to say, successfully, and now every case of stone in the bladder is got rid off except under exceptional circumstances by litholapaxy. This time I perform the operation without injecting any fluid into the bladder,and therefore patients do not strain as much as they used to do when the bladder was filled witli fluid in my former cases. The operation takes much time, and a beginner (jets nervous when a patient is long under chloroD form, sometimes with irregular, rapid, and noisy breathing. A beginner would also become diffident by failure or delay in getting hold of the In the beginning of this stone by the lithotrite. series,therefore, when the stone was small, it was completely crushed; but when at all large, and I feared to prolong the operation, I stopped crushing any longer and terminated the operation by performing median lithotomy and getting rid of all the remaining fragments,?litholapaxy combined with mediau lithotomy?thus relieving the patient. I could thus see what work the lithotrite had performed and what had remained ?
?
O
?
uncompleted.
I could also judge of the state of the bladder. a short time I got more confidence aud litholapaxy is now the ruling operation for stone in the bladder of old persons, adults, and children, whether male or female. When Michael Angelo lay on his death-bed, he is reported to have " I am learning still." His skill was said, unrivalled; his fame world-wide; he was in ex" treme old age, aud yet he was learning still." " still." Each one is learning patient teaches Every us something., aud our failures are the stern but kindly monitors from whom we learn the most. When Hannibal, the famous general, was asked in his old age, how it was that he always won his batHe replied, because he was always beaten tles. when young, and so it is. The touch-stone of disaster tries aud teaches us all. Each mishap is a step, and the loss of youth is compensated by the skill, the foresight and the command of success which prolonged experience and constant practice alone can give. Experience affords confidence and prepares men to battle against disease with firmness and circumspection. In
EXPERIENCES OF A BEGINNER IN LITHOLAPAXY. By T. M. SHAH, Assistant-Surgeon, Junagadlv State Hospital, About three years back I took to litholapaxy. After four or five successful cases I lost three or four patients, and theu I gave up the operation and resorted to the old established operation of lithotomy. Though old and of established reputation, lithotomy always entails more or less anxiety after the performance of the operation, especially when done in persons grown up and advanced in years. Hemorrhage, pyaemia, peritonitis, cystitis, and kidney disease are lurking enemies which now and then snatch away the life of the patient to the great annoyance of lithotomists. Added to these, the tedious process of recovery, the prolonged stay in hospital, the soaking of bed-clothes with urinary discharges and long confinement in bed, afforded sufficient reasons for inventing a better, cleverer, speedier, less risky method of dealing with this mechanical urinary disease. Lithotrity or the operation for crushing the calculus in bladder is of no recent date, but the credit of bringing the process to perfection is due to the eminent American Surgeon Dr. Bigelow. The operation is known by his name, or is now
commonly designated Litholapaxy. Keegan's statistics published in the Indian Medical Journal, January and February 1890,
more
Dr.
afforded
stimulus to retry the operation of I began to perform the operation cautiously and tenaciously, and, I am glad me a
litholapaxy.
more
Cases.?Litholapaxy
with
Median
Operation. 1.
Rauchor
fered from
Naran, male, symptoms
stone
cet. 20 years, sufa He year.
for
cut for stone by a quack twelve years ago ; there is a mark of the operation on the right side of the raphe. Presence of stone ascertained by sounding the bladder. was
1890.?Put under chloroform, aud partly and some debris aspirated. Catheter was not suitable to the sucking apparatus. After trying the crushing and aspirating processes for an hour, mediau operation was performed, and the large fragments were removed,1 24th
May
stone crushed
Nov.
T. M. SHAH'S OASES OF LITHOLAPAXY.
1891.]
the
remaining pulverized portion was aspirated through the perineal opening; bladder washed out. Total quantity of debris and fragments collected, weighed 300 grains. 8 p.m.?Bleeding from wound; bladder distended; the patient straining; female catheter
introduced
through perineal wound
25th.?Female catheter
came
and retained.
away
during
night. Bleeding again. Bladder washed out; preforated tube introduced and retained. Yesp. Tube came out; patient is straining; no
bleeding.
