LITIIOLAPAXY IN MALE CHILDREN AND MALE ADULTS: A SECOND SERIES OF CASES PERFORMED AT TIIE INDORE CHARITABLEHOSPTTA T. By Suegeon Major D. F.
Keegan, M. D. (Dublin).
In the May-number of the Indian Medical Gazette for 1884, there appeared a paper of mine advocating the extension of the operation of litholapaxy to the treatment of stone in male children. This paper has, on the whole, received favourable criticism, but in some quarters the practice which I advocated is considered dangerous and heterodox. In the paper referred to, I related twenty-four cases of stone in male children, their ages varying from one year and nine months to twelve years, in which Dr. Beaumont, my predecessor at the Indore Charitable Hospital, my assistant, Mr. Gunput Singh, and I had performed litholapaxy with one death. I endeavoured to show, and I trust not unsuccessfully, that this one
LITHOLAPAXY IN MALE CHILDREN.
June, 1885.] iatal
should not militate against the performance of litholapaxy in male children, and whilst hoping that some of my professional brethren in India might be induced to give litholapaxy in male children a fair and patient trial, I promised to seize the earliest opportunity of laying before my readers the results ot a more extended trial of the operation I case
then advocated. A year has
elapsed
since my first paper
this subject appeared, and I shall
now
on
briefly
state the conclusions at which I have arrived as to the merits or demerits of litholapaxy in stone
in male children. Since my first paper was written, forty-six patients, their ages varying from two to eightyfive, have been admitted into the Indore Charitable Hospital, suffering from stone in the bladder. In forty-two of these cases I performed litholapaxy or lithotrity at one sitting; in three I was obliged to perform lithotomy, and in one case I began the operation of litholapaxy, but, for reasons which will appear in the sequel, I extracted the stoue by lithotomy. I have lost but one patient out of forty-six, and I have performed all these operations mj'self. As a matter of convenience I have grouped all these litholapaxies, whether in the case of men or boys, into one table, as I wish to give some details of two cases of litholapaxy in men. Later on, I shall give a slight sketch of the three cases of lithotomy and of the case in "which I attempted litholapaxy, but was obliged
to
perform lithotomy. glance at the table,vide next page,shows that I have successfully performed eighteen litholapaxies in boys, their ages varying from two A
to eleven. This number added to the twentyfour cases, published in May 1884, gives a total
cases of litholapaxy in boys, with I can, therefore, confidently assert that I have proved that litholapaxy is an operation perfectly applicable to the treatment of stone in male children. A further glance the accompanying table shows that the weight of the stones crushed in these eighteen cases varied from 5 grains to as many as 308 grains, aud that the average number of days spent in hospital by boys was 6*6. On referring to the register of the Indore Charitable Hospital, I find that, in 113 lithotomies performed during the past twelve years on boys, the average stay in hospital, after operation, was 17*61 days. Here the superiority of litholapaxy in boys over lithotomy at
of
forty-two
one
once
death.
becomes apparent.
In the May-number of this journal for 1884, I stated that I was not prepared to recommend the operation of litholapaxy in boys labouring under the presence of a hard mulberry calculus, because I had not at the time had an opportunity of performing litholapaxy in such cases.
179
A more extended experience of this operation has now convinced me that any fears I may have entertained on this score were groundless, as an inspection of the annexed table shows. Serial number 15, 37, and 39 in the table annexed are cases in point, in which I crushed and evacuated at one sitting mulberry calculi, weighing respectively 308, 236 and 200. grains. A further analysis of this table shows that the average length of time occupied by each operation in boys lasted a little over an hour, and that the average weight of the stones crushed and removed at one sitting was 128 grains. YY hen it is remembered that, in the majority of these eighteen cases, as small an evacuating catheter as a No. 7 or No. 8, English, was employed, it will not be a matter of surprise that so much time was occupied in the performance of each operation. I do not consider it a matter of very great importance whether a boy is kept for half an hour or an hour under chloroform, so long as the chloroform is administered with all due precautions. Most of the deaths which have occurred in Europe and elsewhere under chloroform have occurred during the first five minutes of its administration. To perform litholapaxy with success in male children no larger lithotrite should be employed than will readily pass through the urethra into the bladder, and it is a wise precaution always to employ a fenestrated lithotrite which cannot become clogged with the debris of a soft clayey stone. The evacuating catheter also should be one that will pass readily in and out of the bladder. Now, what does the annexed table and the table which appeared in the May-number of the Indian Medical Gazette for 1884 prove as regards the size or capacitj' of the urethra in boys. It teaches this fact, and it is futile for theorists to gainsay it, that, as a rule, to which of course there are exceptions, the urethra of a boy between four and six years of age will admit the passage of a No. 7 or a No. 8 lithotrite, and equally so the passage of a No. 7 or a No. 8 evacuating catheter. As a rule, the urethra of a boy of eight or the admit ten years of age will readily a passage of a No. 8, or in some cases No. 10 lithotrite, and a No. 9 or 12 evacuating catheter; and with lithotrites and evacuating catheters of these dimensions, it is a hard perfectly feasible to crush and evacuate mulberry stone, weighing between 200 and 300 grains, in a little over an hour. There is, as I remarked in the May-number of this journal for 1884, as great a difference in the capaciousness of the urethra in male children as we find to be the case in male adults. In some children of four or five years of age, it is unsafe to pass a No. 7 lithotrite. In some it is On the other hand, some children of not so. four years of age have more capacious urethras ??
?
?
THE INDIAN MEDICAL GAZETTE.
180
[June,
1885.
of 42 Litholapaxies performed on Male Children and Male Adults at the Indore Charitable Hospital.
Table
showing particulars
a
1
a
S?
Composition
x'H
-= 3 ?
of
Names.
Result.
Stone. O
2s .cs
18
Sheikh Mahomed
G7
18-5-84 240
Madari Singh Wallia*
25
19-5-84 26-5-84
14 55 Oxalate of Lime 9 & 12 160 Phosphatic I French 445 Oxalate of Lime 29 S French ( 1600 Urate of Lime 29 J French I of Ammonia & 328 ("Urate 25 i 15 ( Oxalate of Lime 9 75 Phosphatic 7&10 11 & 15 7
Chottoo Nuaroo *
45 7
7-5-84 12-5-84
Ghulla
22
17-5-84 101 10
Hera Ghasirara Mohomed
...
3* 80
*
n
27-5-84 29-5-84
*
6
3-7-84
30
7-7-84
Mugneram Rutton
Rama Dowlut Salum Budloo
Rughoobur
GoolamAlly*
...
Thawur
Sha
Gunput Singh
...
24
11
56
8
140 22
30 11
44 30-10-84 20-11-84 112
65
21-11-81 2-12-84
100 28 71 20 38 155
25
19-12-81
51
65
24-12-84
105
8
30-1-85
104
10
30-1-85
85
8 15
M. H.
M. M.
29 i 7
14 7 & 9 French)
29 J 11&15 15 14 & 16 French) 29 J 15 12 8 French) 25 ) 15 16 15 French) 25 J 11 & 15 7 7 14 11 14 12 & 11 & 8
5-12-84 10-12-84 15-12-84 17-12-84
28 2 20 49
French) 9 & 11
10
22-9-84 25-10-84
36
14
11
French]
29 ] 9
11&15 8
24
210
755
336
27 28
Man Singh
38
29 SO 31
Shamjee
Venayack
50 9 10
8-3-85 19-3-85 27-3-85
4 78 10
French) 29 J 15 14 11 French ] 25 ) 11 7&9 8 9 8
32
Naharjee
30
27-3-85
12
11
33
Naujjee
85
2-4-85
67
34
Nunda*
5
5-4-85
58
8
35
Gotomo
11-4-85
31
8
3G
Lokria
12-4-85
91
11&15
14
229
37
Rutton * Rama Gunesh *
67
8& 10 15 8
12 16 9 9 7
236 31 200 140 91
38
39 40
41 42
*
...
