instruments
and
likely to be of dressing forceps.
use
scalpels,
were
catheters
There was no staff, hut I was at no loss on that score, for I remembered an interesting account, published some time ago in the Indian Medical Gazette by Surgeon Cullimore, Madras Medical Service, in which he stated how he improvised a staff by filing a groove in the convexity of a silver cathetcr. As I had only a dressing-forceps, I sent for the smith and all his armoury ; but the only forceps he had was a common farrier 8 tongs winch was like an enlarged dressing-forceps, and quite as useless. At length the idea occurred to me of a
making
forceps
a
out of
two tea spoons, and a moment's
reflection showed as a silver catheter
me
the thing was feasible. As noon was converted into a staff according to the method mentioned above, I got from the dfilc bun-' galow two tea spoons, which I need hardly say were not
returned, but
replaced by
Having roform, I
were
sounded the at once
man
recognised
others.
with
the
a
catheter under chloof his great pain.
cause
The calculus was situated in the neck of the bladder, but not firmly so, for, while using the point of the catheter to determine its size and fixity, the stone slipped back into the bladder. If I had done no more than this the patient would have obtained much relief, for the paroxysms during micturition were undoubtedly due to the manner in which the stone was grasped during the I judged, though spasms of the neck of the bladder. wrongly as the result proved, the stone was a small one, and that there would be no difficulty in removing it. Having cut into the bladder and removed the staff, it now remained to introduce the new forceps. I* saw that, having placed the concavities of the bowels of the spoons facing each other, the bulk was too great to allow their introduction ; I therefore placed one bowl within the other, and in this way introduced them with but Slight
trouble, taking care by having the concavity of the bowls looking upwarus and outwards, the edges corresponded A NEW LITHOTOMY FORCEPS. ^
By Suuoeon John
O'Neill,
Civil Surgeon,
M.
D., M. Ch.,
last twenty miles runs a rough and uneven course over the hilis. Last winter, while inspecting the dispensary there, a man suffering from stone entreated me to afford him relief. He was in a pitiable condition, and could only walk slowly owing to the pain in his bladder; and lie said micturition was so painful that he always looked forward to it with fear. Though I nearly always take lithotomy instruments with me when going into the district on the chance of getting an operation, I had, unfortunately, this time come unprovided. The patient's
disappointment was great when I told him it would be l>est to go to the Sadr ; he begged me to do something to relieve his pain, he said he had no friends to take him to the Sadr, and that it was only yesterday he came in from his village five miles away when he heard I was coming
visit the
dispensary.
The
1 failed three or four times, the great difficulty bein^ the small hold I had of the handles, for owing to the shortness of the spoons the tips of my fingers were in the perinceum I caught the stone once, but as the way.
Shahpur.
Forty miles distant from the shallt>ur Sadr is the village of Nowshera, approached by a road which in its
to
witu the angles of the prostatic incision, and no unnecessary dilatation of the wound was caused. I now parted the spoons, and taking a handle in each hand crossed theiu and endeavoured to seize the stone in the ordinary
only
available
handles wore crossed in an irregular manner, I knew the bowls were not properly opposed, so I relinquished my hold and withdrew the spoons. Another method was The spoons were introduced as before, the lying within that of the other, and without This manoeuvre is any trouble placed under the stone with the confirst the stone is for tapped very simple, vexity of the bowl to make sure of its position, then the
next tried.
bowl of
one
lateral edge is slipped- under the stone which readily falls into the bowl. There were now under the calculus the two blades of our forceps. Holding the handle of the upper spoon steadily, for it was on this the sto e rested, with the left hand the lower spoon describe a curve to the operator's
[ being
to cause
was
left,
made to the object
the bjwl of the lower spjjn to become
August
2,
1880
]
A NEW" LITHOTOMY FORCEPS.?BY SURGEON J.
