a bit of stone in the prostate of that part, or such a position of the to close or obstruct the entrance into the neck the stone having altered its position in the in-
should the obstruction hare been
causing irregularity vesical stone na of the bladder,
of the staff Hawkins says :? paid to its use in children, as a false passage is readily made, so that the instrument enter-* the pelvis below the bladder instead of passing into it." A false passage was twice made by one of my Sub-Assistant
terim.
With
regard
to
the
"Great attention and
passing
care
must be
into the cellular tissue between the bladder and rectum?in one case, on account of so large a staff having been used as to require some force to push it onwards; and in the the staff after the legs and hands were other, from
Surgeons
LITHOTOMY.
By W. P. Harris, M.D.,
Civil
(Continued from
Surgeon, Shahjehanpore. page
153.)
Section III. Examination
ly
means
of
the sound, and the introduction
the staff.?Although the introduction of the sound and staff is in general easily performed yet difficulty may occur on account of diseased states to which the urethra, prostate, and neck of
of
liable from the presence of stone ; such as,-spasm, membrane, enlarged-glandular openings, and
bladder
are
relaxed
mucous
deformities in the prostatic portion of the urethra, the presence of bits of stone in the prostate.
produced by
use of the staff, it is well in young moderate sized one, as a large one fdls up the neck of the bladder so completely as to render the introduction of the finger after incision a matter of difficulty.
With
respect
children to choose
to the a
The staff is more liable to become entangled in obstruction than the sound, and more so in children than in adults. in the passage of the staff onwards to the bladder from passing the point too low, or in other words, in not
Delay occurs
the
point in constant gentle contact with the upper surface of the urethra, so that it catches in the inferior wall of the bulbous portion of the urethra, either in one of the openings of Cowper's glands there situated, or in the lower portion of the triangular ligament. It also occasionally catches in the keeping
relaxed
mucous membrane of the lower surface of the urethra the apex of the prostato or under the ligamentous band at the neck of the bladder, if this part be spasmodically contracted, or the entrance into it obstructed and deformed by a portion of
at
the stone To staff
being lodged
overcome
gently,
and
there.
these obstructions draw back the point of the try if it will pass on when directed more to the
upper wall of the urethra. No force however should be used
as
false passages are
readily
In some instrances it is obstructed by spasm of the urethra, in which case, if the instrument bo kept pressed against the part for a few minutes, the spasm may presently yield, or if the administration of chloroform may be useful. Where the point of the instrument constantly catches in
fail,
some obstruction, passing it immediately after micturition has been found successful; and in these cases a large instrument will often ride over an obstaclo in which a smaller onn catches; though it should not be tight in the urethra, as it then cannot be introduced with that gentleness which is the
safeguard
against making a false passage. If, after a trial of not more than 10 minutes in duration, the instrument cannot be introduced, the operation should be deferred to another day, as longer fruitless efforts may cause impatience and lead to force being used, which may result in the formation of Ihe
same
a
false passage. may not be mel with
difficulty
[passing together?a practice
was
known in
It now altogether forbidden. cases,?by the instrument deviating from the central line, being superficially felt by the finger in the rectum; by not hearing and feeling the point of the staff strike the stone fully (though a sound was heard from the side of the staff coming against the stone at the mouth of the bladder) ; and by the abdominal walls not. being pushed up by the point of the staff when its handle was depressed. I took the case out of the hands of my subordinate, and having passed the staff into the bladder, immediately operated. The boy was kept during the after-treatment in a semi-sitting posture, and
on
a
second trial*
one
I have
of the
made
a good recovery. In the other case, all the above indications of false passage were indistinct, and there was, moreover, a loud click produced by the side of the staff striking against the stone lying at the
mout.li of the bladder. The Sub-Assistant Surgeon made his incisions in the usual way, and was then greatly surprised not to find a stone. On examination, I at once came upon the well-defined, soft lips of the bladder unopened, and the entrance to the false
passage with thin undefined margin by the side of them. The stone was easily extracted, and the case made an equally good
recovery with the other. The rule, never to cut into the bladder, unless the stone can be distinctly heard as well as felt, and I would add felt as an isolated and moveable body in the bladder, is a most important one. Professor Humphrey says that the touch is often deceptive in children in whom the projecting and slightly roughened rugae of the bladder frequently communicate, when the sound is passed quickly over them, a sensation like that given by a "
stone."