Jusput Singh Bhooria
*
Choonia
*
*
...
13-4-85 20-4-85 28-4 85 30-4-85 2-5-85
90 43 80
7-5-85
41
20
11 & 15
8
7& 8
16 9
Do. Do.
Triple
Phosphates {Earthy
Do. Do. Do. Died.
Successful.
Phosphatic
and Uric 170 ("Phosphates I Acid Acid and Urate 372 of Ammonia f Uric Acid and Urate 770 \ of Ammonia 47 Oxalate of Lime
Do.
{Uric
Do. Do. Do.
...
6 Oxalate of Lime
Do.
90 Uric Acid 43 Oxalate of Lime /"Oxalateof Limenuc28 ?! leus and covering I of Lithic Acid ("Fawn colored Lithic 373 ( Acid 140 Phosphate of Lime I" Oxalate of Lime with 57 < covering of Phos-
Do. Do.
Do. Do. Do.
...
l phates
7& 8
:
Do.
Do.
1-2-85 16-2-85
14
and
Do. 26
Do.
30 80
*
Do. Do.
285
31-1-85 105
...
1 pliate
400 Uric Acid
16
*
Do. Do.
5 Uric Acid 155 Oxalate of Lime 272 Uric and Phosphoric... f Fawn colored Lithic 186 < Acid with small Oxo(. late of Lime nucleus
Tatia
97
Do. Do
...
183 Fawn colored Uric Acid
26
14
Do.
308 Oxalate of Lime Acid and cover346 /Uric \ ing Oxalate of Lime 60 Oxalate of Lime
Aup Singh
Khooshall Dass
Do. Do.
25 Uric Acid
25
Tajjoodeen Khan
Do. Do.
Uric Acid Acid & Oxalate of Lime covering of Lime and Uric Acid Uric Acid f Triple & Earthy Phos-
{Uric {Oxalate 38 42
24
...
Do.
120 Uric Acid
Khoodabux Fuklsa * *
Successful.
...
CO
22 ...
Singh *...
Nunney
22-8-
4
*
Mukkoo Bhuwaneeram
23
2
Boys.
Do.
AcidandEarthy Phosphates {Uric Oxalate Oxalate Oxalate Oxalate
Do. Do. Do. Do. Do. Do.
( Phosphatic covering
Do.
of Lime of Lime of Liine of Lime Phosphatic and Uric... f Oxalate of Liine with
D. F.
KEEGAN, m.d., Indore, 24th May,
1885.
June, 1885.]
LITHOLAPAXY IN MALE CHILDREN.
than children of ten. The lust two cases iu the above table are examples of this fact. The No. 8 lithotrite? did not pass with the same facility into the bladder of case No. 41, whose age was ten, as it did into the bladder of case No. 42, whose age was only four. My friend, Dr. Ward, of the 5th Bombay Infantry, happening to be present when I performed lifholapaxy in case No. 42, expressed his surprise at the facility with which I was enabled to pass a No. 8 lithotrite into this boy's bladder. To show the reverse side of this picture, I may mention that today, as I write, I crushed a small phosphatic stone in a man, aged 35, whose urethra would not accommodate a larger sized lithotrite than No. 11, or a larger sized evacuating catheter than No. 12. I find that a No. 8 fenestrated lithotrite made by Weiss & Son is perfectly capable of crushing a hard mulberry calculus weighing between two and three hundred grains. I have not had much practical experience of lithotrites made by other manufacturers. I know what trusty lithotrites Weiss & Son make, and I never intend to use any other kind. Three days ago I crushed in a man's bladder an almost perfectly black mulberry calculus, weighThe man had suffered from ing 540 grains. stone for twelve or fifteen years. This is by far the hardest calculus I have ever crushed. I used on this occasion a No. 14 fenestrated lithotrite by Weiss & Son, The amount of pressure I was obliged to exert in screwing up the lithotrite was represented by the whole strength of my hand and forearm. The lithoIn attacking trite did its work splendidly. such stones I screw up the lithotrite as tight as I think I can do so with safety, and then wait for some seconds before endeavouring to give the screw an extra half turn, and I generally find that, in the interim, the stone gives way with a snap under the continued pressure exerted by the blades of the lithotrite. I am glad to perceive that at last litholapaxy in male children has begun to receive attention from other lithotritists besides myself in India. J. Anderson, who has suc-
Surgeon Surgeon P.
J. Freyer at Moradabad, in the reports April-number of the Gazette a successful case of litholapaxy in a boy, aged ten, with a stone weighing 168 grains. Surgeon Anderson tells us that he was surprised at the facility with which he was able to passandtheI necessary instruments and remove the stone, doubt not thatother lithotritists will be equally surprised when they follow his example. But the table which I have given above shows that Surgeon Anderson is not perfectly accuratewhen he states that the^urethra of a child up to seven or eight years of age is exceedingly small. In flomechildrenthe urethra is very small up to seven or eight years of age^but it is not always so, and ceeded
181
it is in such cases that I assert with the utmost confidence that litholapaxy is a safe and successful operation when performed by a careful and skilled Jithot ritist. Surgeon Anderson further tells us that, during the year 1884, he performed a dozen lithotomies in children, the subjects of stones not larger than a pea, and that he is now fully convinced that every one of these cases might have been successfully treated by litholapaxy. Doubtless, they might have been so treated, and in the future such cases will, I hope, be so treated in India. It would be interesting to learn the average stay in hospital of these dozen cases after the operation of lithotomy. Every month in the year hundreds of boys are subjected to lithotomy in India, whose cases would be more rapidly and appropriately treated by litholapaxy. With the experience I have now gained in this operation, I assert that I would just as soon think of cutting an old man for a small stone, as I should think of cutting a boy ten or twelve years old whose urethra readily admitted a No. 8 lithotrite, and whose stone was small. I cannot say tiiat I much envy the feelings of a lithotritist, who, with suitable instruments at hand, cuts a boy of ten years of age for a stone, the size of a He must certainly be remarkably fond of pea. performing lithotomy. Why is it that, at every large civil hospital and dispensary throughout many districts in India, we so frequently meet with so many large stones in boys of comparatively tender years? I answer, simply because the parents or relatives of these unfortunate boys, fearing to subject their children to the terrors of a cutting operation, have postponed the day of relief to the last hour. Again, how many unfortunate boys in remote villages in India drag out a miserable existence for years and perish with their stones in their bladders ? I cannot answer this question, for vital statistics are not at hand to guide me. Nevertheless, I feel quite certain that scores of boys are allowed to pine away and die by reason of the terrors which surround the operation of lithotomy in the minds of the natives of this country. And I am strengthened in this opinion by the fact, that the number of admissions for stone in the bladder is rapidly increasing at those hospitals and dispensaries throughout India in which litholapaxy has become an
When established and recognised operation. a small stone can be that know to come parents disposed of without a cutting^ operation, then their children when parents will seek relief for their stones are small. Surgeon P. J. Freyer, who has recently published in the Lancet and in this journal a most brilliaut series of 111 cases of litholapaxy, stated in the Indian Medical Gazette for March 1884, that instruments had been invented by which no litholapaxy could be performed with safety in
182
THE INDIAN MEDICAL GAZETTE.
