A FURTHER
"SERIES
OF 42 CASES OF
LITHOLAPAXY. By Surgeon P. J. Freyer,
Bengal
M.A., MJ).,
^
Medical Service.
In tlie December number of the Indian Medical Gazette of 1882, in (he February number of 1883, anil in the March number of 1884, three papers by Surgeon P. J. Frevec were published, in which full details of seventysix cuses of litholapaxy performed by him up t.othe end of 1883 were given. The folio wine
106
THE INDIAN MEDICAL GAZETTE.
report, submitted by Dr. Freyer General N.-W. P. and Oudl),
tl?e Surgeonhis work in litholapaxy and lithotomy during the year 1884, forms a fitting sequel to these papers, and was forwarded to us for publication by Dr. "Walker, the Surgeon-General, N.-W. Provinces. Shorn of the usual official commencement and termination, the report runs as follows : Fo.uty-five cases of stone occurred in adult males. In all these litholapaxy was the operation at first entertained. It was found, however, that, in three instances, this operation was unsuitable. In one case, the presence of calculus was complicated by a narrow stricture of the urethra, so that the litholapaxy instruments could not pass into the bladder. In two cases, there was great enlargement of the prostate, in addition to the calto
on
?
5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
26" 27 28 29 30 31 32 33 34 35 36 37 38 39 40
5th January 24th ? 2nd March 11th ? 15 th ,, 25th 29th ? 16th ? 15th April 16th ? 26th ? 23rd May ...
7th June 21st ? 27th ? 29th ? 11th July 16th ? 1st August 13 th
16th 18th 24th 25th 26th 6th 8th
M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M.
Habib Chit llam Emam Bux Ghasee Shib Lall Emam Baksh Khairati Dallchand
Chotay
Kunder Singh Khadr
Mansookh Lucbmun Kooiah
Hamer Singh Abdul Mahomed Heera Singh Dbang Sammah Ali Khan Azimullah Rugbur Dial
Jungli Buddhu
Jangi Pershad
Sept, ?
10th
?
19 th 24th
?
29th
?
?
6th Octobe 11th , '
26th
,,
11th Nov, 28th ? 31st ? 2nd Dec, 6th ?
being
were,
very
large
therefore, subjected
Variety. ?
3 4
and hard. These three cases to lithotomy, death resulting in one instance. This latter case I had the honor of operating on in your presence on the 7th March ; and it may be within your recollection thiit, in addition to the calculus being very large (4?ounces),there was a tumour of the middle lobe of the prostate, which was brought away during the removal of the stone. The patient, who was 75 years of age, did well for a few days, but died, eventually, of exhaustion. In the remaining forty-two cases of stone in the adult male, litholapaxy was performed, one death only resulting, all the others making excellent recoveries. The following table will show at a glance some of the most important features of interest connected with each of these cases :? culi
Name.
operation.
2
1885.
Weight.
Date of
1
[April,
Siva Ram Tika Ram Bhadur Golam Abbas Holasee Madari Mulloo Kalloo Teekee Ram Nain Sookh
M.
Bophal
Dhoomi
M.
H.
M.
Sobhi
H.
M.
M.
13 10 0 30 30 30 5 48 40 54 3 0 10 15 0 0 10 15 20 20 30 25 5 0 15 30 20 12 15 0 11 5 8 5 45 16 16 20 18 0
II.
M. M.
M. M. M. M. M. M. M. M.
Jangi Pershad
& c
Uric
Phosphate ...
ft
Uric
Phosphate J*
Uric and Oxalate
Phosphate
Uric Uric and
Oxalate Uric
Phosphate
1 17 35 29 20 5 10 25 54 15 5 11 7 10 17 28 17 11 27
li
Oxalate Uric and Oxalate Uric
52 6
Phosphate 9f
Uric
Phosphate Uric
Oxalate Uric and Oxalate Oxalate
g -ga
otI.S
drs. grs
M. II. M. M. H. M. M. H. M. H. M. H. H.
H. H. H. M. M. H. M. H. H. M. H. H. H. M. M. H. M. H. H. H. H. H. H.
M.
Najjoo
.2
...
Uric and Oxalate Uric and Phosphate Uric ...
Result.
Successful.
Di
Successful.
2 18 5 36 15 5 5 10 35 20 2 11 26 15 6 14 20 33
By Assistant Surgeon Behabi Lall Ghose. 41 42
2nd 9th
July ?
Kashi
Singh
Nansookh *
80 40
M. M.
H. H.
19 9
The operation was, in this case,
performed by
0 0
18 10
Oxalate
Dr. J. L. Corbett, I.M.S.
15 12
Successful.
April, 1885.]
