LITHOLAPAXY
IN
MALE
CHILDREN.
A
SERIES OF CASES PERFORMED AT THE
INDORE CHARITABLE HOSPITAL. By Surgeon-Major U. F. Keegan, m.d.,b.m.s.,
Residency Surgeon, Indore. Litholapaxy
in
established and
male most
adults is
now
one of the
best
successful operations in the
THE INDIAN MEDICAL GAZETTE.
132
whole domain of surgery, and the time is not very distant when it will almost completely supersede
stone in the bladder may
ever,
with on
tight
a
Lateral Lithotomy.
of very
cases
with
TABLE A.
Lithotomy will always hold its own place large or very hard calculi, or where
lithotomy. in
happen
to
be
stricture of the urethra. The
of the present paper is to
safety
show that
we
j3 in
a
may
Class of
Year.
Patient.
a
go
Freyer in the December number of the Indian Medical Gazette for
how successful the
of
on
Surgeon-Major
done the
in the March number of the Indian
Medical Gazette for of the Indian P.
Surgeon
J.
R. C.
In
1883.
Saunders
the March
has
"As
yet
no
in
by which litholapaxy safety in males below the
such
"
successful.
laying
can
age of
I need therefore make
before the
profession litholapaxy can
be
should be
lithotomy
cases
stone
the bladder
in
treated
were
January 1879 172
cases
in to
there 8
this
a
no
series of
as
apology cases
come
occurring
in
institution
the present date. 16 deaths. were
male from
the
1st
Out of these
Lithotomy litholapaxy was
was
will be detailed in the sequel when record some special cases of this series.
case
to
19
Men
17
Boys
22
Men
25
Boys
18
1883
1st
quarter of f Men
1884
...
i
Boys
Grand Total
104
8
112
60
52
172
patients
following table shows the comparative number of lithotomy and litholapaxy cases treated in the Indore Charitable Hospital for each year, from the beginning of 1879 to the present date. The
Boys
which
One death occurred of young male children. of 24 cases, and the history of series this amongst I
12
for
case
this fatal
Men
1882
but rule
a
also deaths, and by followed by 8 deaths. Out of these 172 cases 60 were treated by litholapaxy, and the balance 112 were treated by lithotomy, and out of these 60 cases of litholapaxy 24 operations were performed in the
followed
18
performed
puberty,
be performed on male children of tender years with a very great measure of success. On looking up the records of the Indore Charitable Hospital, I find that 172 cases of prove that
Boys
1881
instruments have been
invented with
13
of
litholapaxy performed during the year 1883, in the Moradabad Civil Hospital, observes in an able and most interesting paper on cases
Men 1880
number
Medical Gazette of the present year, Freyer in reviewing his brilliant addi-
tional series of 57
Litholapaxy,
Boys
male adult natives of
this country. same
Men
1879
1883, has conclusively shewn operation of litholapaxy is when
skilful hands
performed by
February number
for
journal
same
and in the
1882,
Litholapaxy.
complicated object, how-
step further and perform litholapaxy male children of tender years. Surgeon P. J.
the
[May, 1884.
On the present occasion I shall of the
36
cases
of
litholapaxy
not
give
a
table
in adults treated in this
hospital from the beginning of 1879, with the weights and composition of the stones crushed, the length of time occupied in the operation and other details, nor shall I stop to enter into the particulars of fatal cases which followed litholapaxy in adults. Suffice it to say that three of my fatal cases were almost hopeless from the beginning, and that the result would probably have not been different had these patients been subjected to the operation of lithotomy. One case was suffering from advanced albuminuria, another patient was ancemic and afflicted with great enlargement of the spleen, and the third case died from sheer debility most
some
weeks after the operation.
Surgeon
Freyer's
table in the March number of the Indian Medical
Gazette of the present year proves
superiority
LITHOLAPAXY IN MALE CHILDREN.
"jKEEGAN ON
May, 1884.]
of
litholapaxy
once
lithotomy
over
Thompson's sound possesses
and for all fhe when per-
formed in suitable cases, and its special claims to success when this operation is performed in patients of very advanced years
litholapaxies ing puberty, weight
grains
in
performed middle-aged men, on
were on
merely add
that these
one case.
and
of very
to
keep him
use
of the
those used
aspirator improved principles,
all other sounds
or
The instruments I
adults do
not
in
use
materially
by Surgeon P. J. Freyer. by Weiss on the
constructed
an
but I
prefer a Berkeley by Coxeter, as being I have always found it perfectly more handy, and efficient. Turning now to the immediate subject of this paper, I append a table showing some particuHill's debris extractor, made
This is the largest stone I have sitting. It consisted of uric acid,
considered wise
the great
latest
hospital perfectly well 20 days after the operation. Indeed, he might have returned to his home very much sooner, was
on
I have
yet crushed at one the patient's age was 20, and he left the
but it
small stones
differ from
attain-
on men
detecting
diagnosis. performing litholapaxy in
36
patients just
over
fragments of stone, and aspirator or .debris extractor
for
for purposes of
years, and that the calculi crushed varied from a few grains, in some cases, to 1,140
advanced in
I will
133
lars of 24
children
cases
that the records of
under observa-
litholapaxy performed on male Charitable Hospital. I regret the hospital do not tell some im-
of
at the Indore
portant particulars of these 24 cases, but the table, days in hospital. imperfect though it be, proves that a new and wide Before passing on to the immediate subject of this field has been opened up for litholapaxy, and that paper, I would add that I most strongly concur in Bigelow's operation is susceptible of extension in the opinions put forth by Surgeon P. J. Frever on the treatment of stone in the bladder in the case the great importance of removing the entire calculus children suffering from this disease. of male at one sitting, on the advantages which Sir Henry TABLE B. tion for
some
Showing some particulars of
24 Litholafaxy Operations performed the Indore Charitable Hospital.
o
Date of
Name.
