THE INDIAN MEDICAL GAZETTE.
130
Cases
[May,
1887.
of Litholapaxy 'performed on Children in the Hospitals of the Baghelkhand Political Agency By Surgeon-Major S. J. Goldsmith, Bombay Medical Service. Duration Stone.
OF
Operation.
Lithotrites.
.?
g 5 s =
C3
Remakks.
s s Q.
?
g B
& 1886. 2 years
21st Feb.
62grs.
Soft
No. 7
shell, hard
3 time: Nos. 8 Cure and 9.
As the urethra stretched by the repeated introduction of instru-
ments, considerable difficulty was experienced in preventing the injected water from leaking
nuc-
leus.
out of the bladder; this ralher protracted the operation. The child was practically relieved of all symptoms of bladder trouble 2 days after operation.
M.
3 years
5th April 166
Hard
15
No. 7
nuc-
Do.
leus.
M.
4
M.
6 months 22nd
10
5 years
27th
May
65
May
100
Rather soft,
40
No. 7
Twice No. 8 Do.
Very
35
No. 7
3 times No. 9 Do.
hard. 5
F.
3
1
year
M.
Ditto
M.
3 years
9
12
Had
mild attack of urethritis: well in a week from date of operation. No pain in bladder when once the stone had been removed. a
was
practically
On the next morning but one after the operation, he was running about. No pain on pressure over bladder. No micturition or urethral discharge. Father refused to stay longer. No trouble
slight
1st June
64
Rather soft.
35
8 th June
34
Hard
35
No. 7
22nd June 220
Very
40
No. 7
hard.
8
Notre- Do. corded
No. 7
whatever beyond of meatus.
a
soreness
Nos. 8, Do. 9, 10.
Incontinence of urine for two days owing to dilatation of urethra.
No. 7 Do.
Child playing about the morning after operation. Slight soreness of meatus.
5 times No. 8 Do.
Operation difficult owing to presence of stricture 2? inches from meatus urethra (from prolonged grasping of penis for relief of
Do.
Do.
No trouble after this.
pain?). It was felt that the lithotrite was too light for the work demanded of it, and it was in fact slightly damaged. On the afternoon of the day of operation, the boy, contrary to orders, got up and played about, lhe next morning temperature was 101? F. ; the day after this he seemed quite well.
F.
5
6 months 14th
M.
7
3
10
M.
11
years
July
15th Oct.
131 122
Notre Notrecorded corded Medium.
45
No. 7
Notre No. 8 corded
No. 7
Twice Nos. 8 and 9.
16th Oct.
30
Do.
30
No. 7.
Do.
No. 8
M.
8 months 18th Oct.
148
Soft
30
No, 7
Do.
No. 8
12
M.
1
6th Jan.
116
Hard
13
M.
11th Jan.
72
Medium.
5
1?
years
No
symptoms from the day of operation.
Slight
fever
on
the
day
after
operation. No bladder trouble.
Had cystitis at the time of operation. Urine got clearer day bv day after evacuation of bladder contents, and after the third day it was quite normal. 12
?No trouble after operation.
1887. year
Ditto
40
No. 7
3 times No. 8
No. 7
Twice No. 8
Was feverish for first three days, probably from malarial causes. No bladder trouble. No symptoms meatus.
beyond
soreness
of
LITHOLAPAXY IN MALE CHILDREN.
Mat, 1887.] Cases
131
of Litholapaxy performed on Children in the Hospitals of the Baghelkhand Political Agency By Surgeon-Major S. J. Goldsmith, Bombay Medical Service?(continued). Duration Stone.
Lithotrite.
of
Operation.
o O
Tb50 c C3
?
a
2 ?3
^3
Remarks.
sw .
C3 r
a)
1
W
o
& 1887. No. 7
15
Once No. 10 Cure
No symptoms.
years 16th J.in.
4
years 25tli Jan.
50
?
Hard
25
No. 7
years 29th Jan.
136
?