29th.?Some bleeding from the wound again. June.?A few clots of blood came away from bladder. 12tli. Discharged cured; wound healed up; ail urine passing per urethra, 2. Rama Jasa, male, ait. 30, suffered from stone symptoms for the last four years. Bladder sounded and stone detected. 9tli June 1890.?Put under chloroform. & gr. of morphia injected under skin and lithotrite introduced. The stone was extremely hard, so much so that the aid of an assistant was required two or three times to rotate the screw. Catheter was unsuitable ; however some debris was withdrawn. Then the median operation was performed, and a hard dark mulberry oxalate stone weighing 360 grs. extracted. The debris weighed 40 grs. besides. 11 tli.?Had fever with shivering.
28th.?Subsequent
wound
healed;
discharged.
progress
all urine
passing
satisfactory per
;
urethra;
3. Kalo Natlio, male, cet. 20 years, suffered from stone symptoms for eight years ; urine contained some albumen ; patient healthy in appearance, and stone felt in bladder. 14tli June 1890.?Put under chloroform and morphia injected under skin. After injecting 4 oz. of water into bladder, lithotrite was introAfter several crushduced and stone crushed. ings, a large cannula was passed in and a little debris withdrawn; much did not come out. Lithotrite again passed, and fragments further crushed. At last a fragment became jammed between the blades of lithotrite, and the male blade did not quite go home into the female one. All attempts to get rid of the jammed portion failed. No force could drive the male blade home; en the other hand, the screw-action of lithotrite became impaired. The blades remained about ^ inch open, and all hopes to close them were given up. The lithotrite was then withdrawn as it was, the open ends with jammed debris between receded from the neck, passed the membranous portion of urethra and then stopped at the commencement of penile portion. No judicious amount of force could effect its further progress. The elbow of the blades was then made prominent in the perineal region and cut down upon in the median line. The point of
327
the knife passed into the fenestrum of the female and next guided by this groove a director was passed into the bladder, knife was drawn along the director, wound enlarged, and all the fragments aud debris washed out of bladder. Lastly, the jammed ends of blades of lithotrite were passed out of the perineal wound, aud all the compressed debris extracted from between them; they were then closed fully, and finally withPerforated tube indrawn from the urethra. troduced into bladder per periueo and retained. Operation occupied If hour. Quantity of collected debris weighed 180 grains. 7 p.m.?Patient unconscious; body cold ;
blade,
breathing
stertorous.
restored; body temperature 100?; pulse 100. 15^.?Consciousness
warm;
Scrotum is swollen ; vomiting. Vesp. temperature 103?; pulse 135. A fit of shivering ; urine passing per tube. 22nd.?Temperature and pulse kept high
the last week, but they are now down; tube came away, swelling of scrotum subsiding, but left testicle is inflamed. 29th.?Swelling of testicle continues, but is less tender. Has urticarial eruptions. Patieut then gradually improved. 15tli July.?Patient is well in every other way, but all urine still passes per wound and none through urethra. Catheter does not pass through urethra into bladder.
during
22nd.?The
urethra
having been roughly
dealt with in the beginning, appears to have contracted about its scrotal portion, aud its continuity is obstructed. Put uuder chloroform, and director passed through perineal opening into bladder. Catheter was next introduced per external meatus aud forced into the bladder along the director and tied in. 24th.?Urine passes through catheter; none
through perineum.