* u
operation.
_C
a. a s -C
2 5 4 7 8
27-9 83
9-10-83 9-10-83
5
No record. Do. Do. Do. Do. Do. Do. Do. Do. 45 min. record. No
35 m}n-
30 min. No record 20 min. 70 min.
*7
Gotia
15-12-83
Not recorded,
18
Khering
17-12-83 29-12-83
No record. 60 min. 38 min.
'9
Rama
20
Bhagwan
26-1-84
Gheesa
16-2-84
30 min.
3-3-84
55 m5n-
II
Sooklia 23 24
Shivram loolia
2
iM
5 ^
g 5 ?
10-3-84 27-3-84
4 32
-
0
None used. Do. Do. Do. Do. Do. No. 9
'5 8
9 9 .. 9 None used. No. 9 9 j ! 9 ?
?
? ,, ? >>
?
M
8 5 8 8 8
Result.
No record, No record. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. 3? 15 10
17
55 5
16
7 7
84
7
35 200
158
?
7 7
104
,?
7
5i 240
5
at
u
5 5 5 5
..
Children,
3
^
No. 5
..
Male
tg
p.#
?-
?J
H-a
o
1
zr
.5
011
1
5 1
?
9
?
7
7 18
Successful,
Phosphates
No record, Uric acid. Do. Do. Do. Do.
Phosphates growing >-,:Died. round tilli stalk
Phosphates
Uric acid. Do. U rate of ammonia & uric acid. Earthy &
triple phosphates Uric acid. Do.
Successful.
?E INDIAN MEDICAL GAZETTE.
134
The first six
in the above table
cases
performed by
were
T.
Beaumont, my predecessor at Surgeon-Major dore and now "Residency Surgeon at Hyderabad. Beaumont left Indore in him in that month. were
performed by
in
ant
Dr.
from
and I succeeded
June 1881,
the Indore Charitable
district
absence in the
on
Hospital, during my inspection duty, and numoperated on, once by my
ber 17, the fatal case, was assistant and twice by myself. this series
were
All the other
performed by
included the first six
cases
Although
me.
in
I have
of my
am
small
tively
was
unaware
that
In the above extract
fatally.
stating
that
by him,
they
were
but I believe all
compara-
Soon after my
joining my present appointment at Indore, the screw lithotrite, corresponding in size to No. 8 English catheter, and the ones.
small xo,
evacuating catheters or canuloe, sizes No. 9 and arrived, but I must confess that, knowing the success
which
usually
some
category of litholapaxy, they cannot fairly claim to The operation performed in come under this head.
of
patients.
in
writing
of the stones crushed
correct in
for
cases
ended
his letter Dr. Beaumont does not mention the
weights I
cases
the above table in the
follows
months to
lithotomy in children, I hesitated perform litholapaxy in this class
However towards the close of 1881
received from Dr. Beaumont in reply to one of mine requesting him to furnish me with some details of his
performed litholapaxy on a child of 5 years of age. In 1882 I performed this operation twice in children, and in 1883 ten operations of this kind were performed at the Indore Hospital. From the beginning of 1884 to the present date I have performed litholapaxy on five children, four of whom were extremely young.
six
In
these first six
would be
cases
more
"
very thorough lithotrity," from extracts which I shall give as
.
one
Numbers 18 and 19 in the series Mr. Gunput Singh, my assist-
time of his
mont at the
In-
[May, 1884.
as
as
Surgeon-Major
cases.
far
India,
as
I
for
know,
to
correctly described
will presently appear from
Beaumont
perform
letter
a
lately
the first,
was
Bigelow's
operation in performed litho-
Table A shows that he
I
1882 Weiss
lithotrite
screw
lapaxy in two adult males in 1S80, and to him must be given the credit of originating the idea that litholapaxy could with safety be extended to the treatment
have
of stone in the bladder in the
method of
dren
suffering
lowed claim ture"
cases
of young male chil-
this disease.
from
I have
only folout his ideas on the subject, and I lay no to the credit of originating this new deparin litholapaxy. The following extract from "
"
his letter speaks for itself. no records of the lithotrity cases in children except what are in I did all the cases successfully without the hospital. I have
all, breaking the stones up very fine with the small hand lithotrite, and the debris were passed safely without the use of any evacuating in-
an
evacuator at
strument.
successful,
On
doing
the first
case
and
finding
it
I ordered out the small tubes to fit Berke-
Hill's evacuator anda screw lithotrite size No. 8, forlitholapaxy in children. They arrived about the time
corresponding no
to No.
the
stones
me
to
in
5
out a still smaller
No.
lately ordered
doubt I shall
with small
from
Son sent
corresponding
and I have
catheter, one
and
7 size
English
out a still
smaller
English catheter,
which I
in
dealing
find most
useful
The very young children. in children differs litholapaxy
performing operation
same
in
adults, only in
the size of
the lithotrite used and in the size of the evacuating Great gentleness and as light catheters or canulfe.
possible are required in performing this operation on children, and the catheters or canuloe employed should be as short as possible, and all
a
hand
as
lateral and up and down movement of lithotrite and catheters should be a voided as much as possible so as
train the tender neck of the young bladder. Very often I air obliged to slit up the meatus of the urethra in very young children before I can pass a No. 7 lithotrite ; but it is surprising how large a cathnot to
be
passed
into
a
child's bladder
of tender
ley
eter can
I left Indore.
the employment of any great force. years without case No. in 23 table B, I passed a For instance with comparative ease, catheter No. evacuating
Gunput Singh told
lithotrite I had made very much.
overstating
the case,
nor
giving
me
me
You
you liked the
will
too much
not
be
credit,
if you say when you succeeded me at Indore you found I had practiced litholapaxy successfully in 6 very young children, that you carried out my ideas and practice with the instruments I had made, and have as
treated
I know I
24 was
children successfully since. the first
to
practice
children, and I told you of my success."
it
So far
in young Dr. Beau-
9
although I hesitated
to pass
a
No.