I combated this assermales below puberty. tion by publishing 24 cases of litholapaxy in We all must admire children with one death. an as Dr. P. J. Freyer accomplished lithotritist, and his success in cutting 132 boys for stone without a single death is a brilliaut triumph of we ought not to be much surgery, and, perhaps, that he is determined to learn to surprised limit his practice of litholapaxy to males above puberty, so long as he can maintain the degree But of success which he has already achieved. bases his to the Dr. when Freyer objections extension of litholapaxy in the case of boys, to the undeveloped condition of the geuito-urinary organs in children, to the sinallness of the bladder, the narrowness of the urethra, and to the liability of laceration of the mucous membraue of bladder and urethra, he should recollect that it has been found practicable to overcome all these objections by the use of suitable lithotrites, evacuating catheters, and aspirators. We all know the history of Bigelow's operation and the objections raised against this operation, in the first instance by those who have now become its warmest supporters. We were told that the bladder and urethra would not tolerate ?with impunity the use of large lithotrites and evacuating tubes ; and that it would be a wiser aud a safer plan to crush a stone in three or four short sittings than to complete the operation at one long sitting. Experience, however, has taught us the folly and dangers of ancient lithotrity or lithotrity at many sittings, and that it cannot compare in brilliancy and success to litholapaxy or lithotrity at a single sitting. We should, therefore, not feel much surprised at the large amount of opposition which the extension of litholapaxy in the treatment of stone in children has hitherto met, and continues to receive botli in this country aud in England. The extreme liability to laceration of the urethra in boys is one of the many time-cherished delusions in surgery, and, like other delusions, must, in the end, give way to the hard logic of practical experience. The urethra, prostate and neck of bladder will stand an amount of damage and rough handling in children, which would prove fatal to a man's bladder or urethra. If this be not so, then how can we explain the great success which, as a rule, follows the operation of lithotomy in children. The damage done in the performance of the operation of lithotomy in extracting a large stone from a boy's bladder is just as great if not greater in comparison than the damage done in extracting a large stone from the bladder of a man aged twenty-five. In the boy's case we expect a successful result, in the man's case, experience has taught us not to be too confident of a favourable termination. The fact is, that the urethra and bladder are, to a very great extent, simply urinary organs up to the time of puberty, and it is.uot until
has beeu
[Jone,
1885.
reached that these organs genito-urinary. This I take it to be the reason of the success we generally meet with in lithotomy in children, and the reason that catheter fever is unknown in childhood. The smalluess of the bladder in boys can scarcely be seriously advauced as an objection to litholapaxy, because a very little consideration will show that this smallness can be readily combated or neutralised by employing a small aspirator, or by gently working a full sized aspirator. Experience has taught me that this is a perfectly futile objection. When, however, Dr. Freyer proceeds to say?"it must be remembered that, in order that the aspirator may be of any practical utility for removing fragments, a much larger canula must be used than could with safety be introduced through the urethra of a male child," I reply, that, if a stone of considerable size be finely crushed iu the bladder, a No. 7 or a No. 8 an aspirator attached to evacuating catheter can, and does, remove such a stone in a little over an hour. And that a No. 7 or a No. 8 evacuating catheter can in most cases be readily introduced into the urethra of a child between six and eight years of age I know to be a fact. Reginald Harrison states that aspirator is not necessary or even desirable iu performing lithotrity iu children. With this opinion of a distinguished surgeon I cannot agree, for I consider the success and safety of litholapaxy in children to depend in a great measure iu not leaviug, if possible, a single grain of stone behind in the bladder. The unsuccessful results arrived at by French surgeons in lithotrity in children have, no doubt, in a great measure, deterred British surgeons from employing litholapaxy in the treatment of "stone in boys. Bryant, in the last edition of his Practice of Surgery," writes: "lithotrity in a child, with fine instruments, may be a justifiable operation in exceptionable cases when the calculus is known to be small; but, as a rule, in patients under puberty, lithotomy ought to be selected." Our great master in the art of lithotrity, Sir Henry Thompson, has not yet, so far I am aware, extended the operation of as lithotrity at a single sitting to cases of boys labouring under the presence of large stones. And I am well aware that the consensus of surgical opinion in England is opposed to the practice which I now advocate. 1 write for my professional brethren in this country, and I cannot, therefore, help remarking that I can see no reason why we Surgeons of the Indian Medical Service, with our unrivalled opportunities and experience in treating stone in patients of all ages, should slavishly follow in the hesitating footsteps of our less favoured English If French surgeons have brethren at home. failed to secure success that is no reason why I we in India should be equally unfortunate.
puberty become
LITHOLAPAXY IN MALE CHILDEEN.
June, 1885.]
183
Burlcut Ali, a boy, aged 3, was admitted into the 12th November 1884. oil His observed symptoms of stone for had parents than eighteen years' service in India, which during to admission. On endeaperiod I have treated a very large number of cases five months previous to pass a No. 7 lithotrite into the of stone in young and old, I can now vouring recolonly bladder, I found it tightly grasped at (he beginlect having lost one or at the most two children. To show that litholapaxy is not always suit- ning of the scrotal portion of the urethra. I, 5 staff, able to the treatment of stone in boys, and that therefore, withdrew it, passed in a No. and cut the an oval stone, Aveighremoving boy, caution and judgment should be exercised in with an the selection of cases, and that I am not pre- ing 64 grains, composed of phosphates uric acid nucleus. the left The hospital boy pared to ride my hobby to death, I shall now well on the 25th November 1884. briefly state the history of the case in which I a boy, aged 7, with symptoms of stone attempted litholapaxy, but was obliged to per- forKoria, th ree years previous, was admitted into hospiform lithotomy. tal on the 25th April 1885. On passing a lithoKoora, a boy, aged 8^- years, was admitted I struck the stone impacted in the prostatic trite, into the Indore Hospital on the 28th April 1884, urethra. The stone was evidently a large one, suffering from symptoms of stone for years. for it could be readily felt in the perineum, and The same day I passed with comparative ease into the rectum, and it could be also felt bulged a No. 7 lithotrite into the bladder, and at once firm pressure above the pubis. I seized a stone and commenced to crush. After by making to pass a staff into the bladder; and in managed a few crushings, I withdrew the lithotrite, which lateral lithotomy, I came on the "was not fenestrated, from the bladder, and, in performing Instone almost at once and cut down on it. doing so, I experienced considerable difficulty in the staff, into the the knife groove troducing iu getting it to pass through the urethra slightly I continued my incision on through the prostatic anterior to its membranous portion, as the blades had become clogged with the debris of a soft urethra, and so on into the bladder; and extracted the stone with comparative ease. It formed clayey stone. This clogging had the effect of a regular cast of an enlarged prostatic urethra, the size of the lithotrite from a No. 7 increasing was constricted at the neck of the bladder and to a No. 8. Fearing that this clotjginor mio-lit bulbous in its bladder portion. The stone was withdrawal of the lithotrite recur on a second inches its at its thickest portion 2| long, girth from the bladder, I determined to cut the boy, measured 4 inches, and it weighed 657 grains and passing in a No. 5 staff I performed lithoand consisted of phosphate of lime. The boy tomy, making a very small cut in the prostate, made a good recovery, and was discharged on and extracted the broken fragments from the the 22ud May. bladder by means of an ordinary dressing forThere are but two cases of litholapaxy in ceps. The stone weighed 127 grains, and was adult males in the table appended, calling composed of mixed phosphates and urates. The for any special mention, serial number 4, in boy made an excellent recovery, and left the which a stone weighing 1,600 grains and hospital well on the 11th May. Here was a composed of urate of lime was successfully boy, aged 8|- years, with a far less capacious removed at one sitting, and serial number 21, urethra than I have often found to exist in the fatal case. Bigelow has observed,?" we boys of four or five years old. This case also need no further statistics relating to small suggests the idea that, in cases of large stones stones," and when lie made this observation, he in children, and indeed in adults, it might not spoke of small stones in the adult male. Regibe a bad plan first to crush the stone into several nald Harrison, of Liverpool, well remarks: "The them small fragments, and afterwards to extract direction I take it in which information will by lithotomy, although I am well aware that still be of value is when the confines between some eminent lithotomists consider such a prolithotomy and lithotrity are reached?when ceeding to be dangerous in practice. the question arises whether to crush or to cut And now to give a brief history of the three is the safer proceeding. Where stones are I selected lithotomy in precases in which large, or where their presence is comunusually ference to litholapaxy. Bhugga, aged 30, plicated with co-existing disease in the urethra, admitted into hospital on the 12th May 1884. bladder or kidneys, it cannot be said Next day, on passing the largest lithotrite, prostate, that there is a consensus of opinion as to the a No. 15, into the bladder, I struck a stone so best method of procedure."* I shall, therefore, large that it exceeded the working capabilities state at some length the particulars of the of the lithotrite. The man being young and which appears in the table as serial case once I at performed lithotomy, and number 4. healthy, extracted a lithic acid stone, weighing one The man made drachm less than four ounces. * Observations on Lithotomy, Lithotrity and the early an uninterrupted recovery, and left the hospital detection of stone in the bladder by Reginald Harrison, 1883, "well on the 16tli June 1884.
have not been driven to adopting litholapaxj in children by my failures in lithotomy, for in more
?
