing the knife, made an incision in themesial plane, cutting through the membranous part of the ure-thra to the extent of half an inch or more, and extending theincision through the raphe of the perinaum for an inch and aquarter in length ; so that part of the external sphincter, andthe point of junction of the transverse perinæum were divided,and possibly the spongy tissue of the bulb at its posterior andlower part. I next passed a large probe along the groove ofthe staff into the bladder, and the staff was withdrawn. Ithen very gradually, by a semi-rotatory motion, passed myleft index-finger along the probe into the bladder, and felt thepiece of glass-tube lying near the neck of the bladder, andacross the mesial plane. The prostatic portion of the urethrasoon became more dilated, and I was able to pass by the sideof my finger a pair of polypus forceps, the blades of which Ihad grooved lengthwise, and lined with leather, the better tohold the glass, and to guard against its breaking when graspedby the forceps. I had no difficulty in seizing the glass cross-wise, but it was only after a dozen attempts or more that Icaught it endwise, in such a manner that the long axis of thetube was in the same right line with the long axis of the for-ceps, and then there was no difficulty in extracting it. Whenseized in any other manner, its extraction was of course im-possible. The operation was therefore, as I had predicted,very long, and difficult of accomplishment. The amount of

bleeding was about the same as is usual in the lateral opera-tion. I passed an elastic catheter, No. 12, through the wholecourse of the urethra, and left it there. He took immediatelyhalf a drachm of Battley’s solution.Nine hours after the operation, I found that he had had a

rigor, and the urine had been bloody, flowing chiefly throughthe catheter, which, though so large, did not prevent someurine passing by the wound, which caused him unusually greatsmarting. His pulse was but 84.Twenty hours after the operation, the catheter was removed,

having caused much irritation. The urine now passed freelythrough the urethra, but none by the wound. He felt well,his appetite was good, and his pulse 84.

Thirty hours after the operation, I found that he had hadanother rigor, followed by fever, and he was at this time in aprofuse sweat. His pulse was 104, full and soft. The urinewas copious, and none passing by the wound.Two days after the operation, his pulse was quicker-108 to

112; but he had slept well, had eaten his breakfast, and hadno other constitutional disturbance besides an accelerated circu-lation. The urine was copious, free from blood, but depositeda little adhesive mucus, and again, began to pass, in some mea-sure, by the wound. The presence of the piece of glass in hisbladder, and the operation for its extraction, had no doubtcaused a very minor degree of inflammation of the mucousmembrane of the bladder.Three days after the operation, the bowels having been freely

acted on by small doses of calomel and jalap, the pulse fell to-80, and he was evidently doing well.Five days after the operation, he said that he could hold or

pass his urine at will, above half of it, however, flowingthrough the wound at each time of micturition. The righttestis had gradually become much swollen and tender, whichcondition, he said, began soon after the operation. The cause.of this was, no doubt, the violence done to the prostatic por-tion of the urethra, affecting the right vas deferens (the cordwas tender), and, through it, the testis.Ten days after the operation, he was up and walking about,

and no urine had passed by the wound during the last three-days.Two weeks after the operation, he voided his urine in as-.

large a stream as ever he did, and in every respect naturally.The wound was healed a week after the operation, and re-mained so. The testis was still a little enlarged, but not-

painful. Six leeches had twice been applied over it, and hehad taken small and frequent doses of tartarized antimony.On the 30th of November, fifteen days after the operation,

he left the hospital, feeling quite well, but somewhat reducedin flesh and strength. The fractnred surface of the piece ofglass tube extracted from his bladder exactly corresponds withthe fractured surface of the remainder of the tube, and there-fore it is certain that there can be no fragment remaining inthe bladder. The piece extracted was in his bladder betweenseven and eight days, and is now seen to be thinly incrustedwith a phosphatic deposit, the surface of the interior of thetube being nearly all covered, whilst the exterior is incrustedonly at the broken extremity. The rapidity with which foreignbodies, lodged in the bladder, become incrusted, varies in diffe-rent cases; but where there is a large secretion of adhesivemucus, a phosphatic deposit very soon covers the surface of thesubstance exposed to contact with it and with the urine.

ON

DIA-PERI-STALTIC AND ANTI-PERISTALTIC

ACTION:

OBSERVATIONS AND SUGGESTIONS.

No. IV.

BY MARSHALL HALL, M.D., F.R.S.;OF THE INSTITUTE OF FRANCE; ETC., ETC.

IF in a rabbit the pneumogastric nerves be divided in theneck above the origin and junction of the cesophageal branches,and if the animal be given parsley to eat, a great part of thisvegetable is found to remain in the oesophagus. The principalaction in cesophageal deglutition is diastaltic.

If now the animal be killed, and the cesophagus be laid forobservation on the table, a slow contractile movement of thesuccessive portions of the organ is perceived, induced by thecontact of the atmospheric air, whilst a part of the parsley isexpelled from its lower end. The action of the cesophagus istherefore peristaltic.