Having determined the fact of a stono being present in the bladder and whether there is more than one, it then becomes necessary to judge of the size. This
point
instrument
made.
this
tied
is best determined
is seldom
by
to
a
lithotrite
;
but
as
this
in India, it is necessary to consider what other means of diagnosis are available to form a judgment on this point. If the sound strike
bladder and feel is
supplied
on
the stone
dispensaries
immediately
immovably fixed,
on
entering
the
it indicates that the stone
probably a very largo one. Tho extont of mobility of the stono in the bladder should be determined, both when this viscus is empty and after injection of water into it.; for if immovable, in tho latter case, it must
bo
a
largo
calculus.
Hawkins says:?"The size is determined by first traversing the surfaco of tho stone with tho convex part of tho sound from side to side, and then carrying tho point from before backwards." Also, inserting tho finger into tho rectum will assist in forming an opinion of the length and breadth of the stono and of its amount of mobility in the bladder. Eriohsen says:?"Any calculus above 0110 inch and a half iu its shorter diameter will present considerable difficulties in being extracted through an incision in tho prostate of tho
ordinary
size ;
namely,
not
exceeding eight
lines in
length."
July 1, The
by me was one of the following inches, length 3 inches, thickness If weighing ?iv and jvi.
largest
dimensions
:
and
inches,
A MIRROR OF HOSPITAL PRACTICE.
1873.] stone extracted
breadth 2i
of this case and from the diffithe stone, though division of the right side of the prostate and bilateral incision of the perineum were adopted, I should say that a calculus of this size, even if the patient is young and healthy, is as large as it is safe to attempt
Judging from
culty
of
the
experience
extracting
tlie extraction of.
The
case
was as
follows.
Lull, aged 30, Hindoo, healthy, with the exception of a little ana>mia. Has suffered from symptoms of stono for three years. Clieda
lie was operated upon by the left lateral operation, but sufficient space not being found for the extraction of the calculus, the right side of the prostate was incised by means of a probescalpel and bilateral incision of the perineum was made;
pointed
then by steady traction and twisting, with forcible pushing back of the neck of the bladder and prostate (which latter was
pulled
down to
calculus
was
The forco
near
the external
wound)
over
the stone, the
extracted.
required
was
such
as
to bend the blades of the
forceps. The
man
made
a
good though
rather tedious recovery.
Section IV. Choice
of operation?Lithotomy or Lithotrity.?Having examined the patient and decided that the case is one that may be operated on with a justifiable chance of success, the next, question to determine is the kind of operation which should be performed, i.e., Lithotomy or Lithotrity. It is not probable that lithotrity will ever be much in vogue in India, where a native would grow impatient and run away from hospital oidy half cured and iu a worse state than before the operation. Without wishing to detract from the merits of the crushing operation, yet for the comfort of those unversed in its mysteries, I will quote from a lecture by professor Humphrey, lately
published
in the Lancet.
good case for lithotrity is one in which lithotomy carefully performed is attended with very little risk, with quite as little, I believe, as lithotrity. "But
"
a
painful, quicker and more certain ; and the greater patients prefer this more expeditious process."
It is less
number of
Section Y.
Preliminary Treatment.?It is seldom the custom in India to subject the patient to more than one or two days' preliminary treatment. It certainly cannot be advisable to give anodynes, as these have the effect of blocking up tho secretions, nor can it often be of use to delay the operation with the object of rendering tho urine healthy by acids or alkalies; the surest plan of giving relief to his sufferings and correcting tho diseased urine, being to rid the patient of the calculus. There are some cQnditions, howover, in which it would be very unwise to operate at once,?as when the patient is suffering from constant irritative or hectic fever depending on acute or subacute congestion of the kidneys or bladder which has recently supervened, or if the patient is very emaciated and weak, rather from bad living than from the disease. If the latter bo operated upon without preliminary feeding up, even though the patient should recover, sloughing of the cornea
is liable to supervene.