LITHOLAPAXY AND LITHOTOMY.
The derails (if the fatal case are as follows:? A Mnhammadau male, aged 2G, was admitted into (he Bareilly Civil Hospital on the 12th August, suffering from the usual symptoms of stone, which had existed six During years. the Inst, three years, the symptoms were much On admission, micturition was aggravated. extremely painful and difficult, and the urine was mixed with pus and blood. The man was in extremely bad health, very thin, and anaemic, and scarcely aide to stand up. On the 14th August. I performed litholapaxy, chloroform being administered by Dr. J. L. Corbett, by means ?f Junker's inhaler, and Dr. Humphreys being also present. The calculus was a very large ?ne, weighing 3 oz. and 1^ drs., and consisting ?f oxalate of lime. The operation lasted 52 minutes. A Iter incising the floor of the meatus slightly, a large lit.liot.rite was passed easily ; but, owing to the contraction of the walls of the bladder on the stone, it could not be grasped. The lit,hot l ite was then withdrawn, ami 4 or 5 ounces of tepid water injected, and then the calculus was easily grasped. I had to use all tne force I was capable of before the calculus gave way. The fragments were then disposed one bv one, great force being necessary to crush even the smallest fragment. The litliotrit.e had to be introduced six or seven times, and the ?vacuator as frequently, before the whole of the calculus was removed. Two or three times, during the operation, the patient was extremely faint, and almost ceased breathing ; and after the operation the pulse was almost imperceptible. Artificial respiration had to be maintained occasionally for an hour after the operation. During the course of the day, the patient passed urine freely, the earlier portions being bloodstained, the later, clear. There was no pain in the region ?f the bladder, but slight tenderness along the course of the urethra. Next day the man continued to pass clear urine, but. was extremely Weak, and expired in the afternoon. At the post-mortem examination it was found that the bladder was empty?not a trace of sand present contracted, and its walls much thickened. I he mucous coat was corrugated and slightly sacculated. The urethra was slightly congested. I he ureters were dilated along their whole extent, 80 that the tip of one's little finger could be passed into them from the bladder. The kidneys were
much
extensively diseased,?the calyces being dilated, and the medullary portions hav-
lng almost
The cortical portions The pericardium was distended with clear, straw-coloured fluid. Death 1 ?suited, apparently, from the shock of the operation and exhaustion due to the chloroform ?acting on a constitution worn out by the painful nature of the malady and the extensive disease the bladder, ureters, and kidneys. ?Emboldened by having previously, iu 1882, were
pale
disappeared.
and hard.
107
by litholapaxy si larger calculus, weighsuccessfully, from a patient aged 60, and by a consecutive series of 43 successful cases of litholapaxy, I bad no hesitation in attacking the stone in this Ctse. I feel confident the patient would have survived only for the ex-
removed
ing
oz.,
long-standing disease of the kidneys which existed, and from which he must have succumbed to any operation. A large and powerful lithotrite made for me by Weiss in the early part of last year worked admirably in this case. The manner in which a large oxalate of lime calculus, weighing over 3 oz., and as heard as flint, was crushed to atoms and removed by the aspirator in 52 minutes without any injury to the urinary passages, shows what can be done by the new operation. The patients operated on by litholapaxy varied in age, from puberty to 80 years, the average age being 46^- years ; and in March hist. I had the pleasure of exhibiting to you, at Moradabad, a patient of over 90 years?96 according to his own statement?in excellent health, on whom I had performed litholapaxy five months previously, removing 9^ drs. of hard uric acid calculus. It is due to the operation of litholapaxy to state that patients in the very worst conditions of health were operated on, no patient having been refused surgical relief. Every patient suffering from stone that came under in}' observation during the year was operated on, save two. One was an old man, emaciated from diarrhoea. He was kept in the Bareilly Civil Hospital for about a fortnight, for the purpose of improving his general health before subjecting him to litholapaxy. Growing tired of waiting, he absconded. The other case was rather a surgical curiosity. It was that of a child, who was being chloroformed with a view to my performing lithotomy. When almost fully anaesthetised, he passed urine spasmodically, and with great force ; and with it the calculus, which was small, rushed out suddenly. I have mentioned these facts to show that no selection of cases was made. In a large majority of the litholapaxy cases, I was honored by the presence of Medical Officers of the I.M.S., A.M.D., and the Medical Missionary staff, during the operations; and many of them can testify to the fact that several of the patients submitted to litholapaxy were in such an extremely wretched state of health that no cutting operation could be entertained. At the risk of lengthening this report somewhat, I am tempted to give details of one such case. The patient, Golatn Abbass, a respectable Mohammadan, of Bareilly city, aged 45, came to the hospital, suffering from all the symptoms of stone, which had existed two years. The presence of a stone was confirmed by the sound. Previously "to coming under observation, he had " undergone four courses of purgatives at the bauds of a native hakim, under the impression treme and
THE INDIAN MEDICAL GAZETTE.