*
O
O
hospital
184
THE INDIAN MEDICAL GAZETTE.
Sheikh Mahomed, aged 67, an inhabitant of Indore, was admitted into hospital on the 18th May 1884, suffering from symptoms of stone, which had existed for 15 years. His face bore the traces of great suffering. Pain on passing water was so great that sometimes he used to strike his forehead against the ground, or the wall of his room, in paroxysms of despair. The uriue was alkaline in reaction, and I passed a its specific gravity was- 1015. No. 15 fenestrated lithotrite into the bladder, and readily seized a very large stone. The bladder was roomy, and the urethra capacious. The stone, however, I found to be too large to permit of its being cracked across with the To have cut an old man with a lithotrite. stone would almost certainly have killed huge him, and I, therefore, determined to nibble away at the stone until I could reduce its size to the working capacity of the lithotrite. I was obliged to spend a very long time in chipping away at the outer shell of the stone, and when nearly half an hour had elapsed, I had the satisfaction of finding that I had reduced the Once stone to the capacity of the lithotrite. the stone was cracked across, the operation presented no remarkable features except its great tediousness. At the end of two hours 1 had only extracted half the stone and I almost began to despair of success. But my old patient's pulse improved, and his breathing was perfectly regular, and he required but little additional chloroform to keep him in a condition of perfect anaesthesia, and so I was determined to extract the entire stone at one sitting, if possible. I was obliged to introduce the lithotrite fourteen different times, and applied the aspirator an equal number of times. At the end of the fourth hour, I had nearly extracted the entire stone, and the last quarter of an hour of the operation was spent in sounding, disposing of the last fragments, and in working The evacuating catheters used the aspirator. The stone consisted of were 25 and 29, French. urate of lime, and when damp weighed 1,600 grains. I have weighed this stone recently, and after two hot weathers it weighs 1,470 grains. 18?/i May?Evening temperature 102*4?, pulse 96. 19th May?Feels slight pain over bladder region, urine reddish colour, not much pain in passing water, has almost recovered from effects of chloroform. 2Is* May?Patient feels quite well, and walks about his room, is anxious to go home. 23rd May?A small lithotrite introduced into bladder, and a small fragment of stone detected lying close to neck of bladder?fragment removed between blades of lithotrite. 24th May?Urine perfectly clear, no pain in micturition, at his own urgent request allowed to go home.
[June/
1885.
The above case is a good specimen of the results which can be achieved by Bigelow's operation. I saw and spoke to this man yesterday. He is in the enjoyment of excellent health, and is free from all bladder trouble. His testicles have never descended into the scrotum or inguinal canal. He affirms that he has had two children, and suffered once from syphilis and once from gonorrhoea, proving that a man may be the subject of retained abdominal testicles aud still possess virile power undiminished. Perhaps, Petersen's modification of suprapubic lithotomy might theoretically have been the most appropriate operation for attacking a stone of this size; but no procedure or operation could have been more successful or more satisfactory to my patient than the one I adopted. With a still larger lithotrite than No. 15, Weiss & Son, I should not have the slightest hesitation in attacking a moderately hard stone weighing four ounces. A few brief remarks on the one fatal case in the above table : Munesh Shah, 49 years of age, suffering from stone symptoms, was admitted into the Indore Hospital on the 16th December 1884. He suffered from emphysema of the lungs, his heart was weak, and he was very corpulent, muscular system very flabby, urine acid, specific gravity 1014, no albumen. On the 17th December he was placed under chloroform, which he took very badly. Equal p:irts of chloroform The largest lithoand ether were then tried. trite which could be used with safety was The stone was readily No. 12 fenestrated. seized, but the inspiratory and expiratory efforts so were deep and laboured, that the water injected iuto the bladder was soon expelled, and so the bladder kept continually contracting on the lithotrite, rendering the operation A No. 14 English most difficult and tedious. catheter was the largest I was able evacuating The lithotrite was introduced to employ. sixteen times, and the operation lasted 2 hours and 35 miuutes, although the stone only weighed This will give some idea of the 272 grains. difficulties attending the operation of litholapaxy in this case.
bth December?pulse 120, evening tempera104?, suffering from an attack of asthma, right testicle swollen, some pain on pressure 1
ture
bladd er. 22nd December?Peels burning at time of micturition, condition of testicle unchanged, souuded bladder, but no fragment of stone could be felt. 26th December?Does not sleep well, pain experienced in epigastric region, getting weaker, has difficulty in breathing, had two fits of asthma. 27th.?Dyspnoea increasing, pulse rapid and weak, becoming drowsy?died during the night. No ?post-mortem examination was obtainable. I ascribe the fatal issue in this case to the
over
June, 1885.]
LITHOLA.PAXY IN MALE CHILDREN-ELEPHANTOID TUMOUR.
lengthened administration of chloroform aud ether in a patient suffering from emphysema of lungs and weak heart. If I were again to meet with a similar case, I should most certainly perform lithotomy in preference to litholapaxy, for I consider that litholapaxy is contra-indicated in cases were a contracted bladder keeps on continually grasping the lithotrite and expelling the water injected by the aspirator.
The length to which this paper has already extended prevents me on the present occasion from entering into the details of the eighteen litholapaxies in boys in the table appended. On a future occasion, I hope to give detailed histories of some of the most interesting cases in this series. In four or five cases the operation of litholapaxy was followed by some swelling of the penis and prepuce, and in three or four cases there was considerable pain in passing water for some few days after the operation, but eventually all the cases left the hospital quite well and free from pain. For the information of those who may feel disposed to give litholapaxy in boys a trial, I may mention that the No. 7 1 ithotrite I use is uufenestrated. It is 6 in the stem and 7 at the angle, and that No. 8 lithotrite is fenestrated, and is 7 in the stem and 8 at the angle. Since I began to write this paper, I have performed two additional litholapaxies in men, which I have not These two included in the table appended. cases will turn out well, for they are perfectly simple cases. I have, therefore, treated 48 cases of stone in the bladder since the end of April This 1884 to the present date, with one death. I consider a very satisfactory result. In conclusion, I would lay down the following rules for the successful performance of litholapaxy in boys : Use small fenestrated lithotrites; if possible, crush the stone in the bladder into fine powder, and you will not then require large sized catheters to evacuate the debits; never use a lithotrite or an evacuating catheter which will not pass readily in and out of the bladder aud urethra ; be extremely gentle and careful in practising all manipulations on the uriuary passages ; do not be in a hurry to complete the operation ; use the aspirator freely, and never, if possible, leave a single grain of debris behind in the bladder; and rest assured that if all these conditions are fulfilled, you may count Some cases on a vei'3r large measure of success. no lithotrites, howyou will meet with where ever small, can be employed with safety, and these are the cases which should be dealt with
by lithotomy. Indorc. 2ith
May,
1885.
