LITHOLAPAXY IN MALE CHILDREN AND MALE ADULTS.
Sept., 1885.]
\J
?rijinal
ticulars of these ten cases of sive
LITHOLAPAXY IN MALE CHILDREN AND MALE ADULTS, WITH NOTES OF THREE CASES OF LITHOTOMY : A THIRD SERIES OF CASES PERFORMED THE INLORE CHARITABLE HOSPITAL.
AT
BY
Surgeon-Major D. F. Keegan, M.D. (Dublin).
Since the 24th May 1885, thirteen patients have been admitted into the Indore Charitable Hospital suffering from stone in the bladder. Six of these patients were boys, varying in age from to 11 years. Seven were male adults, varying in age from 20 to 40 years. Four of the boys were subjected to litholapaxy, and on two lithotomy was performed. In six adults, litholapaxy was the operation selected; and one adult, the subject of a stone weighing 6f oz., was This last mentioned case proved cut. fatal. The accompanying table shows the parTable showing
particulars of
12 additional
267
of two charged from
written.
litholapaxy excluwhich had not been disHospital when my last paper was
cases
In the above table there are only five cases mention : the four cases and serial number 111, in which the stone weighed 1100 grains. I shall first deal with the five cases of litholapaxy, and then relate some particulars connected with the three cases of lithotomy. Case Serial No. 105. Vensio, a boy aged 10, was admitted into Hospital on the 26th May 1885 suffering from stone symptoms, which had existed for six years. His spleen was greatly enlarged. Urine neutral and clear. Next day beiug placed under chloroform, a No. 8 lithotrite was passed into his bladder, when a large stone was easily seized and crushed. A No. 9 catheter passed with ease into his bladder.
calling for any special of litholapaxy in boys
Litholapaxies performed on Male Hospital. (%rd Series.)
Children and Male Adults at the Indore
Charitable
oj
^
Composition of Stone.
a
II 15 104 105 106
lfumjan Vensio Jaintio
108 109 110
Krishnarao .1 od ho Motie
111
llahadia Mahomed Hoosen Khan
112 113
Mungle Singh
114
Jhapar
.
?
.
1"
( 16 English. 125 French.
Oxalate of Lime
12 9 25 French.
II 8 15
28-5-85
11
16
9-G-85 14-6-85 28-6-85
7 11 16 & 15
7 14
..
French.
9-7-85 12-7-85
8 15 & 11
The lithotrite was introduced six times, and the operation lasted 94 minutes. The stone, composed of uric acid and phosphates, weighed 360 grains, and was completely removed at one
sitting.
28th May.?Pain along course of urethra and over bladder region ; pain in passing water. At the root of penis there is a slight swelling. 29th May.?Swelling less; pain in passing water less; urine quite clear. 3\st May.?Swelling at root of penis dimU nishing ; some pain along course of urethra; eats well. 4:th June. All swelling disappeared; passes water freely and without pain; complains of pain over region of spleen. Discharged cured of stone, and re-admitted for treatment of splenic enlargement. Left Hospital for his home on the 9th June. This is the largest stone I have yet ?
..
..
..
..
..
7 & 9
Successful.
..
Phosphates
Urates and Phosphates Uric Acid and Oxalate of Lime covering. Oxalate of Lime and thiok covering of Phosphates. Uric Acid Uric Acid Uric Acid and covering of Oxalate of Lime. Oxalate of Lime and Uric Acid. Uric Acid Lithie Acid and Oxalate of Lime, Oxalate of Lime
15& 16
.
.
too C?
1
23-5-85 27-5-85 27-5-85
/ 25
Result.
100 360 342
Do. Do. Do. Do.
11 55 696
Do. Do. Do.
Do. 32 787
Do. Do.
..
crushed at one sitting in a boy of ten years of age. Case Serial No. 108. Krishnarao, a boy aged 2^ years, admitted into Hospital on the 9th Juue suffering from symptoms of stone, which had existed for three months. A No. 7 catheter and a No. 7 lithotrite passed readily into the bladder. The lithotrite was introduced on four different occasions. On each withdrawal of lithotrite from bladder, some debris On last withcame away between its blades. drawal of lithotrite, the meatus of the urethra was was
torn
slightly.
employed only
Weight
of stone,
less
in
Evacuating catheter No. 7 to remove the debris. 11 grains. Time occupied
once
by operation, 17 minutes. 10^/t June.?Urine clear; boy cries much when passing urine. 12th June. Doing well; urine clear. Much
pain
passing
water.