Do.
20
No. 7
Twice Nos. 7 Do. and 8
Urethra small. Spasms protracted the operation. No subsequent trouble.
31st Jan.
52
?
Very
No. 7
3 times
Much spasm. Stone crushed with great difficulty owing to its extreme hardness. No bad symptoms after operation.
10th Feb.
95
No. 7
4
Ditto
5
18
45 grs Soft
3
years
Do.
hard.
42
Nncleus
?
No. 8
Ditto.
Do.
No Do. record.
times No. 8 Do.
very
Lard.
After first operation
10;
after 2nd opera-
tion,
7
Operation very difficult. Bladder much sacculated, folds of mucous membrane repeatedly got caught in the lithotrites. After repeated attempts to catch the last fragment had been made, the boy became very faint, so farther attempts were temporarily abandoned. After 10 days (during which there was pain on pressure over the bladder and much pain in the anus on making water, the urine being turbid and alkaline), the operation was resumed, when the remaining fragment was easily seized, crushed and removed. The
columns projecting into the bladder cavity had, apparently, disappeared to a great extent and there was no spasm. After the bladder second operation the symptoms subsided within 24 hours, and the boy was soon quite well.
19
II
2
10
Note.
Very
50
No. 8
Do.
No. 8 Do.
Hard
25
No. 8
Twice
No. 9 Do.
Apparently quite well the morning after operation.
Soft
12
No. 8
Once
No. 9 Do.
Wanted to get up and play on afternoon of operation. No trouble whatever.
Medium.
15
No. 7
Do.
No. 7 Do.
Child
years 4th March 162
1
year
5
years 19th
April
5 months 23rd
April
8th April
Average stay
in
hospital
38
after
,.
operation
6*3 days.
Observations.?The accompauyiug cases specially selected, but represent all the
were cases
suffering from stone who applied for during the last fourteen months, with the exception of one boy, whose urethra was too
relief
No. 7 lithotrite
even
after the
meatus had beeu iucised. The series is published not because I am ambitious of throwing
any
new
light
upou the
subject
of
very undersized. Instrupassed with great difficulty. Soreness of meatus the only trouble after operation.
In the case of each boy operated upon, the meatus urethras was incised.
of children
a
A mild attack of urethritis, but no cystitis. Stone lodged in saccule of bladder. Fragments were seized with difficulty.
ments
not
small to admit
12
hard.
crushiug
the
but because the procedure is it is therefore desirable that statistics of a large number of cases, operated upon by different hands, be recorded and brought together to enable surgeons to judge of the relative merits of litholapaxy and lithotomy in children. I have not recorded the symptoms of each case iu detail for the simple reason that, with stones of
children,
comparatively
new;
132
THE INDIAN MEDICAL GAZETTE.
to most of the children, when the operation had ouce been performed, the case ceased to have any interest, there being no symptoms with the exception of slight scalding whenever the urine was passed through the incised meatus. I would, however, draw attention to case No. 18, in which the fragments of stone were not entirely removed at one sitting; as its course, in marked contrast to that of all the others, shows what a vital point the complete evacuation of all fragments is in this operation. The few cases that I am able to bring forward, of course taken by themselves, prove very little, as many surgeons have frequently performed 22 consecutive lithotomies in children with a successful result: but I doubt if an equal number of lithotomies ever caused an operator so little anxiety as I experienced in respect of the cases now under review.