(To
he
continued.)
181
should the obstruction hare been
causing irregularity vesical stone na of the bladder,
of the staff Hawkins says :? paid to its use in children, as a false passage is readily made, so that the instrument enter-* the pelvis below the bladder instead of passing into it." A false passage was twice made by one of my Sub-Assistant
terim.
With
regard
to
the
"Great attention and
passing
care
must be
into the cellular tissue between the bladder and rectum?in one case, on account of so large a staff having been used as to require some force to push it onwards; and in the the staff after the legs and hands were other, from
Surgeons
LITHOTOMY.
By W. P. Harris, M.D.,
Civil
(Continued from
Surgeon, Shahjehanpore. page
153.)
Section III. Examination
ly
means
of
the sound, and the introduction
the staff.?Although the introduction of the sound and staff is in general easily performed yet difficulty may occur on account of diseased states to which the urethra, prostate, and neck of
of
liable from the presence of stone ; such as,-spasm, membrane, enlarged-glandular openings, and
bladder
are
relaxed
mucous
deformities in the prostatic portion of the urethra, the presence of bits of stone in the prostate.
produced by
use of the staff, it is well in young moderate sized one, as a large one fdls up the neck of the bladder so completely as to render the introduction of the finger after incision a matter of difficulty.
With
respect
children to choose
to the a
The staff is more liable to become entangled in obstruction than the sound, and more so in children than in adults. in the passage of the staff onwards to the bladder from passing the point too low, or in other words, in not
Delay occurs
the
point in constant gentle contact with the upper surface of the urethra, so that it catches in the inferior wall of the bulbous portion of the urethra, either in one of the openings of Cowper's glands there situated, or in the lower portion of the triangular ligament. It also occasionally catches in the keeping
relaxed
mucous membrane of the lower surface of the urethra the apex of the prostato or under the ligamentous band at the neck of the bladder, if this part be spasmodically contracted, or the entrance into it obstructed and deformed by a portion of
at
the stone To staff
being lodged
overcome
gently,
and
there.
these obstructions draw back the point of the try if it will pass on when directed more to the
upper wall of the urethra. No force however should be used
as
false passages are
readily
In some instrances it is obstructed by spasm of the urethra, in which case, if the instrument bo kept pressed against the part for a few minutes, the spasm may presently yield, or if the administration of chloroform may be useful. Where the point of the instrument constantly catches in
fail,
some obstruction, passing it immediately after micturition has been found successful; and in these cases a large instrument will often ride over an obstaclo in which a smaller onn catches; though it should not be tight in the urethra, as it then cannot be introduced with that gentleness which is the
safeguard
against making a false passage. If, after a trial of not more than 10 minutes in duration, the instrument cannot be introduced, the operation should be deferred to another day, as longer fruitless efforts may cause impatience and lead to force being used, which may result in the formation of Ihe
same
a
false passage. may not be mel with
difficulty
[passing together?a practice
was
known in
It now altogether forbidden. cases,?by the instrument deviating from the central line, being superficially felt by the finger in the rectum; by not hearing and feeling the point of the staff strike the stone fully (though a sound was heard from the side of the staff coming against the stone at the mouth of the bladder) ; and by the abdominal walls not. being pushed up by the point of the staff when its handle was depressed. I took the case out of the hands of my subordinate, and having passed the staff into the bladder, immediately operated. The boy was kept during the after-treatment in a semi-sitting posture, and
on
a
second trial*
one
I have
of the
made
a good recovery. In the other case, all the above indications of false passage were indistinct, and there was, moreover, a loud click produced by the side of the staff striking against the stone lying at the
mout.li of the bladder. The Sub-Assistant Surgeon made his incisions in the usual way, and was then greatly surprised not to find a stone. On examination, I at once came upon the well-defined, soft lips of the bladder unopened, and the entrance to the false
passage with thin undefined margin by the side of them. The stone was easily extracted, and the case made an equally good
recovery with the other. The rule, never to cut into the bladder, unless the stone can be distinctly heard as well as felt, and I would add felt as an isolated and moveable body in the bladder, is a most important one. Professor Humphrey says that the touch is often deceptive in children in whom the projecting and slightly roughened rugae of the bladder frequently communicate, when the sound is passed quickly over them, a sensation like that given by a "
stone."