THE INDIAN MEDICAL GAZETTE.
268
The 13th June.?Patient feels much better. father living not far from Indore took the child home. On the 26th July, the father brought the boy to the Hospital to show him to me. The boy had grown plump and fat, and has continued to pass urine without pain and with perfect freedom. Case Serial No. 112. Mahomed Hoosen Khan, a boy aged 2f years, admitted into Hospital on the 8th July 1885 with stone symptoms, which had existed for three months. Urine clear, and acid in reaction. There is great straining on passing water, which comes away
boy's
drop by drop. Evening temperature 100 6? F. On the July, a No. 8 lithotrite passed readily
9th into A bladder. Lithotrite introduced five times. No. 7 evacuating catheter employed to remove debris. Stone weighed 32 grains, brick-dust and colour, consisting of uric acid. Operation lasted 31 minutes. 10th July.?Urine quite clear; slight pain in
passing
water.
in passing water. The On the 19t,h July father took the boy home. the father brought the child to the Hospital The boy complains of no for inspection. and passes urine quite freely of stone, symptoms and without any pain. 12th
July.?No pain
Case Serial No. 114.
Jhapur,
a
boy aged
8, admitted into Hospital on the 31st July 1885. Urine alkaline in reaction; specific gravity 1018. Slight quantity of albumen present. Ou
the 1st August, a No. 8 lithotrite passed readily into the bladder?stone seized readily; the greater portion of the stone was crushed and evacuated in fifteen minutes. No. 7 and No. 9 evacuating catheters employed to bring away the debris. A click was still heard, when the aspirator was used; much difficulty experienced in finding and seizing the last fragments of stone. The lithotrite was introduced into the bladder five different times. Finally, the whole stone, which weighed 28 grains, and consisted of oxalate of lime, was disposed of; but the operation lasted 57 minutes. 2nd August.?No pain oil deep pressure being made over pubis. There is some pain when pressure is made along course ot urethra: passes urine freely, and of natural colour ; had sound sleep, but could eat nothing owing to after-effects of chloroform. 3rd August.?Doing well; no pain on pressure over urethra. 4th August. Sounded bladder with small sound ; no fragments or debris could be detected ; wishes to go home; discharged cured. Case Serial No. 111. Mahadia, a man aged 40, was admitted into Hospital on the 3rd July 18$5 suffering from stone symptoms, which had existed for some years. No. 15 lithotrite ?
[Sept.,
1885.
being introduced into the bladder, a, large stone The stone was was readily seized and crushed.
very hard one. The litliotrite was introduced six different occasions, and the debris exThe tracted by a No. 16 evacuating- catheter. operation lasted 88 minutes, and the stone, which consisted principally of oxalate of lime with some mixture of uric acid, weighed 1100 grains. I merely place this case on record on account of the size of the stone, which approaches the class termed by Mr. Teale " boundary stones." The operation presented no features of novelty a
ou
or
difficult}'.
4th
July.?Urine clear;
passing
water.
lias
some
pain
in
5th July.?Pain much less; feels quite well. Sir Henry Thompson's sound being passed into the bladder, no particle of stone could be detected. This is a 6th July.?Gone home quite well. of to be results achieved good example by Bigelow's operation. And now to relate some particulars connected with the three cases of Lithotomy. Bhau Singh, Rajput, a labourer, aged 22, was admitted into Hospital on the 5th July with symptoms of stone, which had existed for several years. Specific gravity of urine, 1011 ; alkaline in reaction, containing a large quantity of albumen. On the 6th July the patient having been placed under chloroform, the bladder was injected with tepid water, and a No. 15 litliotrite being introduced into the bladder, a large stone was at once struck and seized. The stone I found was much too large for the working capacity of the litliotrite. Thinking it might be irregular in shape, I endeavoured to seize it in I therea shorter diameter, but failed to do so. fore came to the conclusion that the stone was Once or twice somewhat spherical in shape. I seized the stone at its rim or circumference, but on working the litliotrite I found that the stone slipped out from between its blades. During these manipulations, the bladder began to contract rather violently, and much of the water injected previous to the introduction of the litliotrite leaked out through the urethra. I once again seized the stone in its greatest diameter, but finding the stone to be far beyond the working capabilities of the litliotrite, I made up my mind to withdraw the litliotrite from the bladder and perform lithotomy. But this procedure I found not so easy of accomplishment, for on divaricating the litliotrite so' as to allow the stone to fall out from between its blades, I found that I was unable to shake out the stone, for the bladder now almost empty of water had grasped the stone and the instrument so firmly that I experienced the greatest' difficulty iu effecting my object. The situation
LITHOLAPAXY IN MALE CHILDREN.