respect
The great value of litholapaxy in children be that the great majority of cases are practically well within 48 hours after the operation. A further advantage of litholapaxy, in addition to the comparatively short stay in hospital that it entails, is the absence of a cutting operation?a recommendation that is likely to have great value in the eyes of the Indian peasant, and to induce him to bring his children to be operated upon while their stones are still small. It remains to be ascertained if the recurrence of stone in children is more frequent after litholapaxy than after lithotomy, as is said to be the case with adults. Even should this prove to be the case, it is quite possible that litholapaxy may be shown to be c. mparatively so harmless a procedure that the addition of a few more operations in a given number of cases may not largely affect its value : before these important points cau be determined, a very large number of operations must be placed on record. seems to
As regards the operation itself, I do not know that I can say much that will be of any value to other surgeons. I find it most convenient to have the patient not in the ordinary lithotomy position, but lying on his back with a thin pillow under the hips, and the head but slightly raised. I take up my position on the right hand side of the patient (about opposite the hip3), standing upon a board raised about three inches from the ground, the patient having been brought to my side of the table; in this way I am enabled, wheu manipulating the lithotrite in the bladder, to keep my left arm from the shoulder to the elbow steadied against my side, and so, I think, to keep the lithotrite steadier than it would be if my arm were free to move from the shoulder. I do not recommend this position as one to be universally adopted, but mentiou it as the one 1 have found most convenient.
[May, 1887.
I puss the lithotrite with the lett hand, that is to say, I steady it with that hand while it makes its own way into the bladder; I then take it in the right hand and proceed in the
ordinary
way.
If the stone be of moderate size (say, of from | inch in diameter), it is, I think, best to diligently crush it up thoroughly, until no fragments are caught which, in the judgment of the operator, are too large to pass through the largest evacuatiug catheter that he expects to get into the bladder. He may, it is true, in this way repeatedly grasp fragments that are small enough to have passed through the evacuator, and so take a little longer over the operation : but he will avoid the repeated passing of instruments to and fro through the neck of the bladder, and it is this more than the actual presence of an instrument in the bladder that sets up irritation and spasm.
1 to
I would strongly advise that the first step in the operation be the injection of a moderate quantity of tepid water into the bladder: I generally conclude that I have injected enough when the hand working the syringe experiences the slightest resistance. If the bladder be left with no fluid in it, it is likely to bruise itself by contracting upou the fragments of stone and the blades of the lithotrite: while, if it be moderately distended, the lithotrite has plenty of room to work in, the fragments of stone collect together on the floor of the bladder, and if spasm should come on, the organ has an elastic bag to contract upon which equalizes the strain 011 different parts. I have never yet met with a child's bladder that refused to retain some fluid: I have more than once in the course of a litholapaxy found, when the fluid first injected had leaked out, that a second injection allayed instead of increasing spasm.
Sometimes in the course of an operation the lithotrite grasps something soft which may be membraue or a fragment of stone mucous covered by mucous or blood clot: how is the difference to be determined ? In practice, this is If the mucous membrane has not difficult. been grasped, the operator will not be able to move his lithotrite at all freely, and a gentle attempt at rotating the instrument will soon show him what he has caught. I should hesitate at mentioning such an obvious point had I not been questioned upon the subject by those who have, perhaps, exaggerated notions concerning the difficulties and dangers of litho-
lapaxy.
Rewah, India, April, 1887.
Central
130
Cases
[May,
1887.
of Litholapaxy 'performed on Children in the Hospitals of the Baghelkhand Political Agency By Surgeon-Major S. J. Goldsmith, Bombay Medical Service. Duration Stone.
OF
Operation.
Lithotrites.
.?
g 5 s =
C3
Remakks.
s s Q.
?
g B
& 1886. 2 years
21st Feb.
62grs.
Soft
No. 7
shell, hard
3 time: Nos. 8 Cure and 9.
As the urethra stretched by the repeated introduction of instru-
ments, considerable difficulty was experienced in preventing the injected water from leaking
nuc-
leus.
out of the bladder; this ralher protracted the operation. The child was practically relieved of all symptoms of bladder trouble 2 days after operation.
M.
3 years
5th April 166
Hard
15
No. 7
nuc-
Do.
leus.
M.
4
M.
6 months 22nd
10
5 years
27th
May
65
May
100
Rather soft,
40
No. 7
Twice No. 8 Do.
Very
35
No. 7
3 times No. 9 Do.
hard. 5
F.
3
1
year
M.