108
[April,
1885.
there were, as I have already stated, three that he was suffering from some other disease adults operated on in this way, with one death. than stone. Tlie pinched and anxious expresThere were 47 cases of calculus in male children, sion of his face indicated that lie had undergone or He was pale, thin, and extreme suffering. boys, below the age of 16 years. These were all operated on by lateral lithotomy,?42 of the anaemic ; and his body and limbs consisted almost solely of skin and bone. In fact, he was a living cases being operated on by myself and 5 by my The man was unable to walk from skeleton. assistant-surgeons. All these made excellent to be carried in a and had recoveries. and debility, paiu bed. The Assistant Surgeon and subordinates Lithotomy in the child, when skilfully perof the hospital considered an operation inad- formed, has always been recognised as a sucvisable, as the patient was in a dying state. cessful operation; and it is unlikely that any My friend, Dr. Corbett, also saw the case, and other operation will be attended with such agreed with me in thinking that, were lithotomy good results. Litholapaxy appears to me to the only alternative, it would be advisable to be unsuitable in such cases, owing to the allow the man to die unoperated 011, as he would undeveloped condition of the genito-urinary be likely to die on the operating table from organs,? the bladder being small, the urethra With the kind assist- narrow, and the mucous membrane of both shock and loss of blood. ance of Dr. Corbett I performed litholapaxy, on extremely sensitive and liable to laceration. the 24th September, removing 9 drachms of Besides, in order that the aspirator may be of any hard uric acid calculus, the operation lasting practical use in removing the fragments, a much 35 minutes. With the exception of slight fever larger canula is necessary than can with safety 011 the day of the operation, the patient had be passed through the urethra of a male child. not a bad symptom, and was discharged 011 the Lithotomy and litholapaxy should be regarded 4th October, ten days after the operation, as supplementary to each other, each having its in good health. Subsequently, he frequently own sphere,?the former being the rule in male presented himself at the hospital to make his children, the latter in adults and females of all ages. It was by regarding them as such salaams, untroubled by any urinary symptom. This case is not unique, but one of many that the satisfactory result above recorded?of similar cases operated on during the year. It two deaths amongst 92 operations?has been is in such cases that litholapaxy stands forth obtained. Perhaps it may be pardonable in in brilliant contrast with that of lithotomy, and me to add to these 92 operations two cases creates a marked impression 011 the native mind of litholapaxy in the adult, and three of lithoby the rapidity of the cure and the undisturbed tomy in children, performed by me in private condition of the parts. practice during the same period. This would It will be observed that, in all cases, the give 97 operations for stone in the bladder whole of the calculus was removed at one sitting. with two deaths, or 2 per cent, nearly. Let This I consider the most essential feature of the us compare these results with those of lithotomy operation, and that on which success mainly as the only operation in patients of all ages. A short time ago, when preparing a monodepends. The prolonging of the operation over two or more sittings involves all the dangers of graph on litholapaxy, you were good enough to the old operation of lithotrity. lend me the latest published Medical AdminisThe average number of days spent in hospi- tration Reports of the various Presidencies and tal by the patients subjected to litholapaxy was Provinces in India; and from these I compiled 8*5, and I may mention that my practice has the following :? always been never to allow litholapaxy cases to leave hospital before their cures were complete. Table showing the results of Lithotomy Operations performed in Indian Hospitals in 1882. Indeed, my rule lias been to keep them in hospital two or three days longer than absolutely necessary, so as to be 011 the safe side. Result. Contrast this period with the lengthened stay 5? or Presidency Total iu hospital which lithotomy involves! Province. ??o i In my annual report of last year I referred |5 3l S S> to a new method of diagnosis of stone in the of the aspirator,?to bladder,?viz., by means 5 6 1 181 5 19 10 187 148 10 5 1 in 9 5 which I have called the attention of the profes- Bengal I' N.- W sion iu the Medical Press. During the past year, viiices & Oudh. 49 933 932 824 11 11 85 51 9 1 1 in 11 25 28 127 51 949 999 50 768 13 4 1 in 7"4 Punjab several cases of very small calculi that evaded Central Pro78 G8 5 1 73 vinces 9 12-3 1 in 8 detection by the sound were brought to light Bombay and in this way, and, in some instances, removed 450 477 377 6 6 27 Sindh 45 43 10*0 1 in 10 by Madras 6 7 5 1 1 1 14 4 1 in 9 the aspirator alone, without the aid of any crushro
,
?
r
?-
?