Sept, 1885.]
a very awkward one, aud it was series of ineffectual efforts that I only eventually succeeded in freeing the blades and closing the instrument. I now withdrew the lithotrite, and passing in a large sized staff, performed lateral lithotomy, removing with considerable difficulty a large globular uric acid stone weighing 6f oz. There was very little luemorrhage; no damage was done to the rectum, but the incision was necessarily very large. Evening temperature 100?. Pulse 150. 7th July.?Morning temperature 99'8?. Pulse 125. Patient feels very low, great pain over was
certainly after
a
pubic region. Evening.?Pain not diminished, tympanites, pulse weak and soft. Died at midnight. No post-mortem examination could some
be obtained. Bemarhs.?It is open to question whether the operation I selected for the removal of this stone "was the correct one. Indeed, I am inclined to think that, for all stones weighing over four ounces, and which, therefore, cannot safely be disposed of by litholapaxy, Petersen's modification of suprapubic lithotomy offers the best chance of success. Every one is aware that stones ?weighing far more than seven ounces have been successfully removed from the bladder by lateral lithotomy. Nevertheless, I think the consensus of surgical opinion at the present day is in favour of having recourse to the high operation for stone, when the stone, from its size or hardness, has passed the limits in which litholaAnd with our present paxy can be performed. instruments I would place the limit of litholapaxy at stones weighing four ounces. My main object, however, in placing this case on record is to exemplify a possible danger that may arise in practice when seizing a very large stone in a bladder which has began to contract, and empty itself of water, as shown by the very great difficulty I experienced in releasing the stone from the lithotrite after I found it impossible to crush it. Runchore, a boy aged 11, was admitted into the Indore Charitable Hospital on the 13th July About five years ago, Dr. Beaumont, my 1885. predecessor at Indore, crushed a stone in this boy's bladder. The boy remained free from all stone symptoms for about two years and-a-halt. These symptoms again showing themselves, and increasing in intensity, the boy was brought by his parents, about May or June 188-1, to the Dis-
pensary at Khundwa, supervised by SurgeonMajor P. Cullen, M.D., Civil Surgeon of that station. Dr. Cullen, in a paper (Lithotomy vs. Lithotrity) read on the 5th September 1884 at of the North-West Provinces and a meeting Oudh Branch of the British Medical Association, described this boy's casein the following words: " The last case on my list of operations was a boy on whom lithotrity had been attempted, and the parent's account the stone could not be
by
M
extracted. I found three stones, which, from tlieir appearance, there could be no doubt, were pieces of one large stone which had been broken. In this case also it was said, a good deal of bleeding occurred from the urethra, which I found so tight at the bulb that it was with difficulty I introduced No. 5 sound." Litholapaxy in children has only been tried on an extensive scale in India at the Indore Charitable Hospital, and therefore, as soon as I had read Dr. (Jnllen's paper, I wrote to him for the previous history of this boy's case. Dr. Cullen kindly replied that the boy's name was Sukram, and that Dr. Beaumont, some three years ago, had operated on the boy at the Iutlore Hospital. On receiving this communication, I at once went over most carefully the register of all cases of lithotrity and lithotomy performed by Dr. Beaumont and myself during the last seven years at Indore, but could not discover the name of Sukram. I addressed a letter to Dr. Cullen, which appeared in the January number of the Indian Medical Journal, in which I used these words : " I feel perfectly certain that if my friend Dr. Beanmont, an excellent lithotomist, had attempted lithotrity and had failed in crushing a stone in the bladder, that he would have performed lithotomy without a moment's hesitation. I can certainly, with truth, say that I should have done the same." Dr. Cullen had, by mistake, told me that the boy's name was Sukram, when, as a matter of fact, his name is Runchore or Rungchore. As already stated, the boy was admitted for the second time into the Indore Hospital on the 13th July 1885, and next day being placed under chloroform, a No. 9 evacuating catheter passed with the greatest ease iuto his bladder, although Dr. Cullen, in May or June 1884, had found the greatest difficulty in passing a No. 5 sound. Attaching an aspirator to the No. 9 evacuating catheter, I injected some water iuto the bladder, but found that some of it leaked out through a very fine fistula which existed in the cicatrix left behind by the lithotomy incision. The existence of this fistula negatived the idea of entertaining the operation of litholapaxy, and besides the stone or stones in the bladder were very large, judging from the sensation conveyed to my hand by the evacuating catheter. The boy being placed in the lithotomy position, a No. 9 sound was passed readily into the bladder, and the operation performed through the line of cicatrix left behind by the operation performed by Dr. Cullen fourteen months previously. On reaching the bladder, I found it quite blocked with ease six stones up with stones, and removed
weighing respectively 225, 135, 110, 100, 85,
and 25 grains, and iu addition 72 small stones which weighed in the aggregate 13 grains, and which varied in size from No. 10 shot to that of The stones were a small pea. composed of uric
THE INDIAN MEDICAL GAZETTE.