7
lithotrite,
and
operation by means of the handperformed litliotrite corresponding to size No. 5 English catheter. This case I shall detail subsequently. Experience has taught me that a comparatively large evacuating catheter can be passed with ease when in the same the'
I
case a
smaller size lithotrite will not go readily into the This is due I believe to the difference in
bladder.
KEEGAN ON LITHOLAPAXY IN MALE CHILDREN.
May, 1884.] the
lithotrite
of the terminal end of the
and flatness
curve
as
with that of the catheter.
compared
I
have also found that there is a wonderful difference in the size of the urethra in children. Some children of only three years of age have larger urethne than others of five crushed eye of and
Of
six.
or
No.
a
No.
a
or
7
the stone
course
9
through the evacuating catheter,
in
children,
fine to pass out
comparatively
therefore the
must be
operation
in the
even
stones, lasts a considerable time. One operation, No. 19 in table B, occupied an hour in its performance, but I should not have the slightest case of small
hesitation in keeping the patient under chloroform for two hours if I found it necessary to do so. When it is
believed
bladder,
that all the debris and
no
click
can
patient wave
over
the
of water
happen
region
on
bladder,
I
my
I listen to the If any debris
readily be position, as they
they
most
can
detected by the ear placed in this strike against the end of the canbla. pass
the
of the
the abdomen
on
and out.
in
left behind
to be
over
of the
rushing
working the aspirator to
heard
be
aspirator, I generally hand assistant, and placing my ear
removed from the
are
I shall
now
to detail case No. 17, the fatal case, and prove,
on
hope conclusively,
that it should not militate
against children,
the performance of litholapaxy in young and then I shall give some particulars about Nos. 23 and
24 of this
cases
series.
admission I
the time of his
was
engaged
in the
district inspecting some branch dispensaries. On the following day my assistant, Mr. Gunput Singh, having placed the patient under chloroform, introduced a small
sound and
detected
proving
somewhat
lithotrite
No. 5, and
a
little
over one
times, bringing of
small
a
urethra
the hand-
the stone, which measured quarter of an inch, crushed it several
seizing some
away
the lithotrite.
He
evacuating catheter,
so
of the debris in the blades
could
not
the debris
the bladder in the hope that
safely
The
stone.
he introduced
were
they
No.
9
left behind
in
pass
a
would pass away
with the urine.
During
the
operation he
of the lithotrite
material.
caught
moving
the
At
once
first he
mucous
or
remarked that the blades
twice
thought
grasped that he
some
might
soft
have
membrane of the bladder, but on and forwards, and
the lithotrite backwards
he
perfectly free,
movements
was
convinced
that he had not seized the coats of the bladder. lasted
len
the
On the 18th December I returned
and found the
boy suffering a good deal,
small sound
a
penis was somewhat swolcried a good deal on passing
the child
and
water.
ing
a
small
on
the
of stone
fragments
The
On the second
few minutes.
only operation day after the operation
to
and
I detected
19th,
sticking
Indore on
pass-
some
very
His
in the urethra.
and symptoms of stone not disappearing, on the 20th and passed
sufferings
I put him under chloroform with
comparative ease a No. 7 screw lithotrite and a few fragments of stone left behind in the bladder from the previous operation on the 15th. On my withdrawing the lithotrite for the last time I brought away a piece of what I then considered was woody fibre, crushed
about
^th
width
and
was
of
inch in
an
and about two lines in
length
thickness.
No.
catheter
evacuating
9
introduced and the bladder washed
further debris in
placed
of
piece
and the
detected,
were
fibre removed
woody
on
patient
that
I then considered
bed.
my
No
out.
was
the small
withdrawing the
lithotrite for the last time,had formed the nucleus of the stone, and that the boy had introduced it into his urethra in
play,
children sometimes
as
had
country,
and that the
bladder.
From the 20th to the
piece
rose, he
complained
and there
On the
the bladder. chloroform
trite and
much of
passed
at once
seized
the lithotrite
piece
in
this
into
his
of December the
His temperature in passing water, the
over
again
region
of
put him under
the No.
7 screw titho-
soft
substance, and I had brought
some
of woody fibre
away about
I
30th
and
withdrawing a
pain
tenderness
was some
do
slipped
30th improve.
condition did not
boy's
Case No. 17.?Gotia, a boy four years of age, was admitted into hospital on the 14th December 1883, suffering from symptoms of stone in the bladder. At
finding its
135
I found
nearly
two
inches in length,
quarter of an inch in width, and a line or two in thickness. I had seized this substance with its end a
it
on, and
I
out
came
comparatively easily, although
afraid it must have wounded the urethra in its
am
extraction.
I
then
painfully made aware that operation performed in this first would have been lithotomy. It was now was
the proper
instance
to
too late to cut the
child,
condition, so brought away
I
thinner
of this
more
father
pieces
or
less
was
again
four
as
he was in
a
very weak
introduced the lithotrite and
five very much smaller and woody fibre, all of which were
or
coated
now
have
with
questioned
phosphates. about
the
The
boy's
appearance of the woody fibre in the bladder, and gave the following history. Ten months previous to his
THE INDIAN MEDICAL GAZETTE.
