ON THREE CASES OF MEDIAN LITHOTOMY; WITH REMARKS UPON THE OPERATION

C WHEELHOUSE
1859 The Lancet  
531 these were so constructed that the lower one had its blades fixed in the wrong direction, while those in the upper frame were left movable. As a general rule, the jalousies should be fitted to the verandah or corridor rather than to the windows of the barrack-room itself. & p o u n d ; It is scarcely necessary to say that all barracks and hospitals in tropical countries should be provided with some sort of outer covered gallery on each floor of the buildings to shade them from the direct
more » ... from the direct force of the sun. In many of the barracks there is unfortunately a verandah on one side only of the building-a defect which, by-the-bye, is never found to exist in the officers' quarters. If the verandah be unprovided with jalousies, and left open to the burning sun and to the wind and rain, the men are, of course, often unable to make use of it during the day, and at night it is not possible to regulate the direct admission of fresh air into the barrack-rooms. This is the case at Up-Park Camp, where the barracks were originally built without verandahs at all, these having been only added at a subsequent period, after a season of excessive mortality ! , The lower barrack-rooms are, strange to say, very generally worse ventilated than the upper rooms; and yet if one set stands more in need of free aeration than the other it is certainly the former, seeing that ground-floor apartments in all climates, and particularly in tropical climates, are, ccete)-is pag,ib2ts, always the least salubrious. I have said that, for efficient ventilation, the fresh entering air should be admitted near the floor, and the impure heated air should be discharged at or near the ceiling. Attempts are sometimes made to have both the admission and the escape openings in the upper part of a chamber, distinct from, but near to, each other. But the plan is objectionable, and has never answered well in all seasons and weathers. Besides having all the doors, especially their lower panels, louvred or jalousied, so that the air may at all times enter freely from the passages or verandahs, it will be found very useful to have several openings — grated, or otherwise so guarded as to regulate the admission of air-right through the wall to the outer atmosphere and on the level of the floor. In hospitals, more especially, the advantage of such direct openings is often very great. The wards in the hospital of the Penitentiary at Kingston were provided with them, and Dr. Campbell, the able medical officer of the institution, spoke highly of their utility. In most of the wards of the General Hospital at Scutari they were present; and an equivalent arrangement was introduced into the model hospital huts of our army in the Crimea. Corresponding facilities for the escape of the respired air must, of course, be provided in or near the ceilins of the apartments. The roofs of barracks and hospitals, in hot climates, should B always have ventilating turrets to aid in the withdrawal and dis-I charge of the vitiated air from the wards; and, for the same purpose, it is very needful that the roofs .should invariably be double, having a sufficient intervening space between the ceiling and the outer roof. This arrangement is necessary in all climates: in a hot climate to keep the upper floors sufficiently cool during the day; and, in a cold climate, to keep them duly warm. The interposition of a stratum of air between the outer atmosphere and the atmosphere of the chamber not only facilitates ventilation, but also greatly aids in maintaining an equableness of temperature. Whitening the roofs of buildings serves materially, in tropical climates, to reduce the heat within. That the defective ventilation of barrack-rooms had much to do with the fatality of the cholera amongst the troops cannot be doubted. It is emphatically alluded to in several of the military reports. 1 accordance with a request expressed a short time ago by Mr. Allarton, in a letter addressed to THE LANCET, that those surgeons who had performed " median" lithotomy would publish their cases, I desire to place the three accompanying ones on record, and at the same time to remark upon some points which strike me as worthy of notice with regard to the operation itself. In deviating from the beaten track with regard to an operation so serious in its nature as lithotomy, and so frequently fatal in its results, it behoves the surgeon to consider well the proceedings he is about to adopt, that he may not be led by the fear of dangers, which are undoubtedly great, into the perilous position of attempting a new and untried method of procedure, by which those dangers, instead of being obviated or diminished, may possibly be materially increased. It will be accorded that the " lateral " method of performing the operation of lithotomy is generally acknowledged to be the best; yet no one can for a moment deny the fact that, even in the hands of the most skilful surgeons, the dangers to be met and the difficulties to be overcome in that operation are both many and great, and that the practical surgeon is bound, if possible, to lessen both the one and the other. Such an attempt has been made by Mr. Allarton, the author of "median" lithotomy ; and it remains for time, and the statistics of future operations, to prove whether the conclusions at which he arrives are false or true. Meanwhile, those who may have been induced to perform the operation will be rendering good service to surgical science by placing on record the histories and results of their cases. That many of the evils to which the lateral operation is liable, and some from which it is insepMable, are obviated by the median, can no longer be doubted; bnt whether these advantages are more than counterbalanced by others peculiar to the new operation, remains yet to be proved. Experience has shown that there is far greater power of dilatation inherent in the prostatic urethra than was formerly supposed, and it is upon this property that the superiority of median over lateral lithotomy will be found to depend. The structure of the prostate body points to the probable explanation of this property. The microscope has revealed that, so far from being truly glandular in its structure, very little real gland tissue is found in it as compared with involuntary muscular fibre. Jones, Kolliker, Ellis, and Thompson all assert that it is largely composed of this tissue, Professor Ellis further asserting that it has probably a direct sphincteric action on the contained urethra. Surgeons are well aware of the great extent to which involuntary muscular fibre will dilate under steadily-applied pressure, and, such pressure being removed, how readily it will again contract to its normal condition. Before performing median lithotomy for the first time, I was afraid less this great dilatability of the prostate might have been over-estimated; and it was not until I had many times satisfied myself, by observation on the dead body, as to the fact, that I ventured to trust to it in the performance of an operation on the living. I have now no hesitation in asserting my belief that calculi of very large dimensions may with safety be drawn through a dilated prostate. I have seen one, of which the following are the dimensions and weight, which has been so withdrawn by my friend, Mr. T. Pridgin Teale, iunior, without apparent iniury:-Length, 2 inches ; breadth,
doi:10.1016/s0140-6736(02)45727-3 fatcat:qx3tyoc6jrdsdootn7pk2cg754