270
with a large proportion of phosphates of lime. One of the stones was about the size of a pullet's egg. The hoy made a very good recovery, and left the Hospital on the 10th August 1885. A very fine fistula, through which I could pass a small eye probe, existing in the cicatrix in the perineum. He, however, passed no urine and he has promised the cicatrix, through to return to Indore in about six weeks' time for inspection. About a fortnight ago, and when the wound in the perineum had not healed, he passed through the wound a very small stone about the size of B. B. shot. A few days ago, I sounded the bladder, but could not detect a
acid,
stone.
Remarlis.?I several reasons:
place
this
First,
case
on
record
for
to show that Dr. Beau-
completely crushed the stone in this boy's bladder on the first occasion of his being admitted into the Indore Hospital; secondly, to prove how very erroneous were the conclusions which Dr. Cullen arrived at as regards this case ; thirdly, to show that the calibre of the urethra had not, in reality, contracted as the result of Dr. Beaumont's lithotrity; and lastly, to exemplify how soon after the lithotomy operation performed by Dr. Cullen, calculi were again formed in the kidneys, and with what rapidity they increased in size in the bladder. In Mayor June 1884, Dr. Cullen extracted three stones from this boy's bladder, weighing 1 oz. and 403 grains; and in July 1885, 1 extracted six medium sized stones, and 72 very small stones, weighing in the aggregate 688 grains. The future surgical history of this boy's life will be well worth watchiug, and his parents have now become so convinced of the danger which lies before him, that they have promised to bring him to the Hospital for inspection two or three times every year. Chooda, aged 10, was admitted into Hospital on the 23rd July 1885 suffering from symptoms of stone, which had existed for 27 mouths. The boy was much emaciated, and his mother brought him to the Hospital to have his stone crushed. The fear ot submitting him to a cutting operation had deterred her from seeking relief earlier, and the poor boy had been allowed to pine away and suffer for more than Next day, on his being placed under two years. chloroform, I passed a No. 11 lithotrite and endeavoured to seize the stone, but found it was too large for the working capacity of the instrument. I nibbled away with the lithotrite at the outer shell of the stone lor some time, but could not succeed in seizing it in a diameter sufficiently small to allow me to work the instrument. The mother was then informed that lithotomy was absolutely necessary, and I accordingly cut the boy, removing a large stone, weighing 804 grains, and composed of uric acid, with a thick covering of phosphates. The boy mont
[Skm.,
1885.
is still in Hospital, and although lie is emaciated, and has suffered from diarrhoea?since the operation was performed, still the wound in the perineum looks healthy and is healing, and I trust that, in three weeks or a month, he will be able to leave the Hospital quite restored to health. I trust that this brief report of a third series of litholapaxies performed at the Indore Charitable Hospital may prove interesting to my readers. Up to the present date, 46 litholapaxies have been performed on boys at this hospital with one death. I feel quite convinced that the calibre of the urethra in young boys is, as a rule, mucli larger than is geuerally believed to A few days ago, a mother brought be the case. her male child, 11 months old, to the Indore Hospital, labouring under some symptoms of stone. The child was the subject of phymosis, which I considered the cause of these symptoms. However, I passed a No. 7 evacuating catheter into this child's bladder, and attached the aspirator, but could detect no click. The phymosis was cured, and the stone symptoms soon passed away. I should say that, in most cases, a No. 6 catheter will pass readily into the bladder of a child one year old, and with such a catheter it is quite feasible to evacuate a stone of considerable size from a child's bladder in less than an hour. Indore,
\
/
11 th
August
1885.