185
Keegan, M. D. (Dublin).
In the May-number of the Indian Medical Gazette for 1884, there appeared a paper of mine advocating the extension of the operation of litholapaxy to the treatment of stone in male children. This paper has, on the whole, received favourable criticism, but in some quarters the practice which I advocated is considered dangerous and heterodox. In the paper referred to, I related twenty-four cases of stone in male children, their ages varying from one year and nine months to twelve years, in which Dr. Beaumont, my predecessor at the Indore Charitable Hospital, my assistant, Mr. Gunput Singh, and I had performed litholapaxy with one death. I endeavoured to show, and I trust not unsuccessfully, that this one
LITHOLAPAXY IN MALE CHILDREN.
June, 1885.] iatal
should not militate against the performance of litholapaxy in male children, and whilst hoping that some of my professional brethren in India might be induced to give litholapaxy in male children a fair and patient trial, I promised to seize the earliest opportunity of laying before my readers the results ot a more extended trial of the operation I case
then advocated. A year has
elapsed
since my first paper
this subject appeared, and I shall
now
on
briefly
state the conclusions at which I have arrived as to the merits or demerits of litholapaxy in stone
in male children. Since my first paper was written, forty-six patients, their ages varying from two to eightyfive, have been admitted into the Indore Charitable Hospital, suffering from stone in the bladder. In forty-two of these cases I performed litholapaxy or lithotrity at one sitting; in three I was obliged to perform lithotomy, and in one case I began the operation of litholapaxy, but, for reasons which will appear in the sequel, I extracted the stoue by lithotomy. I have lost but one patient out of forty-six, and I have performed all these operations mj'self. As a matter of convenience I have grouped all these litholapaxies, whether in the case of men or boys, into one table, as I wish to give some details of two cases of litholapaxy in men. Later on, I shall give a slight sketch of the three cases of lithotomy and of the case in "which I attempted litholapaxy, but was obliged
to
perform lithotomy. glance at the table,vide next page,shows that I have successfully performed eighteen litholapaxies in boys, their ages varying from two A
to eleven. This number added to the twentyfour cases, published in May 1884, gives a total
cases of litholapaxy in boys, with I can, therefore, confidently assert that I have proved that litholapaxy is an operation perfectly applicable to the treatment of stone in male children. A further glance the accompanying table shows that the weight of the stones crushed in these eighteen cases varied from 5 grains to as many as 308 grains, aud that the average number of days spent in hospital by boys was 6*6. On referring to the register of the Indore Charitable Hospital, I find that, in 113 lithotomies performed during the past twelve years on boys, the average stay in hospital, after operation, was 17*61 days. Here the superiority of litholapaxy in boys over lithotomy at
of
forty-two
one
once
death.
becomes apparent.
In the May-number of this journal for 1884, I stated that I was not prepared to recommend the operation of litholapaxy in boys labouring under the presence of a hard mulberry calculus, because I had not at the time had an opportunity of performing litholapaxy in such cases.
179
A more extended experience of this operation has now convinced me that any fears I may have entertained on this score were groundless, as an inspection of the annexed table shows. Serial number 15, 37, and 39 in the table annexed are cases in point, in which I crushed and evacuated at one sitting mulberry calculi, weighing respectively 308, 236 and 200. grains. A further analysis of this table shows that the average length of time occupied by each operation in boys lasted a little over an hour, and that the average weight of the stones crushed and removed at one sitting was 128 grains. YY hen it is remembered that, in the majority of these eighteen cases, as small an evacuating catheter as a No. 7 or No. 8, English, was employed, it will not be a matter of surprise that so much time was occupied in the performance of each operation. I do not consider it a matter of very great importance whether a boy is kept for half an hour or an hour under chloroform, so long as the chloroform is administered with all due precautions. Most of the deaths which have occurred in Europe and elsewhere under chloroform have occurred during the first five minutes of its administration. To perform litholapaxy with success in male children no larger lithotrite should be employed than will readily pass through the urethra into the bladder, and it is a wise precaution always to employ a fenestrated lithotrite which cannot become clogged with the debris of a soft clayey stone. The evacuating catheter also should be one that will pass readily in and out of the bladder. Now, what does the annexed table and the table which appeared in the May-number of the Indian Medical Gazette for 1884 prove as regards the size or capacitj' of the urethra in boys. It teaches this fact, and it is futile for theorists to gainsay it, that, as a rule, to which of course there are exceptions, the urethra of a boy between four and six years of age will admit the passage of a No. 7 or a No. 8 lithotrite, and equally so the passage of a No. 7 or a No. 8 evacuating catheter. As a rule, the urethra of a boy of eight or the admit ten years of age will readily a passage of a No. 8, or in some cases No. 10 lithotrite, and a No. 9 or 12 evacuating catheter; and with lithotrites and evacuating catheters of these dimensions, it is a hard perfectly feasible to crush and evacuate mulberry stone, weighing between 200 and 300 grains, in a little over an hour. There is, as I remarked in the May-number of this journal for 1884, as great a difference in the capaciousness of the urethra in male children as we find to be the case in male adults. In some children of four or five years of age, it is unsafe to pass a No. 7 lithotrite. In some it is On the other hand, some children of not so. four years of age have more capacious urethras ??
?
?
THE INDIAN MEDICAL GAZETTE.
180
[June,
1885.
of 42 Litholapaxies performed on Male Children and Male Adults at the Indore Charitable Hospital.
Table
showing particulars
a
1
a
S?
Composition
x'H
-= 3 ?
of
Names.
Result.
Stone. O
2s .cs
18
Sheikh Mahomed
G7
18-5-84 240
Madari Singh Wallia*
25
19-5-84 26-5-84
14 55 Oxalate of Lime 9 & 12 160 Phosphatic I French 445 Oxalate of Lime 29 S French ( 1600 Urate of Lime 29 J French I of Ammonia & 328 ("Urate 25 i 15 ( Oxalate of Lime 9 75 Phosphatic 7&10 11 & 15 7
Chottoo Nuaroo *
45 7
7-5-84 12-5-84
Ghulla
22
17-5-84 101 10
Hera Ghasirara Mohomed
...
3* 80
*
n
27-5-84 29-5-84
*
6
3-7-84
30
7-7-84
Mugneram Rutton
Rama Dowlut Salum Budloo
Rughoobur
GoolamAlly*
...
Thawur
Sha
Gunput Singh
...
24
11
56
8
140 22
30 11
44 30-10-84 20-11-84 112
65
21-11-81 2-12-84
100 28 71 20 38 155
25
19-12-81
51
65
24-12-84
105
8
30-1-85
104
10
30-1-85
85
8 15
M. H.
M. M.
29 i 7
14 7 & 9 French)
29 J 11&15 15 14 & 16 French) 29 J 15 12 8 French) 25 ) 15 16 15 French) 25 J 11 & 15 7 7 14 11 14 12 & 11 & 8
5-12-84 10-12-84 15-12-84 17-12-84
28 2 20 49
French) 9 & 11
10
22-9-84 25-10-84
36
14
11
French]
29 ] 9
11&15 8
24
210
755
336
27 28
Man Singh
38
29 SO 31
Shamjee
Venayack
50 9 10
8-3-85 19-3-85 27-3-85
4 78 10
French) 29 J 15 14 11 French ] 25 ) 11 7&9 8 9 8
32
Naharjee
30
27-3-85
12
11
33
Naujjee
85
2-4-85
67
34
Nunda*
5
5-4-85
58
8
35
Gotomo
11-4-85
31
8
3G
Lokria
12-4-85
91
11&15
14
229
37
Rutton * Rama Gunesh *
67
8& 10 15 8
12 16 9 9 7
236 31 200 140 91
38
39 40
41 42
*
...