?
..
r o
..
..
.. ..
ing instrument. ,
.
4 uruing
now
to
the operation of
Total
lithotomy,
..
..
138
2,592
2,730 2,190
48
51
286
155
ll'O
1 in 9
April, 18S5.J
LITHOLAPAXY AND LITHOTOMY.
the above table the mortality occurring actually in hospital amongst 2,592 lithotomy cases was about 1 in 9, or 11 per cent. There were, however, 51 cases dis1 as otherwise' than ' cured,' 'relieved' charged or 4 died'; and it may be presumed that these, or the great majority of them, were taken away by their friends in a moribund condition to die at home. If these be added to those dying in total mortality will be about 13 the hospital, per cent, or one in eight nearly. I regret I am unable to give the statistics of mortality according to age- As the mortality from lithotomy increases in proportion with the ;lge of the patients operated on, these would bave the effect of bringing out more clearly tbe great diminution in mortality from litholapaxy as compared with lithotomy. The only Administration Report which gives the statistics mortality according to age is that for the N.-W. Provinces and Oudli. Taking the latest statistics for these Provinces (as being the most likely to be correct), those for 1883, we find that, amongst 987 cases of lithotomy performed iu that, year, the mortality up to the age of 20 Was 5*1 per cent., or nearly 1 in 20 ; between the ages of 20 and 40 years, 10*7 per cent., or about 1 in 9*5 ; and above 40 years, 319 per cent., or nearly I in 3. I may here refer to an impression which seems to prevail both in this country and at home, to the effect that lithotomy amongst natives of India is a much more successful operation than amongst Europeans. This impression is erroneous. The mortality above recorded amongst 2,592 cases of lithotomy of all ages, of 13 per cent., is, practically, the same as that recorded in Erichsen's
According
to
i
.
Surgery
as
?
occurring amongst Europeans.
In my own practice, at the end of the period to which this report has reference, I had performed 309 operations for stone in the bladder. Amongst these there were 161 adult males, 142 male and 6 female children. Litholapaxy was performed on 115 adult males, with 4 deaths; In and on 3 female children, with no death. 3 female sucwere the calculi children cessfully removed by rapid dilatation of the urethra: this was before the introduction of litholapaxy in my practice. There were 46 adult wales treated by lithotomy with 9 deaths. In the 142 cases of stone in male children, lateral lithotomy was the operation performed in all; and amongst these no death occurred. There were, therefore, 115 adult males treated hy litholapaxy with 4 deaths, against 46 adult wales treated by lithotomy with 9 deaths. This ?s, however, not a fair comparison, as, since the introduction of litholapaxy in my practice, only cases unsuitable for this operation were treated
by lithotomy.
litholapaxy,
Previously
to
my
practising
I had 33 cases of lithotomy in the adult male, with 6 deaths, or a mortality of
109
per cent. Since then, I have operated on 128 adult males with 7 deaths?115 litholapaxies with 4 deaths, and 13 lithotomies with 3 deaths, or 5'5 per cent. This is the proper mode of comparing the results of the two operations ; and it will be seen that the introduction of litholapaxy in my practice has been attended by a vast diminution in mortality. Though litholapaxy should be the rule in the treatment of stone in the adult, there must always be a small number of cases in which the operation will be inapplicable, as when the calculus is extremely large, or narrow stricture of the urethra exists ; and such cases will still have to be dealt with by lithotomy. As the operator gains experience, however, and with further improvements in the instruments used, the number of cases in which litholapaxy will be unsuitable will gradually diminish in number. Some of the cases treated by me by lithotomy, after I first employed litholapaxy, I would now treat by the latter operation. During the last nine months of 1884, 36 cases of stone in the adult came under my observation, and these were, one and all, treated by litholapaxy. In conclusion, I have to apologize for the length of this report, which has been drawn out to a much longer extent than I anticipated The importance of the when commencing it. subject must, however, be my excuse. I am convinced that litholapaxy is destined to play an important part in the Surgery of the future in this country, where uurivalled opportunities abound for its practice, in reducing by a large percentage the mortality, as well as the sulFering, attendant on operations for stone. The operation can no longer be said to be on its trial. The prejudice against the operation that existed (and still exists) in the minds of many Surgeons, and which is, in great part, due to the association of litholapaxy with the old operation of lithotrity, from which it is radically different, must gradually vanish before the stern reality of facts, such as those recorded in this report. The Surgeon who would give his patients suffering from stone the best prospect of recovery must practice litholapaxy. I have no hesitation in saying that, in the course of a few years, there will be few hospitals in India that will not be provided with litholapaxy instruments. Mftssoorie. over 18
"SERIES
OF 42 CASES OF
LITHOLAPAXY. By Surgeon P. J. Freyer,
Bengal
M.A., MJ).,
^
Medical Service.
