GUY'S HOSPITAL. Gunshot Wound

1850 The Lancet  
Lithotrity in a boy, eight years of age. (Under the care of Mr. WORMALD.) HosPITAL surgeons are very frequently called upon to free patients from the torture of stone in the bladder, and from their experience it would appear that such patients are generally, as regards age, at the top and bottom of the scale. Mr. Coulson has well remarked, in his work, " On the Diseases of the Bladder and Prostate Gland," " Calculus is more common in temperate than in warm or very cold climates, and is much
more » ... es, and is much more incident to early years than to any other period, and to old age more than to the prime of life. Hippocrates notices the fact, that infants at the breast are not exempt from the disease; and our old English author, Philip Barrough, in his * Methode of Physick' observes, Stones in the bladder do ingender oftener in children than in other folhe"' ...... " Although the rich, the luxurious, and the indolent are at a certain age more prone to calculus than other classes, the poor and the destitute, in early years, enjoy no immunity from it; for the ill-fed and half-clothed children of the manufacturing and labouring population are frequently afflicted with stone." Though the actual cause of this occurrence has not yet been satisfactorily made out, it would seem as if primary assimilation had much to do with the phenomena, since we see that those who live luxuriously, as well as the ill-fed, are equally obnoxious to calculous affections. The little boy whom Mr. Wormald had lately under his care, belongs to a very humble class of society; he is thin and pale, only eight years of age, has been suffering from all the symptoms of stone for the last twelve months, and was admitted May 6,1850. When at school his bladder used to be very irritable, and matters were made worse, as the schoolmaster, who suspected boyish tricks, refused to let the child leave the room as often as he requested, and frequently kept him in the whole morning. It is a pity that those who have the care of the young do not take the trouble of learning the leading morbid peculiarities of youth. It often happened that when the boy was at last released, he found it impossible to empty his bladder, and was generally relieved by the catheter. " At other times," as the poor little sufferer truly expressed it, " I tried to pass water every few minutes, and could only void a teaspoonful at a time." So irritated were the bladder and urethra, that a purulent discharge through the latter took place; the child was constantly pulling the prepuce, and his sufferings were very great. At last complete retention came on, caused by a stone blocking up the urethra just at the peno-scrotal angle. The boy was then admitted under the care of Mr. Wormald, and the nature of the case being recognised, an incision was made into the urethra just where the calculus could be felt, and Alr. Wormald had no difficulty in removing it. The fact of this stone (which was about the size of a damson stone, and principally composed of phosphate of lime) having found its way into the urethra, made Mr. Wormald suspect that calculi of the same nature were in all probability lying in the bladder. This induced him to sound that viscus, and having ascertained the presence of a stone, he resolved to have recourse to lithotrity in order to free his patient from this foreign body. Crushing the calculus was preferred to the operation of lithotomy, principally as an aperture of a tolerable size already existed at a short distance from the bulbous por. tion of the urethra, and as it might thus be supposed that the fragments would find a more ready outlet when the stone had been crushed, and likewise because No. 9 instrument could readily be passed. Mr. Wormald broke the stune, which proved to be rather of a hard description. The little patient bore the operation extremely well, and he had very few of the unpleasant symptoms which sometimes follow lithotrity. The operation was repeated five times, four or five days intervening between each, and a great many fragments were passed through the perinaeal wound. This opening, however, closed before the whole of the detritus had escaped, and lTr. Wormald found it necessary to incise the cicatrix in consequence of an accumulation of fragments. About two months after admission, the little patient had greatly improved; he experienced no pain in passing his urine; he did so but three or four times a day. Some of the fragments were being discharged without giving him any trouble, and he, indeed, was sometimes not aware of their passage. Sleep and appetite were in the meanwhile satisfactory. Mr. Wormald took occasion to remark, after one of the operations, how cautious we should be in passing either the staff or the lithotrite into a child's bladder. The urethra in such patients, especially about the membranous portion of that canal, is extremely thin, and the slightest violence would rupture it. It is therefore very advisable that the index finger should be passed into the rectum, so that the force employed might accurately be calculated, and the instrument be gently guided into the bladder. The sensation conveyed to the finger placed in the rectum is just as if the instrument were hardly separated from the former, and Mr. Wormald stated that lie had had an opportunity of making an autopsy upon a child, whose urethra had been thus lacerated, and who had died from extravasation of urine. About three months after admission, the aperture of the urethra in the perinseum, through which so many fragments had passed, closed up ; and the bladder being carefully sounded a few days afterwards, that viscus was found perfectiy free from any calculous concretions or fragments. Some of the latter were rather large, and principally com, posed of phosphates externally and oxalate of lime internally. Though the whole of the detritus was unfortunately not saved, it may be conjectured that the original stone was rather of large size. The patient's health is gradually improving ; his diet has all along been generous, though not too stimulating, and the medicines which were prescribed consisted principally of sedatives. The favourable results obtained in this case are encouraging as regards lithotrity in children; for it is plain that the patient was not of robust health, that his bladder had been subjected to a great deal of irritation, and that he was not altogether a very favourable subject. The great advantage with young patients is the little difficulty offered by the prostate gland; which organ, with adults, may present great obstacles. Thus we find Mr. Coulson saying, in the book above mentioned, , "The state of the prostate gland ought to be particularly examined when considering the propriety of performing litho-' tripsy." It would appear that the secret lies in choosing the ; patients who are fit for the operation of lithotrity; this ; being carefully done, we might perhaps arrive at more favour-; able statistics than the following, which are given by M. ; Velpeau, and quoted by Mr. Coulson:-"Out of 206 patients ! operated upon, 108 (a very little more than one in two) recover immediately; 80, or nearly one in two and a half, die; and r 18 retain the stone, and will be lost; or, in other words, 108 ' cases cured, to 98 in which death is immediately induced, or t may not be averted within a brief interval of time." GUY'S HOSPITAL. Gunshot Wound. (Under the care of Mr. HILTON.) THE peculiarities of gunshot wounds are numerous. Balls, after having struck a bony prominence, or passed through the soft parts, may take a very circuitous and extraordinary course; but, as Mr. Samuel Cooper justly observes, " if we had all the data for our calculations, the seemingly extraordinary course which a ball sometimes takes would be completely explicable by the laws of projectiles." One of the most extraordinary courses a ball can take is to retrace its steps, as it were, and fall out again by the orifice through which it entered. This, as is well known, may occur when a ball drives in a portion of the clothes, which are then inverted like the finger of a glove; and when the extremity of the cone thus formed is not traversed by the projectile, the ball will be brought back again by the tendency of the portion of clothing to resume its original situation. Thus the wound may be found without perforation of clothes and without ball. Such cases must, however, have left considerable doubt in the minds of surgeons before the reason of the unwonted appearances was found out. Nor is this the only way in which a ball may find its way back again out of the body, after having inflicted a wound.
doi:10.1016/s0140-6736(02)88701-3 fatcat:47cwudceurhwjhsr4krzqmbzuu