inverted over the stone. This being done, I saw from the apposition of the handles the bowls were properly placed, and then proceeded to extract. With a fair amount of traction the
forceps
great disappointment there blades. At this time
place ly
was
was
no
removed, but
to my between the
stone
of the attendants fainted, and his village butcher who fortunatein the crowd that had gathered outside the dis-
was
was
taken
one
by
the
pensary door. It seemed likely that in inverting the lower spoon it was not raised high enough, the consequence being it pushed the stone out of the bowl in which it rested. The
forceps
blades
were
was again introduced, and placed under the calculus,
before the in inverttaken to make as
but
the lower Bpoon this time, care was it describe a large arc, with the result that the handles throughout their whole extent could not be brought in contact, showing the calculus was caught, and was of sufficient size to prevent the bowls coming together : I The force used was considerable, but by now extracted. 110 means very great. The moment I commenced traction the resistance was so marked, I felt uneasy as to the amount of dilatation which would be caused later on when
ing
portion of the calculus would be leaving the bladder ; but to my great surprise the resistance ceased as suddenly as it began, and the extraction was finished
the last
with
a
jerk.
dismiss the patient, who made a good recovery, and is in the enjoyment of perfect health. The stone was of a peculiar kind,?it consisted of two parts, one of a bent cylindrical form an inch in length formed of carbonate of lime, and evidently the portion Let
us now
partially plugged the neck of the bladder ; the other portion was a flattened oval attached by one of its ends to the part first mentioned. The oval portion was phosphatic, and measured one inch and a half in length, one inch and a quarter in width, and one inch in thickness. The s;one weighed seven drachms and fifty grains. It was the cylindrical portion which was caught between the ends of the blades and so kept them apart increasing the bulk of the forceps ; but for this the oval part would have well fitted between the closed blades. The spoons were of unequal size, one measuring two drachms and the other a drachm and a half. Though the above method of extraction was adopted in an emergency, it appeared to me that the forceps I used if modified, would present many over which
advantages
the kind ordinarily used. Have we not something very like it in the scoop which is frequently used with great advantage in removing small stones from children, and in cases where the perinseum is not deep, as the stone is retained in the scoop
by
though,
of the finger, the dilatation of the prostate is greater than if two scoops were used, or in other words a forceps similar to the one I had. Let us examine the forces in play during the extraction of a stone. The operator exerts two forces, ?traction and compression, which are opposed by constriction and friction. Now the friction is made up of two factors, firstly, the very small amount between means
the sides of- the passage and the smooth
surfaces of
O'NEILL,
M.D.
207
the blades; and secondly, the very large amount between the sides of the passage and the exposed portions of the stone. By exposed I mean the portion of the stone which the forceps does not cover. The first of these factors is not much, and is overcome by the traction which also overcomes the constriction of the prostate by means of the gradually expanding blades of the forfactor is altogether neutralized ceps ; while the second the the operator exerts, and when tho
by
compression
friction between the exposed portion of the stone and the sides of the passage through which it is dragged exceeds the force exercised by the operator in compression, the stone is wrenched from his grasp. Those who have had much lithotomy practice must have had occasion to well a stone only to find it was ineffecgrasp
and they can realise the great amount of friction which sometimes takes place .between the stone and the passage. If there be reason to believe the stone will slip, the forceps is the more firmly grasped, the result t?o often being a broken stone. Now if we do not permit the stone to touch the sides of the passage, compression Avill be unnecessary, and the chances of the stone being broken will be nil. And to this have we come. Use such a forceps that every part of the stone will be guarded by it, and that stone will neither slip nor be
tually grasped,
broken; differing
such
and
an
instrument will have blades forceps I used. The stone is
but little from the
globe, the external surface causing only slight friction. If the stone be sufficiently large to keep the edges of the blades apart during extraction, the elasticity of the it
on
account of its smoothness
were
in
hollow metallic
as
a
prostate will exercise pressure upon it
; but this pressure
fracture of only the softest stones, such stones as would at once break down on being seized by an ordinary forceps which would be able to bring away but a small portion of the detritus, while by far the larger portion, if not the whole of it, would be retained between the scoop-like blades of the spoon-forceps. alone will
cause
Another advantage I claim for the new forceps is, that little additional bulk will be added to the stone, for the blades need be no thicker than the paper on which this is printed, markedly contrasting with the thickness of the blades now in use. Ayain if the steps of the operation are remembered, it will be apparent that the raucous membrane cannot be pinched by the spoon-forceps while catching the calculus, or even if such were possible, the merest effort at traction would liberate themembrane for the blades are not compressed. Now a few words as to the construction of the forceps. Take two tea spoons and place them together, the concavities of the bowls looking towards each other, and it will be seen that the greatest ?
to the point where the bowls handles, and also the edges of the only at the ends. It can now bo understood why, in extracting the stone from the patient, the resistance at once reached its maximum, for
bulk is
just
anterior
the bowls coincide
join
on
to
the increase in the bulk of the blades was too sudden, there was very little gradual dilatation, and when the widest part made its way, all resistance ceased, and the
THE INDIAN MEDICAL GAZETTE.