Ditto
M.
3 years
9
12
Had
mild attack of urethritis: well in a week from date of operation. No pain in bladder when once the stone had been removed. a
was
practically
On the next morning but one after the operation, he was running about. No pain on pressure over bladder. No micturition or urethral discharge. Father refused to stay longer. No trouble
slight
1st June
64
Rather soft.
35
8 th June
34
Hard
35
No. 7
22nd June 220
Very
40
No. 7
hard.
8
Notre- Do. corded
No. 7
whatever beyond of meatus.
a
soreness
Nos. 8, Do. 9, 10.
Incontinence of urine for two days owing to dilatation of urethra.
No. 7 Do.
Child playing about the morning after operation. Slight soreness of meatus.
5 times No. 8 Do.
Operation difficult owing to presence of stricture 2? inches from meatus urethra (from prolonged grasping of penis for relief of
Do.
Do.
No trouble after this.
pain?). It was felt that the lithotrite was too light for the work demanded of it, and it was in fact slightly damaged. On the afternoon of the day of operation, the boy, contrary to orders, got up and played about, lhe next morning temperature was 101? F. ; the day after this he seemed quite well.
F.
5
6 months 14th
M.
7
3
10
M.
11
years
July
15th Oct.
131 122
Notre Notrecorded corded Medium.
45
No. 7
Notre No. 8 corded
No. 7
Twice Nos. 8 and 9.
16th Oct.
30
Do.
30
No. 7.
Do.
No. 8
M.
8 months 18th Oct.
148
Soft
30
No, 7
Do.
No. 8
12
M.
1
6th Jan.
116
Hard
13
M.
11th Jan.
72
Medium.
5
1?
years
No
symptoms from the day of operation.
Slight
fever
on
the
day
after
operation. No bladder trouble.
Had cystitis at the time of operation. Urine got clearer day bv day after evacuation of bladder contents, and after the third day it was quite normal. 12
?No trouble after operation.
1887. year
Ditto
40
No. 7
3 times No. 8
No. 7
Twice No. 8
Was feverish for first three days, probably from malarial causes. No bladder trouble. No symptoms meatus.
beyond
soreness
of
LITHOLAPAXY IN MALE CHILDREN.
Mat, 1887.] Cases
131
of Litholapaxy performed on Children in the Hospitals of the Baghelkhand Political Agency By Surgeon-Major S. J. Goldsmith, Bombay Medical Service?(continued). Duration Stone.
Lithotrite.
of
Operation.
o O
Tb50 c C3
?
a
2 ?3
^3
Remarks.
sw .
C3 r
a)
1
W
o
& 1887. No. 7
15
Once No. 10 Cure
No symptoms.
years 16th J.in.
4
years 25tli Jan.
50
?
Hard
25
No. 7
years 29th Jan.
136
?
Do.
20
No. 7
Twice Nos. 7 Do. and 8
Urethra small. Spasms protracted the operation. No subsequent trouble.
31st Jan.
52
?
Very
No. 7
3 times
Much spasm. Stone crushed with great difficulty owing to its extreme hardness. No bad symptoms after operation.
10th Feb.
95
No. 7
4
Ditto
5
18
45 grs Soft
3
years
Do.
hard.
42
Nncleus
?
No. 8
Ditto.
Do.
No Do. record.
times No. 8 Do.
very
Lard.
After first operation
10;
after 2nd opera-
tion,
7
Operation very difficult. Bladder much sacculated, folds of mucous membrane repeatedly got caught in the lithotrites. After repeated attempts to catch the last fragment had been made, the boy became very faint, so farther attempts were temporarily abandoned. After 10 days (during which there was pain on pressure over the bladder and much pain in the anus on making water, the urine being turbid and alkaline), the operation was resumed, when the remaining fragment was easily seized, crushed and removed. The
columns projecting into the bladder cavity had, apparently, disappeared to a great extent and there was no spasm. After the bladder second operation the symptoms subsided within 24 hours, and the boy was soon quite well.