J36
coming
Indore his
to
son
by
one
tilli*
of his
playmates
ran
plant
a
playing with some being thrown down
was
other little boys in the fields, and
on
piece of the stalk of the pierced the bladder and
into his anus,
broke off inside the latter organ. to his assistance, but could not in the rectum.
body
dent the child
parents
to sit
days after the accidown, and strange to
say his father does not remember whether
passed urine by the rectum or day v?hen making water the much
pain,
and
came
foreign
any
For three
unable
was
His
detect
On
the
child
was
seized with
the usual
soon
the child
not.
fourth
symptoms of
stone
in the bladder became well developed. At length on the 14th December his father brought him to the Indore This
Hospital
for treatment.
admitted into hospital.
history
of the
asked to do
case
so on
Had
the father
unsolicited,
or
had he
care-
being
told the even
been
the occasion of the second opera-
tion, this child's life would have been in all probability saved, as with a knowledge of its history I should have
not
should have
boy
died
of
thought on
cut
the child
the 31st
and
performing litholapaxy, in the usual way.
December,
and
a
The
post-mortem
stone in the
prostatic portion Withdrawing the sound I passed down a long urethial forceps and seized the stone. I found however that the forceps with the stone between its blades could not be withdrawn through the membranous portion of the urethra. I therefore pushed the forceps with the stone between its blades into the bladder, which was an easy matter, and a
then let go my hold of the stone. Withdrawing the urethral forceps I then introduced the small handthe stone and crushed it
lithotrite(No. 5)seized three
or
four times.
catheter, size
No.
To my
passed readily
9,
evacuating weighed
which
and consisted
grains
a
cicatrix formed
of tilli stalk where it had rectum and
bladder at
pierced point
this
by
the
piece
this viscus. were
firmly
The ad-
herent, but I could not find any well marked cicatrix Inside the bladder on the lining wall of the rectum. were
found
a
few small
pieces
of the tilli stalk and
a
phosphates. I have entered much into detail in recording this case, not only because it is most interesting and instructive in itself, but also with the view of proving that its fatal termination should not militate against the performance in the few
grains
of
operation of litholapaxy in 23.?Secram, a male child, two
future of the Case
children. years
old,
was
brought by his mother to the hospital on the 10th March, 1884. She stated that the child had for some days begun to cry whenever he passed water. On being put under chloroform, I passed a very small * Didynamia angiospermid Sesamum. Schreb-gen. N. 1048. Is annual, and in good soil grows generally to about three or four feet high. Oil from seed used extensively in all Indian Bazars.
bladder.
of uric acid.
operation lasted four minutes, and the child left the hospital perfectly well on the 12th March 1884. I ask, would it have been fair to have subjected
The
this very young child
all the
to
dangers
of litho-
tomy ? Case
24.?Foolia, a male child, one year and nine old, caste Bunniah, was carried in his mother's arms to the hospital on the 24th March 1884.
months
The mother stated that the child
had
prior
found
into the
and removed the debris
catheter 7
thickening of the coats of the bladder. There was some sloughing in the prostatic portion of the urethra. On the right side of the inner lining of the bladder, slightly posteriorly and about an inch and-a-half from was
readily evacuating
I then attached Berkeley Hill's debris extractor to
symptoms of stone for the last four
neck,
the
surprise
examination revealed considerable inflammation and
the
1884.
of the urethra.
the
teaches the great importance of into the history of every case on its
case
fully going
sound and detected
[May,
to
placed
this the child's urine
was
No. 9
months, and that cloudy. On being
under chloroform I detected
of a very small
suffered from
a
sound, and then tried evacuating catheter, intending
stone to
by
means
introduce
a
litho-
to
perform lapaxy. The catheter would not pass, so the operation was postponed to the 27th. In the interim a clever and very intelligent native workman, who makes many instruments for me, made theter. On the
27th
chloroform the No.
me a
No. 7
evacuating
ca-
the child 7
having been put under catheter passed readily, but the
lithotrite No. 7 would not pass. I then small hand-lithotrite (No. 5), the bladthe introduced der having been previously injected with tepid water,
small
screw
and seized the stone.
The hand-lithotrite
duced three times and the
evacuating
was
intro-
catheter also
three times, and Berkeley Hill's aspirator was emThe operation lasted 32 minutes, the stone
ployed. weighed
grains and consisted of uric acid. There On the 28th was not a particle of debris left behind. the child complained of much pain in passing water, and the penis was somewhat swollen. 29th.?Pain in passing water much less, swelling of penis much diminished. 30th.?Pain very slight, swelling nearly gone 18
and the mother took the child home. Here also I
can-
PETERS ON SMALL-POX AND CHICKEN-POX.
May, 1884.J not
think that it would have been fair
to have
perform-
ed
lithotomy. In concluding this hurried paper on the subject of litholapaxy in young male children, I hope that the series of cases I now bring forward may induce some of my professional brethren in India, whose treating stone in the bladder are much greater than mine, to give this " new departure" in litholapaxy a fair and patient trial. I am not, however, prepared to recommend this operation in young children labouring under the presence of a very hard mulberry calculus, for I have hitherto not come across a case of the kind, but with a sufficiently strong lithotrite I should not hesitate to perform opportunities
of
not a very common
Stone in the bladder is cases. disease in Western Malwa, and
the
cases
litholapaxy majority
in such
of the
of this
which
seek
Hospital,
come
disease,
admission into the Indore Charitable
in from very long distances and from other provinces. I am, however, sanguine, that before the close of the present year I may be in a position to lay before the profession a further series of cases of this kind
backed up by fuller details than I have been able to furnish in
table B.
j
137
IN
MALE
CHILDREN.