208
remaining
portion being much smaller, met with little resistance, and the force in extraction not being diminished, the operation was concluded with a jerk. To remedy this detect in the forceps, the bowls of the spoons should be made to coincide throughout the extent of their edges, and the greatest curve of the bowl should be at
its central parr, and not as now close to the handle. The blades of the forceps when closed on a stone should present the appearance of a flattened ellipsoid. To sum up, I claim the following advantages for the
[AcotsT 2,
1880.
any hard substance, was certain I had the I then extracted. The ease with which the forceps was removed surprised all present, it almost slipped out, and between the blades was the stone with-; out a scratch upon it. The inversion of the lower blade was rather awkwardly done owing to the want of proper handles, as anyone may see who by catching the ends of the handles tries
not
feeling
stone, and
to invert one
spoon over another ; but this is a mere matter of detail, and I have 110 doubt it will be easy to
It is not liable to seize the mucous membrane. It adds little to the bulk of the stone. The laceration y means of which the inversion may be quickly and surely made. The child's age was four years ; the stone was a flat ovoid, measuring an inch in length, three quarters of an inch in width, and half an inch in thickness, and
The stone is not so liable to slip. The stone is not s? liable to be broken. If the stone break in its grasp, the greater portion of it will be removed. In removing large stones with the ordinary forceps
Each spoon measured half drachm. The child recovered without a bad symptom, but the fate of the child has nothing to do with the merits of the forceps, for the forceps could not possibly have
spoon-forceps
:
the prostate frequently insinuates itself between the rivet of the forceps and the calculus, and portions of the prostate in such ca-^es have been torn away, 'lhese circumstances cannot occur with the spoon-forceps. I know but a single point in which the ordinary forceps has the advantage over the one I describe, and that is the easier introduction of the former into the bladder bwing to the blades being narrow. But this advantage is not great, as may be demonstrated on the subject, for the blades of the spoon-forceps though broad are not thick, and after the usual dilatation of the prostatic wound with the finger, the lubricated blades will slip in readily if their edges correspond with the ends of the incision. Indeed if the forceps used be a small one, its introduction is far and away easier than the ordinary forceps, for the last phalanx nearly fills up the bowl and the handles lie up against the finger. Though what I have up to this written frequently passed through my mind, I took no steps towards bringing my views into practice till the 5th of June. A child was brought to the dispensary with stone. Rectal examina-
most valuable with children, showed the stone was small one, and I determined to extract with a spoon forceps. I gave two egg spoons to a smith and directed him to so treat them that when the spoons were turned over on a table the entire edges of the howls would lie flat on the table, the handles were to be perfectly straight, and the highest point of convexity at the centre of
tion, a
the
bowls, and not as before close to the handles. Having chloroformed the child, the bladder was
cut
into in the usual way. The egg spoons were smeared with castor-oil, which I prefer to sweet-oil on account of its lesser liability to be rubbed off. The bowls being placed one within the other; in the upper bowl rested the finger, its tips merely projecting, and in this way the directed to the site of the prostatic incision. slightest hitch the bowls were put under the calculus, and the lower one inverted into its place. The handles came in contact throughout their length, but to make certain I had the calculus I used the forceps
forceps
was
Without the
as a
sound, moving
it
freely
about in the
bladder,
but
weighed fifty-three grains. a
injured him, small,
and
and the
on
the other hand the stone was so mortality among infant lithotomy
is so trifling, that in all probability the child would have recovered whatever forceps was used. Anyhow the stone neither slipped nor was it broken, nor could either accident have happened ; and with these remarks I commend the spoon-forceus to the favorable consideration of my professional brethren.