29th.?Perineal opening closed ; catheter removed. All urine passes through urethra. Discharged well. 4. Gigo Bechar, male child, cut. 8 years, suffered from vesical stone for the last six months. 28M June 1890.?Put under chloroform ; stone was partly crushed and 20 grains of debris withdrawn by aspiration. After second introduction of lithotrite, some debris Avas jammed between the blades and difficulty was experienced in its withdrawal, causing more or less bruising of the urethral mucous membrane. Median operation was then performed, and a large mulberry stone weighing 520 grains and measuring two inches in its longest diameter was extracted. Perforated tube tied in. 5th July.?Temperature and pulse rose from the next day of operation and they have now subsided ; tube removed. 13th.?Child had two sharp attacks of diarrhoea, and is very much reduced in flesh and
strength;
328
INDIAN MEDICAL GAZETTE.
bed sores have formed, and urine passes per wound. 25th.?An abscess formed in the scrotum and is discharorina" matter and uiine. Treatment : Quinine, tonics, cod-liver oil, &o. 20th August.?Urine passes per urethram,scrotal fistula and perineal wound with copious discharge of mucus and pus. 31 st.?Perineal and scrotal openings closed. All urine passing per urethram. Discharged well. 5. Bhagwan Bechar, male child, at. 5 years, suffered from symptoms of vesical calculus for some six months. 25th October 1890.?Put under chloroform and lithotrite No. 6 introduced; diameter of stone a little more than f inch. Even after four introductions of lithotrite and cannula, large fragments remained ; it took three-fourths of an hour. Fragments could not be easily caught. Lateral lithotomy was then performed, and all fragments
removed,
weighing
Child had
189 grs.
which was circumcised, meatus was narrow, and was incised for introduction of lithotrite. \1th November 1890.?Wound healed, and child discharged.
phimosis,
Cases 6.
of pure litholapaxy.? Ramji Kano, male, 32 years, suffering from
stone in the bladder for 18 months.
Urine contains albumen 9th August 1890.?Put under chloroform, and morphia injected hypodermically, urethra very capacious. Lithotrite and cannula introduced five times, and a total of 413 grs. of debris extracted. Operation occupied two hours. Patient shivering for some time while under chloroform.
IU/j.?Yesterday temperature was 103?, today it is 101?. Passed a few fragments with urine.
loth.?Discharged well. 7. Uka Shamji, male child,
6 years, suffering from stone in the bladder for two years. 24th August.?Litholapaxy performed under chloroform. Five introductions of lithotrite No. 8 and cannula Nos. S and 10. Urethra capacious. Operation occupied one hour. Quantity of debris extracted, weighed 45 grs. 1st September.?Child had no fever the next day after operation, but on the third day temperature rose to 101-6?. A few small fragments passed with urine. Micturition painful for a few days. Discharged well. Kurson Becharji, male, aged 40. Duration 8. of stone symptoms ten months. Urine contains
albumen. 17th October 1890.?Litholapaxy performed. Lithotrite Nos. 6 and 8 introduced. Cannula introduced once. 8 grs. of debris removed. No more stone
perceptible.
[Nov.
1891,
did not rise above norPassed a small fragment on 20th. Discharged well. Kalo Ladho, male, aged 35. Vesical irri9. tability since one month. 17th October 1890.?Chloroform administered, morphia injected hypodermically. Bladder sounded, and a distinct click was audible. Lithotrite No. 6 introduced three times, and 5 grs. of dark coloured debris extracted. 24th.?Discharged well without auy fever or other trouble. 10. Bhimo Jivan, male, 36 years. Vesical stone of eight months' standing. Some trace of albumen in urine. 24?A November 1890.?Chloroform administered, morphia injected. Lithotrite No. 10 and 100 grs. of debris recannula introduced once. moved. 26th.?Temperature 101?. Burning pain while
25th.?Temperature
mal.
micturating.
December.?Discharged well. 11. Punja Jamal, male, aged 60 years. Stone in the bladder since three years. Urine contains Is extremely debilitated. a trace of albumen. 21 st December 1890.?Litholapaxy under chloroform and morphia. Lithotrite Nos. 10 and 14 and cannula passed five times. Total quantity of debris removed 294 grs., meatus urinarius was incised in order to allow the Nucleus of stone passage of large instruments. was extremely hard, and could not be pulverized by smaller instrument. 29th.?Micturition painful. Passes fragments from time to time. Urine turbid, white in colour. 9th January 1891.?Passes mucus iu urine* Micturition not painful. Patient kept in hospital longer for the sake of weakness. Dis11 jf/i
charged. 12. Poput Dewdas, Vesical
male
child, 5 years* years' standing. 1890.?Litholapaxy performed,
stone of two and-a-half
22nd December and pulverized ; stone weighing 74 grs. extracted. 242/
?