A
SERIES OF CASES PERFORMED AT THE
INDORE CHARITABLE HOSPITAL. By Surgeon-Major U. F. Keegan, m.d.,b.m.s.,
Residency Surgeon, Indore. Litholapaxy
in
established and
male most
adults is
now
one of the
best
successful operations in the
THE INDIAN MEDICAL GAZETTE.
132
whole domain of surgery, and the time is not very distant when it will almost completely supersede
stone in the bladder may
ever,
with on
tight
a
Lateral Lithotomy.
of very
cases
with
TABLE A.
Lithotomy will always hold its own place large or very hard calculi, or where
lithotomy. in
happen
to
be
stricture of the urethra. The
of the present paper is to
safety
show that
we
j3 in
a
may
Class of
Year.
Patient.
a
go
Freyer in the December number of the Indian Medical Gazette for
how successful the
of
on
Surgeon-Major
done the
in the March number of the Indian
Medical Gazette for of the Indian P.
Surgeon
J.
R. C.
In
1883.
Saunders
the March
has
"As
yet
no
in
by which litholapaxy safety in males below the
such
"
successful.
laying
can
age of
I need therefore make
before the
profession litholapaxy can
be
should be
lithotomy
cases
stone
the bladder
in
treated
were
January 1879 172
cases
in to
there 8
this
a
no
series of
as
apology cases
come
occurring
in
institution
the present date. 16 deaths. were
male from
the
1st
Out of these
Lithotomy litholapaxy was
was
will be detailed in the sequel when record some special cases of this series.
case
to
19
Men
17
Boys
22
Men
25
Boys
18
1883
1st
quarter of f Men
1884
...
i
Boys
Grand Total
104
8
112
60
52
172
patients
following table shows the comparative number of lithotomy and litholapaxy cases treated in the Indore Charitable Hospital for each year, from the beginning of 1879 to the present date. The
Boys
which
One death occurred of young male children. of 24 cases, and the history of series this amongst I
12
for
case
this fatal
Men
1882
but rule
a
also deaths, and by followed by 8 deaths. Out of these 172 cases 60 were treated by litholapaxy, and the balance 112 were treated by lithotomy, and out of these 60 cases of litholapaxy 24 operations were performed in the
followed
18
performed
puberty,
be performed on male children of tender years with a very great measure of success. On looking up the records of the Indore Charitable Hospital, I find that 172 cases of prove that
Boys
1881
instruments have been
invented with
13
of
litholapaxy performed during the year 1883, in the Moradabad Civil Hospital, observes in an able and most interesting paper on cases
Men 1880
number
Medical Gazette of the present year, Freyer in reviewing his brilliant addi-
tional series of 57
Litholapaxy,
Boys
male adult natives of
this country. same
Men
1879
1883, has conclusively shewn operation of litholapaxy is when
skilful hands
performed by
February number
for
journal
same
and in the
1882,
Litholapaxy.
complicated object, how-
step further and perform litholapaxy male children of tender years. Surgeon P. J.
the
[May, 1884.
On the present occasion I shall of the
36
cases
of
litholapaxy
not
give
a
table
in adults treated in this
hospital from the beginning of 1879, with the weights and composition of the stones crushed, the length of time occupied in the operation and other details, nor shall I stop to enter into the particulars of fatal cases which followed litholapaxy in adults. Suffice it to say that three of my fatal cases were almost hopeless from the beginning, and that the result would probably have not been different had these patients been subjected to the operation of lithotomy. One case was suffering from advanced albuminuria, another patient was ancemic and afflicted with great enlargement of the spleen, and the third case died from sheer debility most
some
weeks after the operation.
Surgeon
Freyer's
table in the March number of the Indian Medical
Gazette of the present year proves
superiority
LITHOLAPAXY IN MALE CHILDREN.
"jKEEGAN ON
May, 1884.]
of
litholapaxy
once
lithotomy
over
Thompson's sound possesses
and for all fhe when per-
formed in suitable cases, and its special claims to success when this operation is performed in patients of very advanced years
litholapaxies ing puberty, weight
grains
in
performed middle-aged men, on
were on
merely add
that these
one case.
and
of very
to
keep him
use
of the
those used
aspirator improved principles,
all other sounds
or
The instruments I
adults do
not
in
use
materially
by Surgeon P. J. Freyer. by Weiss on the
constructed
an
but I
prefer a Berkeley by Coxeter, as being I have always found it perfectly more handy, and efficient. Turning now to the immediate subject of this paper, I append a table showing some particuHill's debris extractor, made
This is the largest stone I have sitting. It consisted of uric acid,
considered wise
the great
latest
hospital perfectly well 20 days after the operation. Indeed, he might have returned to his home very much sooner, was
on
I have
yet crushed at one the patient's age was 20, and he left the
but it
small stones
differ from
attain-
on men
detecting
diagnosis. performing litholapaxy in
36
patients just
over
fragments of stone, and aspirator or .debris extractor
for
for purposes of
years, and that the calculi crushed varied from a few grains, in some cases, to 1,140
advanced in
I will
133
lars of 24
children
cases
that the records of
under observa-
litholapaxy performed on male Charitable Hospital. I regret the hospital do not tell some im-
of
at the Indore
portant particulars of these 24 cases, but the table, days in hospital. imperfect though it be, proves that a new and wide Before passing on to the immediate subject of this field has been opened up for litholapaxy, and that paper, I would add that I most strongly concur in Bigelow's operation is susceptible of extension in the opinions put forth by Surgeon P. J. Frever on the treatment of stone in the bladder in the case the great importance of removing the entire calculus children suffering from this disease. of male at one sitting, on the advantages which Sir Henry TABLE B. tion for
some
Showing some particulars of
24 Litholafaxy Operations performed the Indore Charitable Hospital.
o
Date of
Name.