patients
__
\
/
and
likely to be of dressing forceps.
use
scalpels,
were
catheters
There was no staff, hut I was at no loss on that score, for I remembered an interesting account, published some time ago in the Indian Medical Gazette by Surgeon Cullimore, Madras Medical Service, in which he stated how he improvised a staff by filing a groove in the convexity of a silver cathetcr. As I had only a dressing-forceps, I sent for the smith and all his armoury ; but the only forceps he had was a common farrier 8 tongs winch was like an enlarged dressing-forceps, and quite as useless. At length the idea occurred to me of a
making
forceps
a
out of
two tea spoons, and a moment's
reflection showed as a silver catheter
me
the thing was feasible. As noon was converted into a staff according to the method mentioned above, I got from the dfilc bun-' galow two tea spoons, which I need hardly say were not
returned, but
replaced by
Having roform, I
were
sounded the at once
man
recognised
others.
with
the
a
catheter under chloof his great pain.
cause
The calculus was situated in the neck of the bladder, but not firmly so, for, while using the point of the catheter to determine its size and fixity, the stone slipped back into the bladder. If I had done no more than this the patient would have obtained much relief, for the paroxysms during micturition were undoubtedly due to the manner in which the stone was grasped during the I judged, though spasms of the neck of the bladder. wrongly as the result proved, the stone was a small one, and that there would be no difficulty in removing it. Having cut into the bladder and removed the staff, it now remained to introduce the new forceps. I* saw that, having placed the concavities of the bowels of the spoons facing each other, the bulk was too great to allow their introduction ; I therefore placed one bowl within the other, and in this way introduced them with but Slight
trouble, taking care by having the concavity of the bowls looking upwarus and outwards, the edges corresponded A NEW LITHOTOMY FORCEPS. ^
By Suuoeon John
O'Neill,
Civil Surgeon,
M.
D., M. Ch.,
last twenty miles runs a rough and uneven course over the hilis. Last winter, while inspecting the dispensary there, a man suffering from stone entreated me to afford him relief. He was in a pitiable condition, and could only walk slowly owing to the pain in his bladder; and lie said micturition was so painful that he always looked forward to it with fear. Though I nearly always take lithotomy instruments with me when going into the district on the chance of getting an operation, I had, unfortunately, this time come unprovided. The patient's
disappointment was great when I told him it would be l>est to go to the Sadr ; he begged me to do something to relieve his pain, he said he had no friends to take him to the Sadr, and that it was only yesterday he came in from his village five miles away when he heard I was coming
visit the
dispensary.
The
1 failed three or four times, the great difficulty bein^ the small hold I had of the handles, for owing to the shortness of the spoons the tips of my fingers were in the perinceum I caught the stone once, but as the way.
Shahpur.
Forty miles distant from the shallt>ur Sadr is the village of Nowshera, approached by a road which in its
to
witu the angles of the prostatic incision, and no unnecessary dilatation of the wound was caused. I now parted the spoons, and taking a handle in each hand crossed theiu and endeavoured to seize the stone in the ordinary
only
available
handles wore crossed in an irregular manner, I knew the bowls were not properly opposed, so I relinquished my hold and withdrew the spoons. Another method was The spoons were introduced as before, the lying within that of the other, and without This manoeuvre is any trouble placed under the stone with the confirst the stone is for tapped very simple, vexity of the bowl to make sure of its position, then the
next tried.
bowl of
one
lateral edge is slipped- under the stone which readily falls into the bowl. There were now under the calculus the two blades of our forceps. Holding the handle of the upper spoon steadily, for it was on this the sto e rested, with the left hand the lower spoon describe a curve to the operator's
[ being
to cause
was
left,
made to the object
the bjwl of the lower spjjn to become
August
2,
1880
]
A NEW" LITHOTOMY FORCEPS.?BY SURGEON J.