Jusput Singh Bhooria
*
Choonia
*
*
...
13-4-85 20-4-85 28-4 85 30-4-85 2-5-85
90 43 80
7-5-85
41
20
11 & 15
8
7& 8
16 9
Do. Do.
Triple
Phosphates {Earthy
Do. Do. Do. Died.
Successful.
Phosphatic
and Uric 170 ("Phosphates I Acid Acid and Urate 372 of Ammonia f Uric Acid and Urate 770 \ of Ammonia 47 Oxalate of Lime
Do.
{Uric
Do. Do. Do.
...
6 Oxalate of Lime
Do.
90 Uric Acid 43 Oxalate of Lime /"Oxalateof Limenuc28 ?! leus and covering I of Lithic Acid ("Fawn colored Lithic 373 ( Acid 140 Phosphate of Lime I" Oxalate of Lime with 57 < covering of Phos-
Do. Do.
Do. Do. Do.
...
l phates
7& 8
:
Do.
Do.
1-2-85 16-2-85
14
and
Do. 26
Do.
30 80
*
Do. Do.
285
31-1-85 105
...
1 pliate
400 Uric Acid
16
*
Do. Do.
5 Uric Acid 155 Oxalate of Lime 272 Uric and Phosphoric... f Fawn colored Lithic 186 < Acid with small Oxo(. late of Lime nucleus
Tatia
97
Do. Do
...
183 Fawn colored Uric Acid
26
14
Do.
308 Oxalate of Lime Acid and cover346 /Uric \ ing Oxalate of Lime 60 Oxalate of Lime
Aup Singh
Khooshall Dass
Do. Do.
25 Uric Acid
25
Tajjoodeen Khan
Do. Do.
Uric Acid Acid & Oxalate of Lime covering of Lime and Uric Acid Uric Acid f Triple & Earthy Phos-
{Uric {Oxalate 38 42
24
...
Do.
120 Uric Acid
Khoodabux Fuklsa * *
Successful.
...
CO
22 ...
Singh *...
Nunney
22-8-
4
*
Mukkoo Bhuwaneeram
23
2
Boys.
Do.
AcidandEarthy Phosphates {Uric Oxalate Oxalate Oxalate Oxalate
Do. Do. Do. Do. Do. Do.
( Phosphatic covering
Do.
of Lime of Lime of Liine of Lime Phosphatic and Uric... f Oxalate of Liine with
D. F.
KEEGAN, m.d., Indore, 24th May,
1885.
June, 1885.]
LITHOLAPAXY IN MALE CHILDREN.
than children of ten. The lust two cases iu the above table are examples of this fact. The No. 8 lithotrite? did not pass with the same facility into the bladder of case No. 41, whose age was ten, as it did into the bladder of case No. 42, whose age was only four. My friend, Dr. Ward, of the 5th Bombay Infantry, happening to be present when I performed lifholapaxy in case No. 42, expressed his surprise at the facility with which I was enabled to pass a No. 8 lithotrite into this boy's bladder. To show the reverse side of this picture, I may mention that today, as I write, I crushed a small phosphatic stone in a man, aged 35, whose urethra would not accommodate a larger sized lithotrite than No. 11, or a larger sized evacuating catheter than No. 12. I find that a No. 8 fenestrated lithotrite made by Weiss & Son is perfectly capable of crushing a hard mulberry calculus weighing between two and three hundred grains. I have not had much practical experience of lithotrites made by other manufacturers. I know what trusty lithotrites Weiss & Son make, and I never intend to use any other kind. Three days ago I crushed in a man's bladder an almost perfectly black mulberry calculus, weighThe man had suffered from ing 540 grains. stone for twelve or fifteen years. This is by far the hardest calculus I have ever crushed. I used on this occasion a No. 14 fenestrated lithotrite by Weiss & Son, The amount of pressure I was obliged to exert in screwing up the lithotrite was represented by the whole strength of my hand and forearm. The lithoIn attacking trite did its work splendidly. such stones I screw up the lithotrite as tight as I think I can do so with safety, and then wait for some seconds before endeavouring to give the screw an extra half turn, and I generally find that, in the interim, the stone gives way with a snap under the continued pressure exerted by the blades of the lithotrite. I am glad to perceive that at last litholapaxy in male children has begun to receive attention from other lithotritists besides myself in India. J. Anderson, who has suc-
Surgeon Surgeon P.
J. Freyer at Moradabad, in the reports April-number of the Gazette a successful case of litholapaxy in a boy, aged ten, with a stone weighing 168 grains. Surgeon Anderson tells us that he was surprised at the facility with which he was able to passandtheI necessary instruments and remove the stone, doubt not thatother lithotritists will be equally surprised when they follow his example. But the table which I have given above shows that Surgeon Anderson is not perfectly accuratewhen he states that the^urethra of a child up to seven or eight years of age is exceedingly small. In flomechildrenthe urethra is very small up to seven or eight years of age^but it is not always so, and ceeded
181
it is in such cases that I assert with the utmost confidence that litholapaxy is a safe and successful operation when performed by a careful and skilled Jithot ritist. Surgeon Anderson further tells us that, during the year 1884, he performed a dozen lithotomies in children, the subjects of stones not larger than a pea, and that he is now fully convinced that every one of these cases might have been successfully treated by litholapaxy. Doubtless, they might have been so treated, and in the future such cases will, I hope, be so treated in India. It would be interesting to learn the average stay in hospital of these dozen cases after the operation of lithotomy. Every month in the year hundreds of boys are subjected to lithotomy in India, whose cases would be more rapidly and appropriately treated by litholapaxy. With the experience I have now gained in this operation, I assert that I would just as soon think of cutting an old man for a small stone, as I should think of cutting a boy ten or twelve years old whose urethra readily admitted a No. 8 lithotrite, and whose stone was small. I cannot say tiiat I much envy the feelings of a lithotritist, who, with suitable instruments at hand, cuts a boy of ten years of age for a stone, the size of a He must certainly be remarkably fond of pea. performing lithotomy. Why is it that, at every large civil hospital and dispensary throughout many districts in India, we so frequently meet with so many large stones in boys of comparatively tender years? I answer, simply because the parents or relatives of these unfortunate boys, fearing to subject their children to the terrors of a cutting operation, have postponed the day of relief to the last hour. Again, how many unfortunate boys in remote villages in India drag out a miserable existence for years and perish with their stones in their bladders ? I cannot answer this question, for vital statistics are not at hand to guide me. Nevertheless, I feel quite certain that scores of boys are allowed to pine away and die by reason of the terrors which surround the operation of lithotomy in the minds of the natives of this country. And I am strengthened in this opinion by the fact, that the number of admissions for stone in the bladder is rapidly increasing at those hospitals and dispensaries throughout India in which litholapaxy has become an
When established and recognised operation. a small stone can be that know to come parents disposed of without a cutting^ operation, then their children when parents will seek relief for their stones are small. Surgeon P. J. Freyer, who has recently published in the Lancet and in this journal a most brilliaut series of 111 cases of litholapaxy, stated in the Indian Medical Gazette for March 1884, that instruments had been invented by which no litholapaxy could be performed with safety in
182
THE INDIAN MEDICAL GAZETTE.