* u
operation.
_C
a. a s -C
2 5 4 7 8
27-9 83
9-10-83 9-10-83
5
No record. Do. Do. Do. Do. Do. Do. Do. Do. 45 min. record. No
35 m}n-
30 min. No record 20 min. 70 min.
*7
Gotia
15-12-83
Not recorded,
18
Khering
17-12-83 29-12-83
No record. 60 min. 38 min.
'9
Rama
20
Bhagwan
26-1-84
Gheesa
16-2-84
30 min.
3-3-84
55 m5n-
II
Sooklia 23 24
Shivram loolia
2
iM
5 ^
g 5 ?
10-3-84 27-3-84
4 32
-
0
None used. Do. Do. Do. Do. Do. No. 9
'5 8
9 9 .. 9 None used. No. 9 9 j ! 9 ?
?
? ,, ? >>
?
M
8 5 8 8 8
Result.
No record, No record. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. Do. 3? 15 10
17
55 5
16
7 7
84
7
35 200
158
?
7 7
104
,?
7
5i 240
5
at
u
5 5 5 5
..
Children,
3
^
No. 5
..
Male
tg
p.#
?-
?J
H-a
o
1
zr
.5
011
1
5 1
?
9
?
7
7 18
Successful,
Phosphates
No record, Uric acid. Do. Do. Do. Do.
Phosphates growing >-,:Died. round tilli stalk
Phosphates
Uric acid. Do. U rate of ammonia & uric acid. Earthy &
triple phosphates Uric acid. Do.
Successful.
?E INDIAN MEDICAL GAZETTE.
134
The first six
in the above table
cases
performed by
were
T.
Beaumont, my predecessor at Surgeon-Major dore and now "Residency Surgeon at Hyderabad. Beaumont left Indore in him in that month. were
performed by
in
ant
Dr.
from
and I succeeded
June 1881,
the Indore Charitable
district
absence in the
on
Hospital, during my inspection duty, and numoperated on, once by my
ber 17, the fatal case, was assistant and twice by myself. this series
were
All the other
performed by
included the first six
cases
Although
me.
in
I have
of my
am
small
tively
was
unaware
that
In the above extract
fatally.
stating
that
by him,
they
were
but I believe all
compara-
Soon after my
joining my present appointment at Indore, the screw lithotrite, corresponding in size to No. 8 English catheter, and the ones.
small xo,
evacuating catheters or canuloe, sizes No. 9 and arrived, but I must confess that, knowing the success
which
usually
some
category of litholapaxy, they cannot fairly claim to The operation performed in come under this head.
of
patients.
in
writing
of the stones crushed
correct in
for
cases
ended
his letter Dr. Beaumont does not mention the
weights I
cases
the above table in the
follows
months to
lithotomy in children, I hesitated perform litholapaxy in this class
However towards the close of 1881
received from Dr. Beaumont in reply to one of mine requesting him to furnish me with some details of his
performed litholapaxy on a child of 5 years of age. In 1882 I performed this operation twice in children, and in 1883 ten operations of this kind were performed at the Indore Hospital. From the beginning of 1884 to the present date I have performed litholapaxy on five children, four of whom were extremely young.
six
In
these first six
would be
cases
more
"
very thorough lithotrity," from extracts which I shall give as
.
one
Numbers 18 and 19 in the series Mr. Gunput Singh, my assist-
time of his
mont at the
In-
[May, 1884.
as
as
Surgeon-Major
cases.
far
India,
as
I
for
know,
to
correctly described
will presently appear from
Beaumont
perform
letter
a
lately
the first,
was
Bigelow's
operation in performed litho-
Table A shows that he
I
1882 Weiss
lithotrite
screw
lapaxy in two adult males in 1S80, and to him must be given the credit of originating the idea that litholapaxy could with safety be extended to the treatment
have
of stone in the bladder in the
method of
dren
suffering
lowed claim ture"
cases
of young male chil-
this disease.
from
I have
only folout his ideas on the subject, and I lay no to the credit of originating this new deparin litholapaxy. The following extract from "
"
his letter speaks for itself. no records of the lithotrity cases in children except what are in I did all the cases successfully without the hospital. I have
all, breaking the stones up very fine with the small hand lithotrite, and the debris were passed safely without the use of any evacuating in-
an
evacuator at
strument.
successful,
On
doing
the first
case
and
finding
it
I ordered out the small tubes to fit Berke-
Hill's evacuator anda screw lithotrite size No. 8, forlitholapaxy in children. They arrived about the time
corresponding no
to No.
the
stones
me
to
in
5
out a still smaller
No.
lately ordered
doubt I shall
with small
from
Son sent
corresponding
and I have
catheter, one
and
7 size
English
out a still
smaller
English catheter,
which I
in
dealing
find most
useful
The very young children. in children differs litholapaxy
performing operation
same
in
adults, only in
the size of
the lithotrite used and in the size of the evacuating Great gentleness and as light catheters or canulfe.
possible are required in performing this operation on children, and the catheters or canuloe employed should be as short as possible, and all
a
hand
as
lateral and up and down movement of lithotrite and catheters should be a voided as much as possible so as
train the tender neck of the young bladder. Very often I air obliged to slit up the meatus of the urethra in very young children before I can pass a No. 7 lithotrite ; but it is surprising how large a cathnot to
be
passed
into
a
child's bladder
of tender
ley
eter can
I left Indore.
the employment of any great force. years without case No. in 23 table B, I passed a For instance with comparative ease, catheter No. evacuating
Gunput Singh told
lithotrite I had made very much.
overstating
the case,
nor
giving
me
me
You
you liked the
will
too much
not
be
credit,
if you say when you succeeded me at Indore you found I had practiced litholapaxy successfully in 6 very young children, that you carried out my ideas and practice with the instruments I had made, and have as
treated
I know I
24 was
children successfully since. the first
to
practice
children, and I told you of my success."
it
So far
in young Dr. Beau-
9
although I hesitated
to pass
a
No.
