No. 1847.

JANUARY 22, 1859.

Clinical LectureON

LITHOTOMY IN CHILDRENDelivered at the London Hospital, Dec. 14th, 1858,

BY JOHN ADAMS, ESQ., F.R..C.S.,SURGEON TO THE HOSPITAL.

GENTLEMEN,-I avail myself of a case of stone in a child eightyears of age, on whom I operated last Thursday, to make a fewremarks on the difficulties which occasionally present themselvesin the performance of this operation, and to show you how suchdifficulties may be avoided. A fair share of experience in thisoperation on children, and the fact that difficulties do now andthen arise, justify me in delivering my opinion on the subject.It is impossible to deny that serious and fatal difficulties dofrequently occur in operating for stone in children, for the ex-perience of all confirms this; and hence an operation compara-tively easy to perform is regarded as the most difficult in

surgery. I cannot help thinking that there is an error in thisopinion, and that the operation may be undertaken with everyprospect of success provided attention is paid to certain definiteprinciples.

I believe that the first and foremost circumstance necessaryis a knowledge of the anatomy of the parts, and no surgeonought to undertake to cut for stone until he has repeatedlydissected the parts, and viewed them in their due relations toeach other. Fortified with the information derived from this

important source, a confidence is engendered which is highlyfavourable to a successful result. Now, anatomy teaches thatthe bladder of the child is situated differently from that of theadult, and that whereas in the latter it occupies a large portionof the pelvis, in the former it mounts higher, and a great partof it is really placed in the abdomen. This circumstance Ishall refer to again when I describe that part of the operationwhich consists in cutting into the neck of the bladder.

I shall not here detail all the symptoms of stone in thebladder, but shall particularly dwell on some circumstanceswhich appear to be rather anomalous, or at any rate difficultof explanation. A rough stone, or a mulberry calculus, is saidto induce symptoms of less urgency than a smooth stone, anda large stone frequently induces less urgent symptoms than asmall one. So also it is found that after a stone has beencrushed in the bladder, the symptoms often subside; and, more-over, when a calculus becomes encysted, the symptoms fre-quently wholly disappear. Why is this ? I think the expla-nation is this: the symptoms of stone are referable, for themost part, to the rolling of the stone against the neck of thebladder, which you know to be the. most sensitive part of thatviscus, and hence arise frequent micturition and great painafter the expulsion of the last drops of urine, &c. &c. Now, arough stone like a mulberry calculus cannot, from its nature,roll very freely towards the neck of the bladder. So also a

large stone lies in the bas fond of the bladder, and an encystedcalculus cannot roll at all; and, in my opinion, the same re-mark holds good when a stone is crashed, for the fragmentslie at the bottom of the bladder; they cannot, from their shape,roll forward, and it is only when they are washed onwards by theurine that they begin to re-excite irritation and the usual signs ofcalculus. It is well known that a stone may become encysted,and that all symptoms of its presence may cease. This wasfound to be the case in the bladder of George IV., where anunsuspected stone was after death found encysted. What-ever the symptoms may be, they are not either separately orcollectively to be regarded as truly pathognomonic; and thesurgeon, therefore, suspecting a stone, passes a steel sound intothe bladder, and at once detects it. But even in sounding youare liable to err; for your instrument may glide over a large

stone without detecting it, and a very small stone can only befelt, at least in many cases, on the introduction of the point ofthe sound into the neck of the bladder ; for being pushed intothe cavity of that viscus, it is often difficult to detect it again.I have seen many instances of this, and I have cut a case inthis theatre when nobody but myself could feel the stone, andI could only feel it myself as the point of tle sound enteredthe urethral opening into the bladder.

I propose now to make some allusion to the difficulties attend-ing the operation of lithotomy in children, for it is in childrenthat failures are apt to occur; and this brings me to a briefdescription of the modus operandi.

’1 he bladder, after being emptied, is to be carefully injectedwith warm water so as to distend it fairly and fully, and a staffis to be introduced. I cannot help attaching the highest im-portance to the selection of a staff, for I am quite sure that awant of attention to this often leads to irremediable error, andhence an operation, simple in itself, becomes altogether im-practicable. I show you instruments of various curves, and itis easy to see how a staff with a short curve may, in one of thesteps of the operation, be withdrawn from the bladder, and thesurgeon, ignorant of this fact, thrusts his knife forwards, andfails to enter the bladder. This I maintain to be a verycommon cause of failure. Hence the inventive genius of somemodern surgeons has been wracked to find out a staff whichshall combine two important elements in cutting for stone-namely, first that it shall duly reach the bladder, and at thesame time shall so present itself to the perinæum that no onecan possibly miss it. I allude to the staff of enormous curveand the rectangular staff--both instruments dangerous in theextreme; they always remind me of books you see advertised,in which the road to learn a language is "made easy to themeanest capacity."

" I would say, avoid such things; rely onyour anatomical knowledge and on fixed principles, which aresufficiently Rimnle.