I combated this assermales below puberty. tion by publishing 24 cases of litholapaxy in We all must admire children with one death. an as Dr. P. J. Freyer accomplished lithotritist, and his success in cutting 132 boys for stone without a single death is a brilliaut triumph of we ought not to be much surgery, and, perhaps, that he is determined to learn to surprised limit his practice of litholapaxy to males above puberty, so long as he can maintain the degree But of success which he has already achieved. bases his to the Dr. when Freyer objections extension of litholapaxy in the case of boys, to the undeveloped condition of the geuito-urinary organs in children, to the sinallness of the bladder, the narrowness of the urethra, and to the liability of laceration of the mucous membraue of bladder and urethra, he should recollect that it has been found practicable to overcome all these objections by the use of suitable lithotrites, evacuating catheters, and aspirators. We all know the history of Bigelow's operation and the objections raised against this operation, in the first instance by those who have now become its warmest supporters. We were told that the bladder and urethra would not tolerate ?with impunity the use of large lithotrites and evacuating tubes ; and that it would be a wiser aud a safer plan to crush a stone in three or four short sittings than to complete the operation at one long sitting. Experience, however, has taught us the folly and dangers of ancient lithotrity or lithotrity at many sittings, and that it cannot compare in brilliancy and success to litholapaxy or lithotrity at a single sitting. We should, therefore, not feel much surprised at the large amount of opposition which the extension of litholapaxy in the treatment of stone in children has hitherto met, and continues to receive botli in this country aud in England. The extreme liability to laceration of the urethra in boys is one of the many time-cherished delusions in surgery, and, like other delusions, must, in the end, give way to the hard logic of practical experience. The urethra, prostate and neck of bladder will stand an amount of damage and rough handling in children, which would prove fatal to a man's bladder or urethra. If this be not so, then how can we explain the great success which, as a rule, follows the operation of lithotomy in children. The damage done in the performance of the operation of lithotomy in extracting a large stone from a boy's bladder is just as great if not greater in comparison than the damage done in extracting a large stone from the bladder of a man aged twenty-five. In the boy's case we expect a successful result, in the man's case, experience has taught us not to be too confident of a favourable termination. The fact is, that the urethra and bladder are, to a very great extent, simply urinary organs up to the time of puberty, and it is.uot until
has beeu
[Jone,
1885.
reached that these organs genito-urinary. This I take it to be the reason of the success we generally meet with in lithotomy in children, and the reason that catheter fever is unknown in childhood. The smalluess of the bladder in boys can scarcely be seriously advauced as an objection to litholapaxy, because a very little consideration will show that this smallness can be readily combated or neutralised by employing a small aspirator, or by gently working a full sized aspirator. Experience has taught me that this is a perfectly futile objection. When, however, Dr. Freyer proceeds to say?"it must be remembered that, in order that the aspirator may be of any practical utility for removing fragments, a much larger canula must be used than could with safety be introduced through the urethra of a male child," I reply, that, if a stone of considerable size be finely crushed iu the bladder, a No. 7 or a No. 8 an aspirator attached to evacuating catheter can, and does, remove such a stone in a little over an hour. And that a No. 7 or a No. 8 evacuating catheter can in most cases be readily introduced into the urethra of a child between six and eight years of age I know to be a fact. Reginald Harrison states that aspirator is not necessary or even desirable iu performing lithotrity iu children. With this opinion of a distinguished surgeon I cannot agree, for I consider the success and safety of litholapaxy in children to depend in a great measure iu not leaviug, if possible, a single grain of stone behind in the bladder. The unsuccessful results arrived at by French surgeons in lithotrity in children have, no doubt, in a great measure, deterred British surgeons from employing litholapaxy in the treatment of "stone in boys. Bryant, in the last edition of his Practice of Surgery," writes: "lithotrity in a child, with fine instruments, may be a justifiable operation in exceptionable cases when the calculus is known to be small; but, as a rule, in patients under puberty, lithotomy ought to be selected." Our great master in the art of lithotrity, Sir Henry Thompson, has not yet, so far I am aware, extended the operation of as lithotrity at a single sitting to cases of boys labouring under the presence of large stones. And I am well aware that the consensus of surgical opinion in England is opposed to the practice which I now advocate. 1 write for my professional brethren in this country, and I cannot, therefore, help remarking that I can see no reason why we Surgeons of the Indian Medical Service, with our unrivalled opportunities and experience in treating stone in patients of all ages, should slavishly follow in the hesitating footsteps of our less favoured English If French surgeons have brethren at home. failed to secure success that is no reason why I we in India should be equally unfortunate.
puberty become
LITHOLAPAXY IN MALE CHILDEEN.
June, 1885.]
183
Burlcut Ali, a boy, aged 3, was admitted into the 12th November 1884. oil His observed symptoms of stone for had parents than eighteen years' service in India, which during to admission. On endeaperiod I have treated a very large number of cases five months previous to pass a No. 7 lithotrite into the of stone in young and old, I can now vouring recolonly bladder, I found it tightly grasped at (he beginlect having lost one or at the most two children. To show that litholapaxy is not always suit- ning of the scrotal portion of the urethra. I, 5 staff, able to the treatment of stone in boys, and that therefore, withdrew it, passed in a No. and cut the an oval stone, Aveighremoving boy, caution and judgment should be exercised in with an the selection of cases, and that I am not pre- ing 64 grains, composed of phosphates uric acid nucleus. the left The hospital boy pared to ride my hobby to death, I shall now well on the 25th November 1884. briefly state the history of the case in which I a boy, aged 7, with symptoms of stone attempted litholapaxy, but was obliged to per- forKoria, th ree years previous, was admitted into hospiform lithotomy. tal on the 25th April 1885. On passing a lithoKoora, a boy, aged 8^- years, was admitted I struck the stone impacted in the prostatic trite, into the Indore Hospital on the 28th April 1884, urethra. The stone was evidently a large one, suffering from symptoms of stone for years. for it could be readily felt in the perineum, and The same day I passed with comparative ease into the rectum, and it could be also felt bulged a No. 7 lithotrite into the bladder, and at once firm pressure above the pubis. I seized a stone and commenced to crush. After by making to pass a staff into the bladder; and in managed a few crushings, I withdrew the lithotrite, which lateral lithotomy, I came on the "was not fenestrated, from the bladder, and, in performing Instone almost at once and cut down on it. doing so, I experienced considerable difficulty in the staff, into the the knife groove troducing iu getting it to pass through the urethra slightly I continued my incision on through the prostatic anterior to its membranous portion, as the blades had become clogged with the debris of a soft urethra, and so on into the bladder; and extracted the stone with comparative ease. It formed clayey stone. This clogging had the effect of a regular cast of an enlarged prostatic urethra, the size of the lithotrite from a No. 7 increasing was constricted at the neck of the bladder and to a No. 8. Fearing that this clotjginor mio-lit bulbous in its bladder portion. The stone was withdrawal of the lithotrite recur on a second inches its at its thickest portion 2| long, girth from the bladder, I determined to cut the boy, measured 4 inches, and it weighed 657 grains and passing in a No. 5 staff I performed lithoand consisted of phosphate of lime. The boy tomy, making a very small cut in the prostate, made a good recovery, and was discharged on and extracted the broken fragments from the the 22ud May. bladder by means of an ordinary dressing forThere are but two cases of litholapaxy in ceps. The stone weighed 127 grains, and was adult males in the table appended, calling composed of mixed phosphates and urates. The for any special mention, serial number 4, in boy made an excellent recovery, and left the which a stone weighing 1,600 grains and hospital well on the 11th May. Here was a composed of urate of lime was successfully boy, aged 8|- years, with a far less capacious removed at one sitting, and serial number 21, urethra than I have often found to exist in the fatal case. Bigelow has observed,?" we boys of four or five years old. This case also need no further statistics relating to small suggests the idea that, in cases of large stones stones," and when lie made this observation, he in children, and indeed in adults, it might not spoke of small stones in the adult male. Regibe a bad plan first to crush the stone into several nald Harrison, of Liverpool, well remarks: "The them small fragments, and afterwards to extract direction I take it in which information will by lithotomy, although I am well aware that still be of value is when the confines between some eminent lithotomists consider such a prolithotomy and lithotrity are reached?when ceeding to be dangerous in practice. the question arises whether to crush or to cut And now to give a brief history of the three is the safer proceeding. Where stones are I selected lithotomy in precases in which large, or where their presence is comunusually ference to litholapaxy. Bhugga, aged 30, plicated with co-existing disease in the urethra, admitted into hospital on the 12th May 1884. bladder or kidneys, it cannot be said Next day, on passing the largest lithotrite, prostate, that there is a consensus of opinion as to the a No. 15, into the bladder, I struck a stone so best method of procedure."* I shall, therefore, large that it exceeded the working capabilities state at some length the particulars of the of the lithotrite. The man being young and which appears in the table as serial case once I at performed lithotomy, and number 4. healthy, extracted a lithic acid stone, weighing one The man made drachm less than four ounces. * Observations on Lithotomy, Lithotrity and the early an uninterrupted recovery, and left the hospital detection of stone in the bladder by Reginald Harrison, 1883, "well on the 16tli June 1884.
have not been driven to adopting litholapaxj in children by my failures in lithotomy, for in more
?