7
lithotrite,
and
operation by means of the handperformed litliotrite corresponding to size No. 5 English catheter. This case I shall detail subsequently. Experience has taught me that a comparatively large evacuating catheter can be passed with ease when in the same the'
I
case a
smaller size lithotrite will not go readily into the This is due I believe to the difference in
bladder.
KEEGAN ON LITHOLAPAXY IN MALE CHILDREN.
May, 1884.] the
lithotrite
of the terminal end of the
and flatness
curve
as
with that of the catheter.
compared
I
have also found that there is a wonderful difference in the size of the urethra in children. Some children of only three years of age have larger urethne than others of five crushed eye of and
Of
six.
or
No.
a
No.
a
or
7
the stone
course
9
through the evacuating catheter,
in
children,
fine to pass out
comparatively
therefore the
must be
operation
in the
even
stones, lasts a considerable time. One operation, No. 19 in table B, occupied an hour in its performance, but I should not have the slightest case of small
hesitation in keeping the patient under chloroform for two hours if I found it necessary to do so. When it is
believed
bladder,
that all the debris and
no
click
can
patient wave
over
the
of water
happen
region
on
bladder,
I
my
I listen to the If any debris
readily be position, as they
they
most
can
detected by the ear placed in this strike against the end of the canbla. pass
the
of the
the abdomen
on
and out.
in
left behind
to be
over
of the
rushing
working the aspirator to
heard
be
aspirator, I generally hand assistant, and placing my ear
removed from the
are
I shall
now
to detail case No. 17, the fatal case, and prove,
on
hope conclusively,
that it should not militate
against children,
the performance of litholapaxy in young and then I shall give some particulars about Nos. 23 and
24 of this
cases
series.
admission I
the time of his
was
engaged
in the
district inspecting some branch dispensaries. On the following day my assistant, Mr. Gunput Singh, having placed the patient under chloroform, introduced a small
sound and
detected
proving
somewhat
lithotrite
No. 5, and
a
little
over one
times, bringing of
small
a
urethra
the hand-
the stone, which measured quarter of an inch, crushed it several
seizing some
away
the lithotrite.
He
evacuating catheter,
so
of the debris in the blades
could
not
the debris
the bladder in the hope that
safely
The
stone.
he introduced
were
they
No.
9
left behind
in
pass
a
would pass away
with the urine.
During
the
operation he
of the lithotrite
material.
caught
moving
the
At
once
first he
mucous
or
remarked that the blades
twice
thought
grasped that he
some
might
soft
have
membrane of the bladder, but on and forwards, and
the lithotrite backwards
he
perfectly free,
movements
was
convinced
that he had not seized the coats of the bladder. lasted
len
the
On the 18th December I returned
and found the
boy suffering a good deal,
small sound
a
penis was somewhat swolcried a good deal on passing
the child
and
water.
ing
a
small
on
the
of stone
fragments
The
On the second
few minutes.
only operation day after the operation
to
and
I detected
19th,
sticking
Indore on
pass-
some
very
His
in the urethra.
and symptoms of stone not disappearing, on the 20th and passed
sufferings
I put him under chloroform with
comparative ease a No. 7 screw lithotrite and a few fragments of stone left behind in the bladder from the previous operation on the 15th. On my withdrawing the lithotrite for the last time I brought away a piece of what I then considered was woody fibre, crushed
about
^th
width
and
was
of
inch in
an
and about two lines in
length
thickness.
No.
catheter
evacuating
9
introduced and the bladder washed
further debris in
placed
of
piece
and the
detected,
were
fibre removed
woody
on
patient
that
I then considered
bed.
my
No
out.
was
the small
withdrawing the
lithotrite for the last time,had formed the nucleus of the stone, and that the boy had introduced it into his urethra in
play,
children sometimes
as
had
country,
and that the
bladder.
From the 20th to the
piece
rose, he
complained
and there
On the
the bladder. chloroform
trite and
much of
passed
at once
seized
the lithotrite
piece
in
this
into
his
of December the
His temperature in passing water, the
over
again
region
of
put him under
the No.
7 screw titho-
soft
substance, and I had brought
some
of woody fibre
away about
I
30th
and
withdrawing a
pain
tenderness
was some
do
slipped
30th improve.
condition did not
boy's
Case No. 17.?Gotia, a boy four years of age, was admitted into hospital on the 14th December 1883, suffering from symptoms of stone in the bladder. At
finding its
135
I found
nearly
two
inches in length,
quarter of an inch in width, and a line or two in thickness. I had seized this substance with its end a
it
on, and
I
out
came
comparatively easily, although
afraid it must have wounded the urethra in its
am
extraction.
I
then
painfully made aware that operation performed in this first would have been lithotomy. It was now was
the proper
instance
to
too late to cut the
child,
condition, so brought away
I
thinner
of this
more
father
pieces
or
less
was
again
four
as
he was in
a
very weak
introduced the lithotrite and
five very much smaller and woody fibre, all of which were
or
coated
now
have
with
questioned
phosphates. about
the
The
boy's
appearance of the woody fibre in the bladder, and gave the following history. Ten months previous to his
THE INDIAN MEDICAL GAZETTE.