In tlie December number of the Indian Medical Gazette of 1882, in (he February number of 1883, anil in the March number of 1884, three papers by Surgeon P. J. Frevec were published, in which full details of seventysix cuses of litholapaxy performed by him up t.othe end of 1883 were given. The folio wine
106
THE INDIAN MEDICAL GAZETTE.
report, submitted by Dr. Freyer General N.-W. P. and Oudl),
tl?e Surgeonhis work in litholapaxy and lithotomy during the year 1884, forms a fitting sequel to these papers, and was forwarded to us for publication by Dr. "Walker, the Surgeon-General, N.-W. Provinces. Shorn of the usual official commencement and termination, the report runs as follows : Fo.uty-five cases of stone occurred in adult males. In all these litholapaxy was the operation at first entertained. It was found, however, that, in three instances, this operation was unsuitable. In one case, the presence of calculus was complicated by a narrow stricture of the urethra, so that the litholapaxy instruments could not pass into the bladder. In two cases, there was great enlargement of the prostate, in addition to the calto
on
?
5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
26" 27 28 29 30 31 32 33 34 35 36 37 38 39 40
5th January 24th ? 2nd March 11th ? 15 th ,, 25th 29th ? 16th ? 15th April 16th ? 26th ? 23rd May ...
7th June 21st ? 27th ? 29th ? 11th July 16th ? 1st August 13 th
16th 18th 24th 25th 26th 6th 8th
M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M. M.
Habib Chit llam Emam Bux Ghasee Shib Lall Emam Baksh Khairati Dallchand
Chotay
Kunder Singh Khadr
Mansookh Lucbmun Kooiah
Hamer Singh Abdul Mahomed Heera Singh Dbang Sammah Ali Khan Azimullah Rugbur Dial
Jungli Buddhu
Jangi Pershad
Sept, ?
10th
?
19 th 24th
?
29th
?
?
6th Octobe 11th , '
26th
,,
11th Nov, 28th ? 31st ? 2nd Dec, 6th ?
being
were,
very
large
therefore, subjected
Variety. ?
3 4
and hard. These three cases to lithotomy, death resulting in one instance. This latter case I had the honor of operating on in your presence on the 7th March ; and it may be within your recollection thiit, in addition to the calculus being very large (4?ounces),there was a tumour of the middle lobe of the prostate, which was brought away during the removal of the stone. The patient, who was 75 years of age, did well for a few days, but died, eventually, of exhaustion. In the remaining forty-two cases of stone in the adult male, litholapaxy was performed, one death only resulting, all the others making excellent recoveries. The following table will show at a glance some of the most important features of interest connected with each of these cases :? culi
Name.
operation.
2
1885.
Weight.
Date of
1
[April,
Siva Ram Tika Ram Bhadur Golam Abbas Holasee Madari Mulloo Kalloo Teekee Ram Nain Sookh
M.
Bophal
Dhoomi
M.
H.
M.
Sobhi
H.
M.
M.
13 10 0 30 30 30 5 48 40 54 3 0 10 15 0 0 10 15 20 20 30 25 5 0 15 30 20 12 15 0 11 5 8 5 45 16 16 20 18 0
II.
M. M.
M. M. M. M. M. M. M. M.
Jangi Pershad
& c
Uric
Phosphate ...
ft
Uric
Phosphate J*
Uric and Oxalate
Phosphate
Uric Uric and
Oxalate Uric
Phosphate
1 17 35 29 20 5 10 25 54 15 5 11 7 10 17 28 17 11 27
li
Oxalate Uric and Oxalate Uric
52 6
Phosphate 9f
Uric
Phosphate Uric
Oxalate Uric and Oxalate Oxalate
g -ga
otI.S
drs. grs
M. II. M. M. H. M. M. H. M. H. M. H. H.
H. H. H. M. M. H. M. H. H. M. H. H. H. M. M. H. M. H. H. H. H. H. H.
M.
Najjoo
.2
...
Uric and Oxalate Uric and Phosphate Uric ...
Result.
Successful.
Di
Successful.
2 18 5 36 15 5 5 10 35 20 2 11 26 15 6 14 20 33
By Assistant Surgeon Behabi Lall Ghose. 41 42
2nd 9th
July ?
Kashi
Singh
Nansookh *
80 40
M. M.
H. H.
19 9
The operation was, in this case,
performed by
0 0
18 10
Oxalate
Dr. J. L. Corbett, I.M.S.
15 12
Successful.
April, 1885.]