*
O
O
hospital
184
THE INDIAN MEDICAL GAZETTE.
Sheikh Mahomed, aged 67, an inhabitant of Indore, was admitted into hospital on the 18th May 1884, suffering from symptoms of stone, which had existed for 15 years. His face bore the traces of great suffering. Pain on passing water was so great that sometimes he used to strike his forehead against the ground, or the wall of his room, in paroxysms of despair. The uriue was alkaline in reaction, and I passed a its specific gravity was- 1015. No. 15 fenestrated lithotrite into the bladder, and readily seized a very large stone. The bladder was roomy, and the urethra capacious. The stone, however, I found to be too large to permit of its being cracked across with the To have cut an old man with a lithotrite. stone would almost certainly have killed huge him, and I, therefore, determined to nibble away at the stone until I could reduce its size to the working capacity of the lithotrite. I was obliged to spend a very long time in chipping away at the outer shell of the stone, and when nearly half an hour had elapsed, I had the satisfaction of finding that I had reduced the Once stone to the capacity of the lithotrite. the stone was cracked across, the operation presented no remarkable features except its great tediousness. At the end of two hours 1 had only extracted half the stone and I almost began to despair of success. But my old patient's pulse improved, and his breathing was perfectly regular, and he required but little additional chloroform to keep him in a condition of perfect anaesthesia, and so I was determined to extract the entire stone at one sitting, if possible. I was obliged to introduce the lithotrite fourteen different times, and applied the aspirator an equal number of times. At the end of the fourth hour, I had nearly extracted the entire stone, and the last quarter of an hour of the operation was spent in sounding, disposing of the last fragments, and in working The evacuating catheters used the aspirator. The stone consisted of were 25 and 29, French. urate of lime, and when damp weighed 1,600 grains. I have weighed this stone recently, and after two hot weathers it weighs 1,470 grains. 18?/i May?Evening temperature 102*4?, pulse 96. 19th May?Feels slight pain over bladder region, urine reddish colour, not much pain in passing water, has almost recovered from effects of chloroform. 2Is* May?Patient feels quite well, and walks about his room, is anxious to go home. 23rd May?A small lithotrite introduced into bladder, and a small fragment of stone detected lying close to neck of bladder?fragment removed between blades of lithotrite. 24th May?Urine perfectly clear, no pain in micturition, at his own urgent request allowed to go home.
[June/
1885.
The above case is a good specimen of the results which can be achieved by Bigelow's operation. I saw and spoke to this man yesterday. He is in the enjoyment of excellent health, and is free from all bladder trouble. His testicles have never descended into the scrotum or inguinal canal. He affirms that he has had two children, and suffered once from syphilis and once from gonorrhoea, proving that a man may be the subject of retained abdominal testicles aud still possess virile power undiminished. Perhaps, Petersen's modification of suprapubic lithotomy might theoretically have been the most appropriate operation for attacking a stone of this size; but no procedure or operation could have been more successful or more satisfactory to my patient than the one I adopted. With a still larger lithotrite than No. 15, Weiss & Son, I should not have the slightest hesitation in attacking a moderately hard stone weighing four ounces. A few brief remarks on the one fatal case in the above table : Munesh Shah, 49 years of age, suffering from stone symptoms, was admitted into the Indore Hospital on the 16th December 1884. He suffered from emphysema of the lungs, his heart was weak, and he was very corpulent, muscular system very flabby, urine acid, specific gravity 1014, no albumen. On the 17th December he was placed under chloroform, which he took very badly. Equal p:irts of chloroform The largest lithoand ether were then tried. trite which could be used with safety was The stone was readily No. 12 fenestrated. seized, but the inspiratory and expiratory efforts so were deep and laboured, that the water injected iuto the bladder was soon expelled, and so the bladder kept continually contracting on the lithotrite, rendering the operation A No. 14 English most difficult and tedious. catheter was the largest I was able evacuating The lithotrite was introduced to employ. sixteen times, and the operation lasted 2 hours and 35 miuutes, although the stone only weighed This will give some idea of the 272 grains. difficulties attending the operation of litholapaxy in this case.
bth December?pulse 120, evening tempera104?, suffering from an attack of asthma, right testicle swollen, some pain on pressure 1
ture
bladd er. 22nd December?Peels burning at time of micturition, condition of testicle unchanged, souuded bladder, but no fragment of stone could be felt. 26th December?Does not sleep well, pain experienced in epigastric region, getting weaker, has difficulty in breathing, had two fits of asthma. 27th.?Dyspnoea increasing, pulse rapid and weak, becoming drowsy?died during the night. No ?post-mortem examination was obtainable. I ascribe the fatal issue in this case to the
over
June, 1885.]
LITHOLA.PAXY IN MALE CHILDREN-ELEPHANTOID TUMOUR.
lengthened administration of chloroform aud ether in a patient suffering from emphysema of lungs and weak heart. If I were again to meet with a similar case, I should most certainly perform lithotomy in preference to litholapaxy, for I consider that litholapaxy is contra-indicated in cases were a contracted bladder keeps on continually grasping the lithotrite and expelling the water injected by the aspirator.
The length to which this paper has already extended prevents me on the present occasion from entering into the details of the eighteen litholapaxies in boys in the table appended. On a future occasion, I hope to give detailed histories of some of the most interesting cases in this series. In four or five cases the operation of litholapaxy was followed by some swelling of the penis and prepuce, and in three or four cases there was considerable pain in passing water for some few days after the operation, but eventually all the cases left the hospital quite well and free from pain. For the information of those who may feel disposed to give litholapaxy in boys a trial, I may mention that the No. 7 1 ithotrite I use is uufenestrated. It is 6 in the stem and 7 at the angle, and that No. 8 lithotrite is fenestrated, and is 7 in the stem and 8 at the angle. Since I began to write this paper, I have performed two additional litholapaxies in men, which I have not These two included in the table appended. cases will turn out well, for they are perfectly simple cases. I have, therefore, treated 48 cases of stone in the bladder since the end of April This 1884 to the present date, with one death. I consider a very satisfactory result. In conclusion, I would lay down the following rules for the successful performance of litholapaxy in boys : Use small fenestrated lithotrites; if possible, crush the stone in the bladder into fine powder, and you will not then require large sized catheters to evacuate the debits; never use a lithotrite or an evacuating catheter which will not pass readily in and out of the bladder aud urethra ; be extremely gentle and careful in practising all manipulations on the uriuary passages ; do not be in a hurry to complete the operation ; use the aspirator freely, and never, if possible, leave a single grain of debris behind in the bladder; and rest assured that if all these conditions are fulfilled, you may count Some cases on a vei'3r large measure of success. no lithotrites, howyou will meet with where ever small, can be employed with safety, and these are the cases which should be dealt with
by lithotomy. Indorc. 2ith
May,
1885.
185