When the staff is passed well into the bladder, your assistanttakes it, and holds it according to your direction. Attend towhat I am now saying. Do not direct your assistant to pushthe convexity of the staff forcibly towards the perinæum; andabove all things, do not tell him to present it to the left side,- both egregious errors. No! direct him to keep it in themesial line, which is most natural, and tell him to hook it wellunder the pubis, so that in your incision you may not trespasson the rectum. It is a great error to push the convexity of thestaff towards the perinteum, for although you. may by thismeans easily enter the groove, you cut the urethra at the bulb,and are consequently a very long way from the bladder itself,-a great error in cutting for stone. I think the managementof the staff one of the most important points of the operation,and such is the opinion of Mr. Coulson-a very experiencedlithotomist, who told me that if he had to begin his operationsde novo, he would take the whole management of the staff inhis own left hand, whilst he cut with his right.Your incision is now to be made with the view of reaching,

the membranous part of the urethra ; in fact, so as to open theurethra as close as possible to the bladder. A pointed scalpelis to be pushed well and deeply into the ischio-rectal fossa, andit often happens that in one incision you enter the groove ofthe staff, having laid bare the membranous part of the urethra.You may thrust boldly into the ischio-rectal fossa, for there isnothing in your way likely to be damaged. And this is farbetter than groping your way by a succession of small mincingincisions. If you please, you may finish the operation with thesame scalpel; but I prefer the employment of the beaked knifefor dividing the neck of the bladder. Be sure that you have

opened well the urethra, and that your instrument is in thegroove of the staff, otherwise all your efforts may fail in thatimportant step of the operation-the opening of the neck of thebladder. Taking the staff in your left hand, and pressingyour knife firmly into the groove, you depress the handle ofthe staff, and advance its point, and in this manner your knife,following the staff, enters the bladder. And how do you know.that your knife is in the bladder ? By the escape of the urine,you will say. Yes, but this will escape often when the mem-

branous part of the urethra is opened. You must rememberthat in a child the bladder is a long way off, much longer thanyou might imagine; and you may suppose that you have reachedits neck when you are not near it. Now, as this is of all thingsthe most important, I would advise you to carry on your leftforefinger along the back of your knife, and never withdrawthe staff until you can satisfy yourself by the sense of vacuityyou experience, and possibly by the feeling of the stone itself,that your finger is fairly and freely in the bladder. You maythen direct your assistant to withdraw the staff, and pass the

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forceps along your forefinger and extract the calculus. Of allthings I would say that, if you are not positive that your leftforefinger is in the bladder, you are not justified in introducingtje forceps.Of course my observations are not applicable wholly to the

operation with the straight statf and scalpel; nevertheless, theprinciples are the same, and I may sum them up in a fewwords. First, let the bladder be fairly distended with water;secondly, let your staff be sufficiently long at the end, so as toensure its constancy in the bladder during that part of theoperation in which this instrument is required; thirdly, directyour assistant to hold it well up under the arch of the pubis,so that you run no risk of wounding the rectum; fourthly, sinkyour knife fully into the ischio-rectal fossa, that by your firstincision you may lay bare the membranous portion of theurethra; fifthly, be quite sure that you have freely opened theurethra in the membranous portion, and that the beak of yourknife is well in the groove of the staff; sixthly, in dividing theneck of the bladder be quite sure that you have fairly enteredits cavity; seventhly, never withdraw the staff, or attempt topass your forceps until you are satisfied that your left forefingeris fully in the bladder; and this you will know by a rush ofurine, a sensation of vacuity, and possibly by feeling the stoneitself. There are many other points, as the limitation of yourincision into the neck of the bladder, &c, but to these I need

only make allusion, as they are well understood. But if youattend to what I have said, I feel assured that you will finishthe operation, if not quickly, or, as it is called, brilliantly, atany rate with safety.

Clinical LectureON

STRUMOUS OPHTHALMIA.Delivered in the Middlesex Hospital,

BY MITCHELL HENRY, ESQ., F.R.C.S.,SURGEON TO THE HOSPITAL, AND TO THE NORTH LONDON OPHTHALMIC

INFIRMARY.

GENTLEMEN,-The aim which I propose to myself in theclinical lectures I shall have the pleasure of delivering to youin this theatre is, to make them as practical as possible-thatis to say, directly conducive to what I believe to be the righttreatment of disease. The nature, symptoms, and especiallythe management of the affections that fall to us as surgeons,will constitute the chief subjects of our study; but the literaryand natural histories of these diseases, as well as their minutepathology, will be referred to only so far as they bear uponthat great subject, the end of all our labours, the correct treat-ment of the patients committed to our charge. For this pur-pose, I shall endeavour to make available whatever I havebeen able to gather from my own experience in practice, par-ticularly in the great field that has been open to me for thepast ten years as one of the surgical officers of this hospital,modified, as such knowledge should be, by the teaching andconversation of others, and by the perusal of books. SometimesI shall take up a particular subject, and illustrate it, so far asmay be, from cases that either are, or a short time ago were,under treatment in the hospital; and sometimes I shall selectan individual case, and endeavour to deduce from it whateverit appears to me capable of teaching. I shall never weary youwith long details, which make no impression on the mind, buttend rather to confuse and embarrass, but shall read only con-densed notes of the cases, with the object of refreshing yourmemories, and of bringing before your mind’s eye examples ofdisease that I would fain hope you are familiar with in thewards. If there be anyone here who thinks that clinicalstudies are of little importance, let me entreat of him to re-member, that what chiefly renders hospital attendance valu-able is the opportunity it affords of bringing to the unfailingtest of practice the principles that have been taught in