inverted over the stone. This being done, I saw from the apposition of the handles the bowls were properly placed, and then proceeded to extract. With a fair amount of traction the
forceps
great disappointment there blades. At this time
place ly
was
was
no
removed, but
to my between the
stone
of the attendants fainted, and his village butcher who fortunatein the crowd that had gathered outside the dis-
was
was
taken
one
by
the
pensary door. It seemed likely that in inverting the lower spoon it was not raised high enough, the consequence being it pushed the stone out of the bowl in which it rested. The
forceps
blades
were
was again introduced, and placed under the calculus,
before the in inverttaken to make as
but
the lower Bpoon this time, care was it describe a large arc, with the result that the handles throughout their whole extent could not be brought in contact, showing the calculus was caught, and was of sufficient size to prevent the bowls coming together : I The force used was considerable, but by now extracted. 110 means very great. The moment I commenced traction the resistance was so marked, I felt uneasy as to the amount of dilatation which would be caused later on when
ing
portion of the calculus would be leaving the bladder ; but to my great surprise the resistance ceased as suddenly as it began, and the extraction was finished
the last
with
a
jerk.
dismiss the patient, who made a good recovery, and is in the enjoyment of perfect health. The stone was of a peculiar kind,?it consisted of two parts, one of a bent cylindrical form an inch in length formed of carbonate of lime, and evidently the portion Let
us now
partially plugged the neck of the bladder ; the other portion was a flattened oval attached by one of its ends to the part first mentioned. The oval portion was phosphatic, and measured one inch and a half in length, one inch and a quarter in width, and one inch in thickness. The s;one weighed seven drachms and fifty grains. It was the cylindrical portion which was caught between the ends of the blades and so kept them apart increasing the bulk of the forceps ; but for this the oval part would have well fitted between the closed blades. The spoons were of unequal size, one measuring two drachms and the other a drachm and a half. Though the above method of extraction was adopted in an emergency, it appeared to me that the forceps I used if modified, would present many over which
advantages
the kind ordinarily used. Have we not something very like it in the scoop which is frequently used with great advantage in removing small stones from children, and in cases where the perinseum is not deep, as the stone is retained in the scoop
by
though,
of the finger, the dilatation of the prostate is greater than if two scoops were used, or in other words a forceps similar to the one I had. Let us examine the forces in play during the extraction of a stone. The operator exerts two forces, ?traction and compression, which are opposed by constriction and friction. Now the friction is made up of two factors, firstly, the very small amount between means
the sides of- the passage and the smooth
surfaces of
O'NEILL,
M.D.
207
the blades; and secondly, the very large amount between the sides of the passage and the exposed portions of the stone. By exposed I mean the portion of the stone which the forceps does not cover. The first of these factors is not much, and is overcome by the traction which also overcomes the constriction of the prostate by means of the gradually expanding blades of the forfactor is altogether neutralized ceps ; while the second the the operator exerts, and when tho
by
compression
friction between the exposed portion of the stone and the sides of the passage through which it is dragged exceeds the force exercised by the operator in compression, the stone is wrenched from his grasp. Those who have had much lithotomy practice must have had occasion to well a stone only to find it was ineffecgrasp
and they can realise the great amount of friction which sometimes takes place .between the stone and the passage. If there be reason to believe the stone will slip, the forceps is the more firmly grasped, the result t?o often being a broken stone. Now if we do not permit the stone to touch the sides of the passage, compression Avill be unnecessary, and the chances of the stone being broken will be nil. And to this have we come. Use such a forceps that every part of the stone will be guarded by it, and that stone will neither slip nor be
tually grasped,
broken; differing
such
and
an
instrument will have blades forceps I used. The stone is
but little from the
globe, the external surface causing only slight friction. If the stone be sufficiently large to keep the edges of the blades apart during extraction, the elasticity of the it
on
account of its smoothness
were
in
hollow metallic
as
a
prostate will exercise pressure upon it
; but this pressure
fracture of only the softest stones, such stones as would at once break down on being seized by an ordinary forceps which would be able to bring away but a small portion of the detritus, while by far the larger portion, if not the whole of it, would be retained between the scoop-like blades of the spoon-forceps. alone will
cause
Another advantage I claim for the new forceps is, that little additional bulk will be added to the stone, for the blades need be no thicker than the paper on which this is printed, markedly contrasting with the thickness of the blades now in use. Ayain if the steps of the operation are remembered, it will be apparent that the raucous membrane cannot be pinched by the spoon-forceps while catching the calculus, or even if such were possible, the merest effort at traction would liberate themembrane for the blades are not compressed. Now a few words as to the construction of the forceps. Take two tea spoons and place them together, the concavities of the bowls looking towards each other, and it will be seen that the greatest ?
to the point where the bowls handles, and also the edges of the only at the ends. It can now bo understood why, in extracting the stone from the patient, the resistance at once reached its maximum, for
bulk is
just
anterior
the bowls coincide
join
on
to
the increase in the bulk of the blades was too sudden, there was very little gradual dilatation, and when the widest part made its way, all resistance ceased, and the
THE INDIAN MEDICAL GAZETTE.