J36
coming
Indore his
to
son
by
one
tilli*
of his
playmates
ran
plant
a
playing with some being thrown down
was
other little boys in the fields, and
on
piece of the stalk of the pierced the bladder and
into his anus,
broke off inside the latter organ. to his assistance, but could not in the rectum.
body
dent the child
parents
to sit
days after the accidown, and strange to
say his father does not remember whether
passed urine by the rectum or day v?hen making water the much
pain,
and
came
foreign
any
For three
unable
was
His
detect
On
the
child
was
seized with
the usual
soon
the child
not.
fourth
symptoms of
stone
in the bladder became well developed. At length on the 14th December his father brought him to the Indore This
Hospital
for treatment.
admitted into hospital.
history
of the
asked to do
case
so on
Had
the father
unsolicited,
or
had he
care-
being
told the even
been
the occasion of the second opera-
tion, this child's life would have been in all probability saved, as with a knowledge of its history I should have
not
should have
boy
died
of
thought on
cut
the child
the 31st
and
performing litholapaxy, in the usual way.
December,
and
a
The
post-mortem
stone in the
prostatic portion Withdrawing the sound I passed down a long urethial forceps and seized the stone. I found however that the forceps with the stone between its blades could not be withdrawn through the membranous portion of the urethra. I therefore pushed the forceps with the stone between its blades into the bladder, which was an easy matter, and a
then let go my hold of the stone. Withdrawing the urethral forceps I then introduced the small handthe stone and crushed it
lithotrite(No. 5)seized three
or
four times.
catheter, size
No.
To my
passed readily
9,
evacuating weighed
which
and consisted
grains
a
cicatrix formed
of tilli stalk where it had rectum and
bladder at
pierced point
this
by
the
piece
this viscus. were
firmly
The ad-
herent, but I could not find any well marked cicatrix Inside the bladder on the lining wall of the rectum. were
found
a
few small
pieces
of the tilli stalk and
a
phosphates. I have entered much into detail in recording this case, not only because it is most interesting and instructive in itself, but also with the view of proving that its fatal termination should not militate against the performance in the few
grains
of
operation of litholapaxy in 23.?Secram, a male child, two
future of the Case
children. years
old,
was
brought by his mother to the hospital on the 10th March, 1884. She stated that the child had for some days begun to cry whenever he passed water. On being put under chloroform, I passed a very small * Didynamia angiospermid Sesamum. Schreb-gen. N. 1048. Is annual, and in good soil grows generally to about three or four feet high. Oil from seed used extensively in all Indian Bazars.
bladder.
of uric acid.
operation lasted four minutes, and the child left the hospital perfectly well on the 12th March 1884. I ask, would it have been fair to have subjected
The
this very young child
all the
to
dangers
of litho-
tomy ? Case
24.?Foolia, a male child, one year and nine old, caste Bunniah, was carried in his mother's arms to the hospital on the 24th March 1884.
months
The mother stated that the child
had
prior
found
into the
and removed the debris
catheter 7
thickening of the coats of the bladder. There was some sloughing in the prostatic portion of the urethra. On the right side of the inner lining of the bladder, slightly posteriorly and about an inch and-a-half from was
readily evacuating
I then attached Berkeley Hill's debris extractor to
symptoms of stone for the last four
neck,
the
surprise
examination revealed considerable inflammation and
the
1884.
of the urethra.
the
teaches the great importance of into the history of every case on its
case
fully going
sound and detected
[May,
to
placed
this the child's urine
was
No. 9
months, and that cloudy. On being
under chloroform I detected
of a very small
suffered from
a
sound, and then tried evacuating catheter, intending
stone to
by
means
introduce
a
litho-
to
perform lapaxy. The catheter would not pass, so the operation was postponed to the 27th. In the interim a clever and very intelligent native workman, who makes many instruments for me, made theter. On the
27th
chloroform the No.
me a
No. 7
evacuating
ca-
the child 7
having been put under catheter passed readily, but the
lithotrite No. 7 would not pass. I then small hand-lithotrite (No. 5), the bladthe introduced der having been previously injected with tepid water,
small
screw
and seized the stone.
The hand-lithotrite
duced three times and the
evacuating
was
intro-
catheter also
three times, and Berkeley Hill's aspirator was emThe operation lasted 32 minutes, the stone
ployed. weighed
grains and consisted of uric acid. There On the 28th was not a particle of debris left behind. the child complained of much pain in passing water, and the penis was somewhat swollen. 29th.?Pain in passing water much less, swelling of penis much diminished. 30th.?Pain very slight, swelling nearly gone 18
and the mother took the child home. Here also I
can-
PETERS ON SMALL-POX AND CHICKEN-POX.
May, 1884.J not
think that it would have been fair
to have
perform-
ed
lithotomy. In concluding this hurried paper on the subject of litholapaxy in young male children, I hope that the series of cases I now bring forward may induce some of my professional brethren in India, whose treating stone in the bladder are much greater than mine, to give this " new departure" in litholapaxy a fair and patient trial. I am not, however, prepared to recommend this operation in young children labouring under the presence of a very hard mulberry calculus, for I have hitherto not come across a case of the kind, but with a sufficiently strong lithotrite I should not hesitate to perform opportunities
of
not a very common
Stone in the bladder is cases. disease in Western Malwa, and
the
cases
litholapaxy majority
in such
of the
of this
which
seek
Hospital,
come
disease,
admission into the Indore Charitable
in from very long distances and from other provinces. I am, however, sanguine, that before the close of the present year I may be in a position to lay before the profession a further series of cases of this kind
backed up by fuller details than I have been able to furnish in
table B.
j
137