systematic lectures. If this brief opportunity is wasted, theloss can never be repaired. With vast, almost, indeed, withhopeless effort, and with diligent study of books, you mayperhaps in after life make up for knowledae which you might

so easily have acquired from the courses of systematic lecturesdelivered in this as in every other school of medicine; but ifyou neglect your hospital practice, the loss is final, and noamount of after-exertion can compensate for it. The livingillustrations of disease have departed; the curtain has dropped;the play is out; the actors in it have gone, and you were notthere to see.To-day I have selected for my lecture one of the commonest,

yet one of the most important of all the ordinary diseases thatcome before us-viz., strumous or scrofulous ophthalmia; andI have done so chiefly because it affords a very good oppor-tunity of considering the general principle upon which manysurgical diseases allied to it should be treated. The name isnot very happily chosen, for the ocular affection is by no meanspeculiar to the scrofulous, the worst cases being often free fromall glandular affection, strumous abscess, or tubercular deposit.It is true that you will often find it associated with all thehideous features of scrofula; but in many instances the diseaseis merely the local evidence of constitutional disorder wherethere is no pretence for imputing the strumous diathesis to thesufferer. Why it is that in some young children any irritationof the primæ viæ is attended with sore eyes, and in others withdiarrheea, or stomach cough, or a genuine flux of the bronchialmucous membrane, or not unfrequently with convulsions, aresecrets belonging to the mysteries of vital peculiarities whichare to us at present inexplicable. The fact should, however,at once suggest to us a caution not to treat any of these affec-tions as if they were mere local ones, lest by injudicious appli-cations we convert what are symptoms of bodily disorder intogenuine obstinate diseases. Now the most striking symptomthat accompanies the so-called strumous ophthalmia is intenseintolerance of light-in medical parlance, photophobia. Thissymptom is almost pathognomonic of the affection; for thoughin other diseases of the eye the patients can hardly bear thelight, in no one of them does the symptom reach to anythinglike the same intensity. Whenever you see a little patientwith the head held down, the chin buried in the bosom, theeyes carefully guarded from the least access of light, either bythe hands or by some other mechanical means, and the lidsthemselves distilling copious scalding tears, whilst the leastattempt at examination causes instantaneous spasmodic twitch-ings and startings of all the muscles of the face, especiallythose of the orbit, you may feel sure that you have before youan example of this disease. If you do get a glimpse withinrthe lids, you find the eyeballs rolled upwards, buried beneaththe upper lid, the white surface of the eye traversed by redtortuous vessels, often gathered in bundles, and leading tolittle irritable-looking pustular prominences on the cornea;whilst the lids themselves and their mucous lining are swollen,.puffy, fiery red, and often white in spots with pus. If thedisease has continued long, or has originally taken that course,you find that which should be a clear white cornea, dull, hazy,and, may be, the seat of one or more little cup-shaped ulcers,which appear as if they threatened to cut their way into theinterior of the eye; and if there have been many such attacks,you find upon the corneal surface dense whitish specks, often,however, as much attributable to the treatment as to the dis-ease. Some persons regard these cup-shaped ulcers as trulyscrofulous, in which case they should have a base of tuberculardeposit; but I am not aware that this has ever been demon-strated, and in many instances I am persuaded that they be-long to the same category of ulcers as the little painful aphthæin the mouth which often trouble persons whose stomachs areirritable. The affection is confined to the external tunics ofthe eye and lids-chiefly to their mucous lining. Truly thereis no retinitis, no iritis, generally no sclerotitis-absolutelynothing but an inflamed and congested mucous membrane.Whence, then, the overpowering photophobia ? If the retinabe sound, why cannot the patient bear the stimulus of light ?The answer to this question is not easy; indeed, I have neverseen a satisfactory explanation of the phenomenon.In reflecting upon the subject, you should remember that in

a state of health the eye is protected by the most delicate of all’coverings-by the finest, softest mucous membrane. A suffi-cient supply of mucus keeps the surface of the ball lubricated,and the lids move up and down -without the smallest friction;but let the minutest foreign body get upon the eye, a speck ofdust so small as almost to evade detection, and what is the im.mediate consequence? A spasmodic closure of the lids, an ab-solute inability to open the eye and expose it to the light, andnext a copious flow of tears to wash away the offending irritant.Are not these results exactly the phenomena of the strumousophthalmia, and do they not proceed, in part at least, from thesame cause--an altered, roughened mucous membrane, which,