LITHOLAPAXY AND LITHOTOMY.
The derails (if the fatal case are as follows:? A Mnhammadau male, aged 2G, was admitted into (he Bareilly Civil Hospital on the 12th August, suffering from the usual symptoms of stone, which had existed six During years. the Inst, three years, the symptoms were much On admission, micturition was aggravated. extremely painful and difficult, and the urine was mixed with pus and blood. The man was in extremely bad health, very thin, and anaemic, and scarcely aide to stand up. On the 14th August. I performed litholapaxy, chloroform being administered by Dr. J. L. Corbett, by means ?f Junker's inhaler, and Dr. Humphreys being also present. The calculus was a very large ?ne, weighing 3 oz. and 1^ drs., and consisting ?f oxalate of lime. The operation lasted 52 minutes. A Iter incising the floor of the meatus slightly, a large lit.liot.rite was passed easily ; but, owing to the contraction of the walls of the bladder on the stone, it could not be grasped. The lit,hot l ite was then withdrawn, ami 4 or 5 ounces of tepid water injected, and then the calculus was easily grasped. I had to use all tne force I was capable of before the calculus gave way. The fragments were then disposed one bv one, great force being necessary to crush even the smallest fragment. The litliotrit.e had to be introduced six or seven times, and the ?vacuator as frequently, before the whole of the calculus was removed. Two or three times, during the operation, the patient was extremely faint, and almost ceased breathing ; and after the operation the pulse was almost imperceptible. Artificial respiration had to be maintained occasionally for an hour after the operation. During the course of the day, the patient passed urine freely, the earlier portions being bloodstained, the later, clear. There was no pain in the region ?f the bladder, but slight tenderness along the course of the urethra. Next day the man continued to pass clear urine, but. was extremely Weak, and expired in the afternoon. At the post-mortem examination it was found that the bladder was empty?not a trace of sand present contracted, and its walls much thickened. I he mucous coat was corrugated and slightly sacculated. The urethra was slightly congested. I he ureters were dilated along their whole extent, 80 that the tip of one's little finger could be passed into them from the bladder. The kidneys were
much
extensively diseased,?the calyces being dilated, and the medullary portions hav-
lng almost
The cortical portions The pericardium was distended with clear, straw-coloured fluid. Death 1 ?suited, apparently, from the shock of the operation and exhaustion due to the chloroform ?acting on a constitution worn out by the painful nature of the malady and the extensive disease the bladder, ureters, and kidneys. ?Emboldened by having previously, iu 1882, were
pale
disappeared.
and hard.
107
by litholapaxy si larger calculus, weighsuccessfully, from a patient aged 60, and by a consecutive series of 43 successful cases of litholapaxy, I bad no hesitation in attacking the stone in this Ctse. I feel confident the patient would have survived only for the ex-
removed
ing
oz.,
long-standing disease of the kidneys which existed, and from which he must have succumbed to any operation. A large and powerful lithotrite made for me by Weiss in the early part of last year worked admirably in this case. The manner in which a large oxalate of lime calculus, weighing over 3 oz., and as heard as flint, was crushed to atoms and removed by the aspirator in 52 minutes without any injury to the urinary passages, shows what can be done by the new operation. The patients operated on by litholapaxy varied in age, from puberty to 80 years, the average age being 46^- years ; and in March hist. I had the pleasure of exhibiting to you, at Moradabad, a patient of over 90 years?96 according to his own statement?in excellent health, on whom I had performed litholapaxy five months previously, removing 9^ drs. of hard uric acid calculus. It is due to the operation of litholapaxy to state that patients in the very worst conditions of health were operated on, no patient having been refused surgical relief. Every patient suffering from stone that came under in}' observation during the year was operated on, save two. One was an old man, emaciated from diarrhoea. He was kept in the Bareilly Civil Hospital for about a fortnight, for the purpose of improving his general health before subjecting him to litholapaxy. Growing tired of waiting, he absconded. The other case was rather a surgical curiosity. It was that of a child, who was being chloroformed with a view to my performing lithotomy. When almost fully anaesthetised, he passed urine spasmodically, and with great force ; and with it the calculus, which was small, rushed out suddenly. I have mentioned these facts to show that no selection of cases was made. In a large majority of the litholapaxy cases, I was honored by the presence of Medical Officers of the I.M.S., A.M.D., and the Medical Missionary staff, during the operations; and many of them can testify to the fact that several of the patients submitted to litholapaxy were in such an extremely wretched state of health that no cutting operation could be entertained. At the risk of lengthening this report somewhat, I am tempted to give details of one such case. The patient, Golatn Abbass, a respectable Mohammadan, of Bareilly city, aged 45, came to the hospital, suffering from all the symptoms of stone, which had existed two years. The presence of a stone was confirmed by the sound. Previously "to coming under observation, he had " undergone four courses of purgatives at the bauds of a native hakim, under the impression treme and
THE INDIAN MEDICAL GAZETTE.