208
remaining
portion being much smaller, met with little resistance, and the force in extraction not being diminished, the operation was concluded with a jerk. To remedy this detect in the forceps, the bowls of the spoons should be made to coincide throughout the extent of their edges, and the greatest curve of the bowl should be at
its central parr, and not as now close to the handle. The blades of the forceps when closed on a stone should present the appearance of a flattened ellipsoid. To sum up, I claim the following advantages for the
[AcotsT 2,
1880.
any hard substance, was certain I had the I then extracted. The ease with which the forceps was removed surprised all present, it almost slipped out, and between the blades was the stone with-; out a scratch upon it. The inversion of the lower blade was rather awkwardly done owing to the want of proper handles, as anyone may see who by catching the ends of the handles tries
not
feeling
stone, and
to invert one
spoon over another ; but this is a mere matter of detail, and I have 110 doubt it will be easy to
It is not liable to seize the mucous membrane. It adds little to the bulk of the stone. The laceration y means of which the inversion may be quickly and surely made. The child's age was four years ; the stone was a flat ovoid, measuring an inch in length, three quarters of an inch in width, and half an inch in thickness, and
The stone is not so liable to slip. The stone is not s? liable to be broken. If the stone break in its grasp, the greater portion of it will be removed. In removing large stones with the ordinary forceps
Each spoon measured half drachm. The child recovered without a bad symptom, but the fate of the child has nothing to do with the merits of the forceps, for the forceps could not possibly have
spoon-forceps
:
the prostate frequently insinuates itself between the rivet of the forceps and the calculus, and portions of the prostate in such ca-^es have been torn away, 'lhese circumstances cannot occur with the spoon-forceps. I know but a single point in which the ordinary forceps has the advantage over the one I describe, and that is the easier introduction of the former into the bladder bwing to the blades being narrow. But this advantage is not great, as may be demonstrated on the subject, for the blades of the spoon-forceps though broad are not thick, and after the usual dilatation of the prostatic wound with the finger, the lubricated blades will slip in readily if their edges correspond with the ends of the incision. Indeed if the forceps used be a small one, its introduction is far and away easier than the ordinary forceps, for the last phalanx nearly fills up the bowl and the handles lie up against the finger. Though what I have up to this written frequently passed through my mind, I took no steps towards bringing my views into practice till the 5th of June. A child was brought to the dispensary with stone. Rectal examina-
most valuable with children, showed the stone was small one, and I determined to extract with a spoon forceps. I gave two egg spoons to a smith and directed him to so treat them that when the spoons were turned over on a table the entire edges of the howls would lie flat on the table, the handles were to be perfectly straight, and the highest point of convexity at the centre of
tion, a
the
bowls, and not as before close to the handles. Having chloroformed the child, the bladder was
cut
into in the usual way. The egg spoons were smeared with castor-oil, which I prefer to sweet-oil on account of its lesser liability to be rubbed off. The bowls being placed one within the other; in the upper bowl rested the finger, its tips merely projecting, and in this way the directed to the site of the prostatic incision. slightest hitch the bowls were put under the calculus, and the lower one inverted into its place. The handles came in contact throughout their length, but to make certain I had the calculus I used the forceps
forceps
was
Without the
as a
sound, moving
it
freely
about in the
bladder,
but
weighed fifty-three grains. a
injured him, small,
and
and the
on
the other hand the stone was so mortality among infant lithotomy
is so trifling, that in all probability the child would have recovered whatever forceps was used. Anyhow the stone neither slipped nor was it broken, nor could either accident have happened ; and with these remarks I commend the spoon-forceus to the favorable consideration of my professional brethren.
patients
__
\
/