Sept., 1885.]
\J
?rijinal
ticulars of these ten cases of sive
LITHOLAPAXY IN MALE CHILDREN AND MALE ADULTS, WITH NOTES OF THREE CASES OF LITHOTOMY : A THIRD SERIES OF CASES PERFORMED THE INLORE CHARITABLE HOSPITAL.
AT
BY
Surgeon-Major D. F. Keegan, M.D. (Dublin).
Since the 24th May 1885, thirteen patients have been admitted into the Indore Charitable Hospital suffering from stone in the bladder. Six of these patients were boys, varying in age from to 11 years. Seven were male adults, varying in age from 20 to 40 years. Four of the boys were subjected to litholapaxy, and on two lithotomy was performed. In six adults, litholapaxy was the operation selected; and one adult, the subject of a stone weighing 6f oz., was This last mentioned case proved cut. fatal. The accompanying table shows the parTable showing
particulars of
12 additional
267
of two charged from
written.
litholapaxy excluwhich had not been disHospital when my last paper was
cases
In the above table there are only five cases mention : the four cases and serial number 111, in which the stone weighed 1100 grains. I shall first deal with the five cases of litholapaxy, and then relate some particulars connected with the three cases of lithotomy. Case Serial No. 105. Vensio, a boy aged 10, was admitted into Hospital on the 26th May 1885 suffering from stone symptoms, which had existed for six years. His spleen was greatly enlarged. Urine neutral and clear. Next day beiug placed under chloroform, a No. 8 lithotrite was passed into his bladder, when a large stone was easily seized and crushed. A No. 9 catheter passed with ease into his bladder.
calling for any special of litholapaxy in boys
Litholapaxies performed on Male Hospital. (%rd Series.)
Children and Male Adults at the Indore
Charitable
oj
^
Composition of Stone.
a
II 15 104 105 106
lfumjan Vensio Jaintio
108 109 110
Krishnarao .1 od ho Motie
111
llahadia Mahomed Hoosen Khan
112 113
Mungle Singh
114
Jhapar
.
?
.
1"
( 16 English. 125 French.
Oxalate of Lime
12 9 25 French.
II 8 15
28-5-85
11
16
9-G-85 14-6-85 28-6-85
7 11 16 & 15
7 14
..
French.
9-7-85 12-7-85
8 15 & 11
The lithotrite was introduced six times, and the operation lasted 94 minutes. The stone, composed of uric acid and phosphates, weighed 360 grains, and was completely removed at one
sitting.
28th May.?Pain along course of urethra and over bladder region ; pain in passing water. At the root of penis there is a slight swelling. 29th May.?Swelling less; pain in passing water less; urine quite clear. 3\st May.?Swelling at root of penis dimU nishing ; some pain along course of urethra; eats well. 4:th June. All swelling disappeared; passes water freely and without pain; complains of pain over region of spleen. Discharged cured of stone, and re-admitted for treatment of splenic enlargement. Left Hospital for his home on the 9th June. This is the largest stone I have yet ?
..
..
..
..
..
7 & 9
Successful.
..
Phosphates
Urates and Phosphates Uric Acid and Oxalate of Lime covering. Oxalate of Lime and thiok covering of Phosphates. Uric Acid Uric Acid Uric Acid and covering of Oxalate of Lime. Oxalate of Lime and Uric Acid. Uric Acid Lithie Acid and Oxalate of Lime, Oxalate of Lime
15& 16
.
.
too C?
1
23-5-85 27-5-85 27-5-85
/ 25
Result.
100 360 342
Do. Do. Do. Do.
11 55 696
Do. Do. Do.
Do. 32 787
Do. Do.
..
crushed at one sitting in a boy of ten years of age. Case Serial No. 108. Krishnarao, a boy aged 2^ years, admitted into Hospital on the 9th Juue suffering from symptoms of stone, which had existed for three months. A No. 7 catheter and a No. 7 lithotrite passed readily into the bladder. The lithotrite was introduced on four different occasions. On each withdrawal of lithotrite from bladder, some debris On last withcame away between its blades. drawal of lithotrite, the meatus of the urethra was was
torn
slightly.
employed only
Weight
of stone,
less
in
Evacuating catheter No. 7 to remove the debris. 11 grains. Time occupied
once
by operation, 17 minutes. 10^/t June.?Urine clear; boy cries much when passing urine. 12th June. Doing well; urine clear. Much
pain
passing
water.