O
?
uncompleted.
I could also judge of the state of the bladder. a short time I got more confidence aud litholapaxy is now the ruling operation for stone in the bladder of old persons, adults, and children, whether male or female. When Michael Angelo lay on his death-bed, he is reported to have " I am learning still." His skill was said, unrivalled; his fame world-wide; he was in ex" treme old age, aud yet he was learning still." " still." Each one is learning patient teaches Every us something., aud our failures are the stern but kindly monitors from whom we learn the most. When Hannibal, the famous general, was asked in his old age, how it was that he always won his batHe replied, because he was always beaten tles. when young, and so it is. The touch-stone of disaster tries aud teaches us all. Each mishap is a step, and the loss of youth is compensated by the skill, the foresight and the command of success which prolonged experience and constant practice alone can give. Experience affords confidence and prepares men to battle against disease with firmness and circumspection. In
EXPERIENCES OF A BEGINNER IN LITHOLAPAXY. By T. M. SHAH, Assistant-Surgeon, Junagadlv State Hospital, About three years back I took to litholapaxy. After four or five successful cases I lost three or four patients, and theu I gave up the operation and resorted to the old established operation of lithotomy. Though old and of established reputation, lithotomy always entails more or less anxiety after the performance of the operation, especially when done in persons grown up and advanced in years. Hemorrhage, pyaemia, peritonitis, cystitis, and kidney disease are lurking enemies which now and then snatch away the life of the patient to the great annoyance of lithotomists. Added to these, the tedious process of recovery, the prolonged stay in hospital, the soaking of bed-clothes with urinary discharges and long confinement in bed, afforded sufficient reasons for inventing a better, cleverer, speedier, less risky method of dealing with this mechanical urinary disease. Lithotrity or the operation for crushing the calculus in bladder is of no recent date, but the credit of bringing the process to perfection is due to the eminent American Surgeon Dr. Bigelow. The operation is known by his name, or is now
commonly designated Litholapaxy. Keegan's statistics published in the Indian Medical Journal, January and February 1890,
more
Dr.
afforded
stimulus to retry the operation of I began to perform the operation cautiously and tenaciously, and, I am glad me a
litholapaxy.
more
Cases.?Litholapaxy
with
Median
Operation. 1.
Rauchor
fered from
Naran, male, symptoms
stone
cet. 20 years, sufa He year.
for
cut for stone by a quack twelve years ago ; there is a mark of the operation on the right side of the raphe. Presence of stone ascertained by sounding the bladder. was
1890.?Put under chloroform, aud partly and some debris aspirated. Catheter was not suitable to the sucking apparatus. After trying the crushing and aspirating processes for an hour, mediau operation was performed, and the large fragments were removed,1 24th
May
stone crushed
Nov.
T. M. SHAH'S OASES OF LITHOLAPAXY.
1891.]
the
remaining pulverized portion was aspirated through the perineal opening; bladder washed out. Total quantity of debris and fragments collected, weighed 300 grains. 8 p.m.?Bleeding from wound; bladder distended; the patient straining; female catheter
introduced
through perineal wound
25th.?Female catheter
came
and retained.
away
during
night. Bleeding again. Bladder washed out; preforated tube introduced and retained. Yesp. Tube came out; patient is straining; no
bleeding.