Having determined the fact of a stono being present in the bladder and whether there is more than one, it then becomes necessary to judge of the size. This
point
instrument
made.
this
tied
is best determined
is seldom
by
to
a
lithotrite
;
but
as
this
in India, it is necessary to consider what other means of diagnosis are available to form a judgment on this point. If the sound strike
bladder and feel is
supplied
on
the stone
dispensaries
immediately
immovably fixed,
on
entering
the
it indicates that the stone
probably a very largo one. Tho extont of mobility of the stono in the bladder should be determined, both when this viscus is empty and after injection of water into it.; for if immovable, in tho latter case, it must
bo
a
largo
calculus.
Hawkins says:?"The size is determined by first traversing the surfaco of tho stone with tho convex part of tho sound from side to side, and then carrying tho point from before backwards." Also, inserting tho finger into tho rectum will assist in forming an opinion of the length and breadth of the stono and of its amount of mobility in the bladder. Eriohsen says:?"Any calculus above 0110 inch and a half iu its shorter diameter will present considerable difficulties in being extracted through an incision in tho prostate of tho
ordinary
size ;
namely,
not
exceeding eight
lines in
length."
July 1, The
by me was one of the following inches, length 3 inches, thickness If weighing ?iv and jvi.
largest
dimensions
:
and
inches,
A MIRROR OF HOSPITAL PRACTICE.
1873.] stone extracted
breadth 2i
of this case and from the diffithe stone, though division of the right side of the prostate and bilateral incision of the perineum were adopted, I should say that a calculus of this size, even if the patient is young and healthy, is as large as it is safe to attempt
Judging from
culty
of
the
experience
extracting
tlie extraction of.
The
case
was as
follows.
Lull, aged 30, Hindoo, healthy, with the exception of a little ana>mia. Has suffered from symptoms of stono for three years. Clieda
lie was operated upon by the left lateral operation, but sufficient space not being found for the extraction of the calculus, the right side of the prostate was incised by means of a probescalpel and bilateral incision of the perineum was made;
pointed
then by steady traction and twisting, with forcible pushing back of the neck of the bladder and prostate (which latter was
pulled
down to
calculus
was
The forco
near
the external
wound)
over
the stone, the
extracted.
required
was
such
as
to bend the blades of the
forceps. The
man
made
a
good though
rather tedious recovery.
Section IV. Choice
of operation?Lithotomy or Lithotrity.?Having examined the patient and decided that the case is one that may be operated on with a justifiable chance of success, the next, question to determine is the kind of operation which should be performed, i.e., Lithotomy or Lithotrity. It is not probable that lithotrity will ever be much in vogue in India, where a native would grow impatient and run away from hospital oidy half cured and iu a worse state than before the operation. Without wishing to detract from the merits of the crushing operation, yet for the comfort of those unversed in its mysteries, I will quote from a lecture by professor Humphrey, lately
published
in the Lancet.
good case for lithotrity is one in which lithotomy carefully performed is attended with very little risk, with quite as little, I believe, as lithotrity. "But
"
a
painful, quicker and more certain ; and the greater patients prefer this more expeditious process."
It is less
number of
Section Y.
Preliminary Treatment.?It is seldom the custom in India to subject the patient to more than one or two days' preliminary treatment. It certainly cannot be advisable to give anodynes, as these have the effect of blocking up tho secretions, nor can it often be of use to delay the operation with the object of rendering tho urine healthy by acids or alkalies; the surest plan of giving relief to his sufferings and correcting tho diseased urine, being to rid the patient of the calculus. There are some cQnditions, howover, in which it would be very unwise to operate at once,?as when the patient is suffering from constant irritative or hectic fever depending on acute or subacute congestion of the kidneys or bladder which has recently supervened, or if the patient is very emaciated and weak, rather from bad living than from the disease. If the latter bo operated upon without preliminary feeding up, even though the patient should recover, sloughing of the cornea
is liable to supervene.
(To
he
continued.)
181