THE INDIAN MEDICAL GAZETTE.
268
The 13th June.?Patient feels much better. father living not far from Indore took the child home. On the 26th July, the father brought the boy to the Hospital to show him to me. The boy had grown plump and fat, and has continued to pass urine without pain and with perfect freedom. Case Serial No. 112. Mahomed Hoosen Khan, a boy aged 2f years, admitted into Hospital on the 8th July 1885 with stone symptoms, which had existed for three months. Urine clear, and acid in reaction. There is great straining on passing water, which comes away
boy's
drop by drop. Evening temperature 100 6? F. On the July, a No. 8 lithotrite passed readily
9th into A bladder. Lithotrite introduced five times. No. 7 evacuating catheter employed to remove debris. Stone weighed 32 grains, brick-dust and colour, consisting of uric acid. Operation lasted 31 minutes. 10th July.?Urine quite clear; slight pain in
passing
water.
in passing water. The On the 19t,h July father took the boy home. the father brought the child to the Hospital The boy complains of no for inspection. and passes urine quite freely of stone, symptoms and without any pain. 12th
July.?No pain
Case Serial No. 114.
Jhapur,
a
boy aged
8, admitted into Hospital on the 31st July 1885. Urine alkaline in reaction; specific gravity 1018. Slight quantity of albumen present. Ou
the 1st August, a No. 8 lithotrite passed readily into the bladder?stone seized readily; the greater portion of the stone was crushed and evacuated in fifteen minutes. No. 7 and No. 9 evacuating catheters employed to bring away the debris. A click was still heard, when the aspirator was used; much difficulty experienced in finding and seizing the last fragments of stone. The lithotrite was introduced into the bladder five different times. Finally, the whole stone, which weighed 28 grains, and consisted of oxalate of lime, was disposed of; but the operation lasted 57 minutes. 2nd August.?No pain oil deep pressure being made over pubis. There is some pain when pressure is made along course ot urethra: passes urine freely, and of natural colour ; had sound sleep, but could eat nothing owing to after-effects of chloroform. 3rd August.?Doing well; no pain on pressure over urethra. 4th August. Sounded bladder with small sound ; no fragments or debris could be detected ; wishes to go home; discharged cured. Case Serial No. 111. Mahadia, a man aged 40, was admitted into Hospital on the 3rd July 18$5 suffering from stone symptoms, which had existed for some years. No. 15 lithotrite ?
[Sept.,
1885.
being introduced into the bladder, a, large stone The stone was was readily seized and crushed.
very hard one. The litliotrite was introduced six different occasions, and the debris exThe tracted by a No. 16 evacuating- catheter. operation lasted 88 minutes, and the stone, which consisted principally of oxalate of lime with some mixture of uric acid, weighed 1100 grains. I merely place this case on record on account of the size of the stone, which approaches the class termed by Mr. Teale " boundary stones." The operation presented no features of novelty a
ou
or
difficult}'.
4th
July.?Urine clear;
passing
water.
lias
some
pain
in
5th July.?Pain much less; feels quite well. Sir Henry Thompson's sound being passed into the bladder, no particle of stone could be detected. This is a 6th July.?Gone home quite well. of to be results achieved good example by Bigelow's operation. And now to relate some particulars connected with the three cases of Lithotomy. Bhau Singh, Rajput, a labourer, aged 22, was admitted into Hospital on the 5th July with symptoms of stone, which had existed for several years. Specific gravity of urine, 1011 ; alkaline in reaction, containing a large quantity of albumen. On the 6th July the patient having been placed under chloroform, the bladder was injected with tepid water, and a No. 15 litliotrite being introduced into the bladder, a large stone was at once struck and seized. The stone I found was much too large for the working capacity of the litliotrite. Thinking it might be irregular in shape, I endeavoured to seize it in I therea shorter diameter, but failed to do so. fore came to the conclusion that the stone was Once or twice somewhat spherical in shape. I seized the stone at its rim or circumference, but on working the litliotrite I found that the stone slipped out from between its blades. During these manipulations, the bladder began to contract rather violently, and much of the water injected previous to the introduction of the litliotrite leaked out through the urethra. I once again seized the stone in its greatest diameter, but finding the stone to be far beyond the working capabilities of the litliotrite, I made up my mind to withdraw the litliotrite from the bladder and perform lithotomy. But this procedure I found not so easy of accomplishment, for on divaricating the litliotrite so' as to allow the stone to fall out from between its blades, I found that I was unable to shake out the stone, for the bladder now almost empty of water had grasped the stone and the instrument so firmly that I experienced the greatest' difficulty iu effecting my object. The situation
LITHOLAPAXY IN MALE CHILDREN.