29th.?Some bleeding from the wound again. June.?A few clots of blood came away from bladder. 12tli. Discharged cured; wound healed up; ail urine passing per urethra, 2. Rama Jasa, male, ait. 30, suffered from stone symptoms for the last four years. Bladder sounded and stone detected. 9tli June 1890.?Put under chloroform. & gr. of morphia injected under skin and lithotrite introduced. The stone was extremely hard, so much so that the aid of an assistant was required two or three times to rotate the screw. Catheter was unsuitable ; however some debris was withdrawn. Then the median operation was performed, and a hard dark mulberry oxalate stone weighing 360 grs. extracted. The debris weighed 40 grs. besides. 11 tli.?Had fever with shivering.
28th.?Subsequent
wound
healed;
discharged.
progress
all urine
passing
satisfactory per
;
urethra;
3. Kalo Natlio, male, cet. 20 years, suffered from stone symptoms for eight years ; urine contained some albumen ; patient healthy in appearance, and stone felt in bladder. 14tli June 1890.?Put under chloroform and morphia injected under skin. After injecting 4 oz. of water into bladder, lithotrite was introAfter several crushduced and stone crushed. ings, a large cannula was passed in and a little debris withdrawn; much did not come out. Lithotrite again passed, and fragments further crushed. At last a fragment became jammed between the blades of lithotrite, and the male blade did not quite go home into the female one. All attempts to get rid of the jammed portion failed. No force could drive the male blade home; en the other hand, the screw-action of lithotrite became impaired. The blades remained about ^ inch open, and all hopes to close them were given up. The lithotrite was then withdrawn as it was, the open ends with jammed debris between receded from the neck, passed the membranous portion of urethra and then stopped at the commencement of penile portion. No judicious amount of force could effect its further progress. The elbow of the blades was then made prominent in the perineal region and cut down upon in the median line. The point of
327
the knife passed into the fenestrum of the female and next guided by this groove a director was passed into the bladder, knife was drawn along the director, wound enlarged, and all the fragments aud debris washed out of bladder. Lastly, the jammed ends of blades of lithotrite were passed out of the perineal wound, aud all the compressed debris extracted from between them; they were then closed fully, and finally withPerforated tube indrawn from the urethra. troduced into bladder per periueo and retained. Operation occupied If hour. Quantity of collected debris weighed 180 grains. 7 p.m.?Patient unconscious; body cold ;
blade,
breathing
stertorous.
restored; body temperature 100?; pulse 100. 15^.?Consciousness
warm;
Scrotum is swollen ; vomiting. Vesp. temperature 103?; pulse 135. A fit of shivering ; urine passing per tube. 22nd.?Temperature and pulse kept high
the last week, but they are now down; tube came away, swelling of scrotum subsiding, but left testicle is inflamed. 29th.?Swelling of testicle continues, but is less tender. Has urticarial eruptions. Patieut then gradually improved. 15tli July.?Patient is well in every other way, but all urine still passes per wound and none through urethra. Catheter does not pass through urethra into bladder.
during
22nd.?The
urethra
having been roughly
dealt with in the beginning, appears to have contracted about its scrotal portion, aud its continuity is obstructed. Put uuder chloroform, and director passed through perineal opening into bladder. Catheter was next introduced per external meatus aud forced into the bladder along the director and tied in. 24th.?Urine passes through catheter; none
through perineum.
29th.?Perineal opening closed ; catheter removed. All urine passes through urethra. Discharged well. 4. Gigo Bechar, male child, cut. 8 years, suffered from vesical stone for the last six months. 28M June 1890.?Put under chloroform ; stone was partly crushed and 20 grains of debris withdrawn by aspiration. After second introduction of lithotrite, some debris Avas jammed between the blades and difficulty was experienced in its withdrawal, causing more or less bruising of the urethral mucous membrane. Median operation was then performed, and a large mulberry stone weighing 520 grains and measuring two inches in its longest diameter was extracted. Perforated tube tied in. 5th July.?Temperature and pulse rose from the next day of operation and they have now subsided ; tube removed. 13th.?Child had two sharp attacks of diarrhoea, and is very much reduced in flesh and
strength;
328
INDIAN MEDICAL GAZETTE.