108
[April,
1885.
there were, as I have already stated, three that he was suffering from some other disease adults operated on in this way, with one death. than stone. Tlie pinched and anxious expresThere were 47 cases of calculus in male children, sion of his face indicated that lie had undergone or He was pale, thin, and extreme suffering. boys, below the age of 16 years. These were all operated on by lateral lithotomy,?42 of the anaemic ; and his body and limbs consisted almost solely of skin and bone. In fact, he was a living cases being operated on by myself and 5 by my The man was unable to walk from skeleton. assistant-surgeons. All these made excellent to be carried in a and had recoveries. and debility, paiu bed. The Assistant Surgeon and subordinates Lithotomy in the child, when skilfully perof the hospital considered an operation inad- formed, has always been recognised as a sucvisable, as the patient was in a dying state. cessful operation; and it is unlikely that any My friend, Dr. Corbett, also saw the case, and other operation will be attended with such agreed with me in thinking that, were lithotomy good results. Litholapaxy appears to me to the only alternative, it would be advisable to be unsuitable in such cases, owing to the allow the man to die unoperated 011, as he would undeveloped condition of the genito-urinary be likely to die on the operating table from organs,? the bladder being small, the urethra With the kind assist- narrow, and the mucous membrane of both shock and loss of blood. ance of Dr. Corbett I performed litholapaxy, on extremely sensitive and liable to laceration. the 24th September, removing 9 drachms of Besides, in order that the aspirator may be of any hard uric acid calculus, the operation lasting practical use in removing the fragments, a much 35 minutes. With the exception of slight fever larger canula is necessary than can with safety 011 the day of the operation, the patient had be passed through the urethra of a male child. not a bad symptom, and was discharged 011 the Lithotomy and litholapaxy should be regarded 4th October, ten days after the operation, as supplementary to each other, each having its in good health. Subsequently, he frequently own sphere,?the former being the rule in male presented himself at the hospital to make his children, the latter in adults and females of all ages. It was by regarding them as such salaams, untroubled by any urinary symptom. This case is not unique, but one of many that the satisfactory result above recorded?of similar cases operated on during the year. It two deaths amongst 92 operations?has been is in such cases that litholapaxy stands forth obtained. Perhaps it may be pardonable in in brilliant contrast with that of lithotomy, and me to add to these 92 operations two cases creates a marked impression 011 the native mind of litholapaxy in the adult, and three of lithoby the rapidity of the cure and the undisturbed tomy in children, performed by me in private condition of the parts. practice during the same period. This would It will be observed that, in all cases, the give 97 operations for stone in the bladder whole of the calculus was removed at one sitting. with two deaths, or 2 per cent, nearly. Let This I consider the most essential feature of the us compare these results with those of lithotomy operation, and that on which success mainly as the only operation in patients of all ages. A short time ago, when preparing a monodepends. The prolonging of the operation over two or more sittings involves all the dangers of graph on litholapaxy, you were good enough to the old operation of lithotrity. lend me the latest published Medical AdminisThe average number of days spent in hospi- tration Reports of the various Presidencies and tal by the patients subjected to litholapaxy was Provinces in India; and from these I compiled 8*5, and I may mention that my practice has the following :? always been never to allow litholapaxy cases to leave hospital before their cures were complete. Table showing the results of Lithotomy Operations performed in Indian Hospitals in 1882. Indeed, my rule lias been to keep them in hospital two or three days longer than absolutely necessary, so as to be 011 the safe side. Result. Contrast this period with the lengthened stay 5? or Presidency Total iu hospital which lithotomy involves! Province. ??o i In my annual report of last year I referred |5 3l S S> to a new method of diagnosis of stone in the of the aspirator,?to bladder,?viz., by means 5 6 1 181 5 19 10 187 148 10 5 1 in 9 5 which I have called the attention of the profes- Bengal I' N.- W sion iu the Medical Press. During the past year, viiices & Oudh. 49 933 932 824 11 11 85 51 9 1 1 in 11 25 28 127 51 949 999 50 768 13 4 1 in 7"4 Punjab several cases of very small calculi that evaded Central Pro78 G8 5 1 73 vinces 9 12-3 1 in 8 detection by the sound were brought to light Bombay and in this way, and, in some instances, removed 450 477 377 6 6 27 Sindh 45 43 10*0 1 in 10 by Madras 6 7 5 1 1 1 14 4 1 in 9 the aspirator alone, without the aid of any crushro
,
?
r
?-
?