Sept, 1885.]
a very awkward one, aud it was series of ineffectual efforts that I only eventually succeeded in freeing the blades and closing the instrument. I now withdrew the lithotrite, and passing in a large sized staff, performed lateral lithotomy, removing with considerable difficulty a large globular uric acid stone weighing 6f oz. There was very little luemorrhage; no damage was done to the rectum, but the incision was necessarily very large. Evening temperature 100?. Pulse 150. 7th July.?Morning temperature 99'8?. Pulse 125. Patient feels very low, great pain over was
certainly after
a
pubic region. Evening.?Pain not diminished, tympanites, pulse weak and soft. Died at midnight. No post-mortem examination could some
be obtained. Bemarhs.?It is open to question whether the operation I selected for the removal of this stone "was the correct one. Indeed, I am inclined to think that, for all stones weighing over four ounces, and which, therefore, cannot safely be disposed of by litholapaxy, Petersen's modification of suprapubic lithotomy offers the best chance of success. Every one is aware that stones ?weighing far more than seven ounces have been successfully removed from the bladder by lateral lithotomy. Nevertheless, I think the consensus of surgical opinion at the present day is in favour of having recourse to the high operation for stone, when the stone, from its size or hardness, has passed the limits in which litholaAnd with our present paxy can be performed. instruments I would place the limit of litholapaxy at stones weighing four ounces. My main object, however, in placing this case on record is to exemplify a possible danger that may arise in practice when seizing a very large stone in a bladder which has began to contract, and empty itself of water, as shown by the very great difficulty I experienced in releasing the stone from the lithotrite after I found it impossible to crush it. Runchore, a boy aged 11, was admitted into the Indore Charitable Hospital on the 13th July About five years ago, Dr. Beaumont, my 1885. predecessor at Indore, crushed a stone in this boy's bladder. The boy remained free from all stone symptoms for about two years and-a-halt. These symptoms again showing themselves, and increasing in intensity, the boy was brought by his parents, about May or June 188-1, to the Dis-
pensary at Khundwa, supervised by SurgeonMajor P. Cullen, M.D., Civil Surgeon of that station. Dr. Cullen, in a paper (Lithotomy vs. Lithotrity) read on the 5th September 1884 at of the North-West Provinces and a meeting Oudh Branch of the British Medical Association, described this boy's casein the following words: " The last case on my list of operations was a boy on whom lithotrity had been attempted, and the parent's account the stone could not be
by
M
extracted. I found three stones, which, from tlieir appearance, there could be no doubt, were pieces of one large stone which had been broken. In this case also it was said, a good deal of bleeding occurred from the urethra, which I found so tight at the bulb that it was with difficulty I introduced No. 5 sound." Litholapaxy in children has only been tried on an extensive scale in India at the Indore Charitable Hospital, and therefore, as soon as I had read Dr. (Jnllen's paper, I wrote to him for the previous history of this boy's case. Dr. Cullen kindly replied that the boy's name was Sukram, and that Dr. Beaumont, some three years ago, had operated on the boy at the Iutlore Hospital. On receiving this communication, I at once went over most carefully the register of all cases of lithotrity and lithotomy performed by Dr. Beaumont and myself during the last seven years at Indore, but could not discover the name of Sukram. I addressed a letter to Dr. Cullen, which appeared in the January number of the Indian Medical Journal, in which I used these words : " I feel perfectly certain that if my friend Dr. Beanmont, an excellent lithotomist, had attempted lithotrity and had failed in crushing a stone in the bladder, that he would have performed lithotomy without a moment's hesitation. I can certainly, with truth, say that I should have done the same." Dr. Cullen had, by mistake, told me that the boy's name was Sukram, when, as a matter of fact, his name is Runchore or Rungchore. As already stated, the boy was admitted for the second time into the Indore Hospital on the 13th July 1885, and next day being placed under chloroform, a No. 9 evacuating catheter passed with the greatest ease iuto his bladder, although Dr. Cullen, in May or June 1884, had found the greatest difficulty in passing a No. 5 sound. Attaching an aspirator to the No. 9 evacuating catheter, I injected some water iuto the bladder, but found that some of it leaked out through a very fine fistula which existed in the cicatrix left behind by the lithotomy incision. The existence of this fistula negatived the idea of entertaining the operation of litholapaxy, and besides the stone or stones in the bladder were very large, judging from the sensation conveyed to my hand by the evacuating catheter. The boy being placed in the lithotomy position, a No. 9 sound was passed readily into the bladder, and the operation performed through the line of cicatrix left behind by the operation performed by Dr. Cullen fourteen months previously. On reaching the bladder, I found it quite blocked with ease six stones up with stones, and removed
weighing respectively 225, 135, 110, 100, 85,
and 25 grains, and iu addition 72 small stones which weighed in the aggregate 13 grains, and which varied in size from No. 10 shot to that of The stones were a small pea. composed of uric
THE INDIAN MEDICAL GAZETTE.