bed sores have formed, and urine passes per wound. 25th.?An abscess formed in the scrotum and is discharorina" matter and uiine. Treatment : Quinine, tonics, cod-liver oil, &o. 20th August.?Urine passes per urethram,scrotal fistula and perineal wound with copious discharge of mucus and pus. 31 st.?Perineal and scrotal openings closed. All urine passing per urethram. Discharged well. 5. Bhagwan Bechar, male child, at. 5 years, suffered from symptoms of vesical calculus for some six months. 25th October 1890.?Put under chloroform and lithotrite No. 6 introduced; diameter of stone a little more than f inch. Even after four introductions of lithotrite and cannula, large fragments remained ; it took three-fourths of an hour. Fragments could not be easily caught. Lateral lithotomy was then performed, and all fragments
removed,
weighing
Child had
189 grs.
which was circumcised, meatus was narrow, and was incised for introduction of lithotrite. \1th November 1890.?Wound healed, and child discharged.
phimosis,
Cases 6.
of pure litholapaxy.? Ramji Kano, male, 32 years, suffering from
stone in the bladder for 18 months.
Urine contains albumen 9th August 1890.?Put under chloroform, and morphia injected hypodermically, urethra very capacious. Lithotrite and cannula introduced five times, and a total of 413 grs. of debris extracted. Operation occupied two hours. Patient shivering for some time while under chloroform.
IU/j.?Yesterday temperature was 103?, today it is 101?. Passed a few fragments with urine.
loth.?Discharged well. 7. Uka Shamji, male child,
6 years, suffering from stone in the bladder for two years. 24th August.?Litholapaxy performed under chloroform. Five introductions of lithotrite No. 8 and cannula Nos. S and 10. Urethra capacious. Operation occupied one hour. Quantity of debris extracted, weighed 45 grs. 1st September.?Child had no fever the next day after operation, but on the third day temperature rose to 101-6?. A few small fragments passed with urine. Micturition painful for a few days. Discharged well. Kurson Becharji, male, aged 40. Duration 8. of stone symptoms ten months. Urine contains
albumen. 17th October 1890.?Litholapaxy performed. Lithotrite Nos. 6 and 8 introduced. Cannula introduced once. 8 grs. of debris removed. No more stone
perceptible.
[Nov.
1891,
did not rise above norPassed a small fragment on 20th. Discharged well. Kalo Ladho, male, aged 35. Vesical irri9. tability since one month. 17th October 1890.?Chloroform administered, morphia injected hypodermically. Bladder sounded, and a distinct click was audible. Lithotrite No. 6 introduced three times, and 5 grs. of dark coloured debris extracted. 24th.?Discharged well without auy fever or other trouble. 10. Bhimo Jivan, male, 36 years. Vesical stone of eight months' standing. Some trace of albumen in urine. 24?A November 1890.?Chloroform administered, morphia injected. Lithotrite No. 10 and 100 grs. of debris recannula introduced once. moved. 26th.?Temperature 101?. Burning pain while
25th.?Temperature
mal.
micturating.
December.?Discharged well. 11. Punja Jamal, male, aged 60 years. Stone in the bladder since three years. Urine contains Is extremely debilitated. a trace of albumen. 21 st December 1890.?Litholapaxy under chloroform and morphia. Lithotrite Nos. 10 and 14 and cannula passed five times. Total quantity of debris removed 294 grs., meatus urinarius was incised in order to allow the Nucleus of stone passage of large instruments. was extremely hard, and could not be pulverized by smaller instrument. 29th.?Micturition painful. Passes fragments from time to time. Urine turbid, white in colour. 9th January 1891.?Passes mucus iu urine* Micturition not painful. Patient kept in hospital longer for the sake of weakness. Dis11 jf/i
charged. 12. Poput Dewdas, Vesical
male
child, 5 years* years' standing. 1890.?Litholapaxy performed,
stone of two and-a-half
22nd December and pulverized ; stone weighing 74 grs. extracted. 242/
