The Pathology of Sick-Headache
BMJ (Clinical Research Edition)
Jan. I8, I873.] THE BRITISH MEDICAL 7OURAAL. 6i fuses to allowtheprofession to learn his results. Canwe come to anyother conclusion but that his reticence is due to a want of success ? The disasters that have occurred to surgeons, when operating for stone, have nearly always been caused through an insufficient opening being made into the bladder, the result being that the viscus receded before the pushing finger, and left the surgeon to grope about in the ischio-rectal fossa for that which he
... for that which he found not. Mr. Ellis has, long ago, proved that there is no such thing as dilatation of the prostate, and has very pertinently pointed out that the most successful cases of lithotomy occur in children, when the boundaries of the prostate muWgst always be overstepped, on account of the very rudimentary condition of that organ. A surgeon will be heard to state that, in the case on which he has just operated, he has extracted the stone by a limited incision, and subsequent dilatation. But I would ask, what proof is there of such having been done? Not having examined the parts, how does he know whether he has, or has not, exceeded the bounds of the prostate. He cannot tell. On the contrary, all the specimens in the London museums which I have examined, prove incontestably that no surgeon has ever extracted a stone, unless a very small one, without exceeding the margin of the prostate. Some years ago, I carried out a series of investigations on dead subjects, and found that no ordinary sized stone could be extracted from the bladder without completely rupturing the prostate and its capsule. (Path. Soc. Tranisactionzs, vol. xvii, p. I86.) Three of the patients whom I cut for stone were troubled with incontinence of urine after the operation, and the reason is clear. When I first began to operate for lithotomy, I followed the plan taught me, making a small incision, and subsequently enlarging the wound with my finger. The result was that my first and second cases were troubled with incontinence. I then altered my method ; the consequence was that all recovered without suffering from incontinence except one boy, from whom I was obliged to withdraw the atone without enlarging the wound, on account of the critical condition he was in from chloroform. I now come to that proof which will carry conviction, and I will, in the first place, explain what I mean by a free incision. No one would more strongly deprecate making a larger wound than is necessary than myself; at the same time, I believe that more injury has been caused to patients through malking incisions too small than too large. I, first of all, make an aperture large enough to permit my finger to slip into the bladder without the slightest force being required. If, however, my finger should not slip in easily, I introduce the knife, and enlarge the wound. And in the bladder I grasp the stone with the forceps (in boys I extract the calculus with the forefinger only), and then commence to withdraw it. If there be the slightest resistance, I introduce a probepointed bistoury, and cut outwards and downwards till the stone glides out without the slightest traction being exerted. So far as I can ascertain, those surgeons who have adopted the cutting plan for extraction have attained a success wholly unapproachable by those who follow the so-called plan of dilatating, which is lacerating. Mr. Gutteridge, Mr. Brett, Mr. Carr Jackson, Mr. Vincent Jackson, and myself have cut 349 patients for stone, and the sum total of all the cases that died after operation only amounts to eleven. These results carry with them the incontrovertible deduction that a method of operation which only loses 3 per cent. of its patienits must have a better basis for its support than one which permits I5 per cent. to die. I will now conclude by giving one of the most important judgments ever uttered on the subject of lithotomy. " It has certainly appeared to me that the very result so much apprehended from a free incision of the nieck of the bladder seems to have followed in most of my unsuccessful cases from a want of a sufficiently free incision ; whereas my unhesitatingly cutting all opposing textures has, especially in my last sixty-eight cases, been followed with the happiest results. Indeed I have almost felt conscious, whenever a case has terminated unfavourably, or the recovery has been slow, that my internal incision has not been sufficiently bold, and that the operation has been protracted thereby. " ( On thze Surgo rical Diseases of India. By Mr. I3rett, p. 206.) Better surgical principles than these no book contains. Assistant-Physician to, and Lecturer on Mledicine at, the Westminster Hospital. SO1IE remarks of Dr. P. XV. Latham, in a recent paper in the BRITISII MIEDICAL JOURNAL, which advert to my late articles on migraine in the Practitioner, call for a reply from me. Dr. Latham has misunderstood the nature of my claimii, and he might, perhaps, have given me credit for familiarity with such hackneyed authors as Tissot, Romberg, and Le1ut. I had no idea of claiming the origination of the idea that migraine was a neuralgia: the statement for which I did venture to claim a certain merit of priority was much larger than that. It was to the effect that migraine is almost the only neuralgia of the period of bodily development, and depends on inherited defects in the nutrition of the medulla oblongata, and that it is intimately mixed up with, and frequently interchangeable with other and more formidable nervous diseases, which are also the results of similar defects in the nutrition of the medulla; and that it is, so to speak, a matter of chance whether a person born of a certain race will have migraine, or epilepsy, or asthma. Your readers will perceive that this, which was stated in outline five years ago, in my article on " Neuralgia" in Reynolds's Systemii, and at much fuller length in m.y book on Neziral,-ia in I871, is quite different-whether true or falsefrom what had been said by any previous writer. But I am exceedingly pleased to see that Dr. Edward Liveing has, quite independently, arrived at conclusions which come very near to mine. He thinks that migraine is an inherited disease, and that each paroxysm is a nervestorm which may range over the whole tract between the optic thalami and the nucleus of the vagus.