270
with a large proportion of phosphates of lime. One of the stones was about the size of a pullet's egg. The hoy made a very good recovery, and left the Hospital on the 10th August 1885. A very fine fistula, through which I could pass a small eye probe, existing in the cicatrix in the perineum. He, however, passed no urine and he has promised the cicatrix, through to return to Indore in about six weeks' time for inspection. About a fortnight ago, and when the wound in the perineum had not healed, he passed through the wound a very small stone about the size of B. B. shot. A few days ago, I sounded the bladder, but could not detect a
acid,
stone.
Remarlis.?I several reasons:
place
this
First,
case
on
record
for
to show that Dr. Beau-
completely crushed the stone in this boy's bladder on the first occasion of his being admitted into the Indore Hospital; secondly, to prove how very erroneous were the conclusions which Dr. Cullen arrived at as regards this case ; thirdly, to show that the calibre of the urethra had not, in reality, contracted as the result of Dr. Beaumont's lithotrity; and lastly, to exemplify how soon after the lithotomy operation performed by Dr. Cullen, calculi were again formed in the kidneys, and with what rapidity they increased in size in the bladder. In Mayor June 1884, Dr. Cullen extracted three stones from this boy's bladder, weighing 1 oz. and 403 grains; and in July 1885, 1 extracted six medium sized stones, and 72 very small stones, weighing in the aggregate 688 grains. The future surgical history of this boy's life will be well worth watchiug, and his parents have now become so convinced of the danger which lies before him, that they have promised to bring him to the Hospital for inspection two or three times every year. Chooda, aged 10, was admitted into Hospital on the 23rd July 1885 suffering from symptoms of stone, which had existed for 27 mouths. The boy was much emaciated, and his mother brought him to the Hospital to have his stone crushed. The fear ot submitting him to a cutting operation had deterred her from seeking relief earlier, and the poor boy had been allowed to pine away and suffer for more than Next day, on his being placed under two years. chloroform, I passed a No. 11 lithotrite and endeavoured to seize the stone, but found it was too large for the working capacity of the instrument. I nibbled away with the lithotrite at the outer shell of the stone lor some time, but could not succeed in seizing it in a diameter sufficiently small to allow me to work the instrument. The mother was then informed that lithotomy was absolutely necessary, and I accordingly cut the boy, removing a large stone, weighing 804 grains, and composed of uric acid, with a thick covering of phosphates. The boy mont
[Skm.,
1885.
is still in Hospital, and although lie is emaciated, and has suffered from diarrhoea?since the operation was performed, still the wound in the perineum looks healthy and is healing, and I trust that, in three weeks or a month, he will be able to leave the Hospital quite restored to health. I trust that this brief report of a third series of litholapaxies performed at the Indore Charitable Hospital may prove interesting to my readers. Up to the present date, 46 litholapaxies have been performed on boys at this hospital with one death. I feel quite convinced that the calibre of the urethra in young boys is, as a rule, mucli larger than is geuerally believed to A few days ago, a mother brought be the case. her male child, 11 months old, to the Indore Hospital, labouring under some symptoms of stone. The child was the subject of phymosis, which I considered the cause of these symptoms. However, I passed a No. 7 evacuating catheter into this child's bladder, and attached the aspirator, but could detect no click. The phymosis was cured, and the stone symptoms soon passed away. I should say that, in most cases, a No. 6 catheter will pass readily into the bladder of a child one year old, and with such a catheter it is quite feasible to evacuate a stone of considerable size from a child's bladder in less than an hour. Indore,
\
/
11 th
August
1885.