?
..
r o
..
..
.. ..
ing instrument. ,
.
4 uruing
now
to
the operation of
Total
lithotomy,
..
..
138
2,592
2,730 2,190
48
51
286
155
ll'O
1 in 9
April, 18S5.J
LITHOLAPAXY AND LITHOTOMY.
the above table the mortality occurring actually in hospital amongst 2,592 lithotomy cases was about 1 in 9, or 11 per cent. There were, however, 51 cases dis1 as otherwise' than ' cured,' 'relieved' charged or 4 died'; and it may be presumed that these, or the great majority of them, were taken away by their friends in a moribund condition to die at home. If these be added to those dying in total mortality will be about 13 the hospital, per cent, or one in eight nearly. I regret I am unable to give the statistics of mortality according to age- As the mortality from lithotomy increases in proportion with the ;lge of the patients operated on, these would bave the effect of bringing out more clearly tbe great diminution in mortality from litholapaxy as compared with lithotomy. The only Administration Report which gives the statistics mortality according to age is that for the N.-W. Provinces and Oudli. Taking the latest statistics for these Provinces (as being the most likely to be correct), those for 1883, we find that, amongst 987 cases of lithotomy performed iu that, year, the mortality up to the age of 20 Was 5*1 per cent., or nearly 1 in 20 ; between the ages of 20 and 40 years, 10*7 per cent., or about 1 in 9*5 ; and above 40 years, 319 per cent., or nearly I in 3. I may here refer to an impression which seems to prevail both in this country and at home, to the effect that lithotomy amongst natives of India is a much more successful operation than amongst Europeans. This impression is erroneous. The mortality above recorded amongst 2,592 cases of lithotomy of all ages, of 13 per cent., is, practically, the same as that recorded in Erichsen's
According
to
i
.
Surgery
as
?
occurring amongst Europeans.
In my own practice, at the end of the period to which this report has reference, I had performed 309 operations for stone in the bladder. Amongst these there were 161 adult males, 142 male and 6 female children. Litholapaxy was performed on 115 adult males, with 4 deaths; In and on 3 female children, with no death. 3 female sucwere the calculi children cessfully removed by rapid dilatation of the urethra: this was before the introduction of litholapaxy in my practice. There were 46 adult wales treated by lithotomy with 9 deaths. In the 142 cases of stone in male children, lateral lithotomy was the operation performed in all; and amongst these no death occurred. There were, therefore, 115 adult males treated hy litholapaxy with 4 deaths, against 46 adult wales treated by lithotomy with 9 deaths. This ?s, however, not a fair comparison, as, since the introduction of litholapaxy in my practice, only cases unsuitable for this operation were treated
by lithotomy.
litholapaxy,
Previously
to
my
practising
I had 33 cases of lithotomy in the adult male, with 6 deaths, or a mortality of
109
per cent. Since then, I have operated on 128 adult males with 7 deaths?115 litholapaxies with 4 deaths, and 13 lithotomies with 3 deaths, or 5'5 per cent. This is the proper mode of comparing the results of the two operations ; and it will be seen that the introduction of litholapaxy in my practice has been attended by a vast diminution in mortality. Though litholapaxy should be the rule in the treatment of stone in the adult, there must always be a small number of cases in which the operation will be inapplicable, as when the calculus is extremely large, or narrow stricture of the urethra exists ; and such cases will still have to be dealt with by lithotomy. As the operator gains experience, however, and with further improvements in the instruments used, the number of cases in which litholapaxy will be unsuitable will gradually diminish in number. Some of the cases treated by me by lithotomy, after I first employed litholapaxy, I would now treat by the latter operation. During the last nine months of 1884, 36 cases of stone in the adult came under my observation, and these were, one and all, treated by litholapaxy. In conclusion, I have to apologize for the length of this report, which has been drawn out to a much longer extent than I anticipated The importance of the when commencing it. subject must, however, be my excuse. I am convinced that litholapaxy is destined to play an important part in the Surgery of the future in this country, where uurivalled opportunities abound for its practice, in reducing by a large percentage the mortality, as well as the sulFering, attendant on operations for stone. The operation can no longer be said to be on its trial. The prejudice against the operation that existed (and still exists) in the minds of many Surgeons, and which is, in great part, due to the association of litholapaxy with the old operation of lithotrity, from which it is radically different, must gradually vanish before the stern reality of facts, such as those recorded in this report. The Surgeon who would give his patients suffering from stone the best prospect of recovery must practice litholapaxy. I have no hesitation in saying that, in the course of a few years, there will be few hospitals in India that will not be provided with litholapaxy instruments. Mftssoorie. over 18