19
II
2
10
Note.
Very
50
No. 8
Do.
No. 8 Do.
Hard
25
No. 8
Twice
No. 9 Do.
Apparently quite well the morning after operation.
Soft
12
No. 8
Once
No. 9 Do.
Wanted to get up and play on afternoon of operation. No trouble whatever.
Medium.
15
No. 7
Do.
No. 7 Do.
Child
years 4th March 162
1
year
5
years 19th
April
5 months 23rd
April
8th April
Average stay
in
hospital
38
after
,.
operation
6*3 days.
Observations.?The accompauyiug cases specially selected, but represent all the
were cases
suffering from stone who applied for during the last fourteen months, with the exception of one boy, whose urethra was too
relief
No. 7 lithotrite
even
after the
meatus had beeu iucised. The series is published not because I am ambitious of throwing
any
new
light
upou the
subject
of
very undersized. Instrupassed with great difficulty. Soreness of meatus the only trouble after operation.
In the case of each boy operated upon, the meatus urethras was incised.
of children
a
A mild attack of urethritis, but no cystitis. Stone lodged in saccule of bladder. Fragments were seized with difficulty.
ments
not
small to admit
12
hard.
crushiug
the
but because the procedure is it is therefore desirable that statistics of a large number of cases, operated upon by different hands, be recorded and brought together to enable surgeons to judge of the relative merits of litholapaxy and lithotomy in children. I have not recorded the symptoms of each case iu detail for the simple reason that, with stones of
children,
comparatively
new;
132
THE INDIAN MEDICAL GAZETTE.
to most of the children, when the operation had ouce been performed, the case ceased to have any interest, there being no symptoms with the exception of slight scalding whenever the urine was passed through the incised meatus. I would, however, draw attention to case No. 18, in which the fragments of stone were not entirely removed at one sitting; as its course, in marked contrast to that of all the others, shows what a vital point the complete evacuation of all fragments is in this operation. The few cases that I am able to bring forward, of course taken by themselves, prove very little, as many surgeons have frequently performed 22 consecutive lithotomies in children with a successful result: but I doubt if an equal number of lithotomies ever caused an operator so little anxiety as I experienced in respect of the cases now under review.
respect
The great value of litholapaxy in children be that the great majority of cases are practically well within 48 hours after the operation. A further advantage of litholapaxy, in addition to the comparatively short stay in hospital that it entails, is the absence of a cutting operation?a recommendation that is likely to have great value in the eyes of the Indian peasant, and to induce him to bring his children to be operated upon while their stones are still small. It remains to be ascertained if the recurrence of stone in children is more frequent after litholapaxy than after lithotomy, as is said to be the case with adults. Even should this prove to be the case, it is quite possible that litholapaxy may be shown to be c. mparatively so harmless a procedure that the addition of a few more operations in a given number of cases may not largely affect its value : before these important points cau be determined, a very large number of operations must be placed on record. seems to
As regards the operation itself, I do not know that I can say much that will be of any value to other surgeons. I find it most convenient to have the patient not in the ordinary lithotomy position, but lying on his back with a thin pillow under the hips, and the head but slightly raised. I take up my position on the right hand side of the patient (about opposite the hip3), standing upon a board raised about three inches from the ground, the patient having been brought to my side of the table; in this way I am enabled, wheu manipulating the lithotrite in the bladder, to keep my left arm from the shoulder to the elbow steadied against my side, and so, I think, to keep the lithotrite steadier than it would be if my arm were free to move from the shoulder. I do not recommend this position as one to be universally adopted, but mentiou it as the one 1 have found most convenient.
[May, 1887.
I puss the lithotrite with the lett hand, that is to say, I steady it with that hand while it makes its own way into the bladder; I then take it in the right hand and proceed in the
ordinary
way.
If the stone be of moderate size (say, of from | inch in diameter), it is, I think, best to diligently crush it up thoroughly, until no fragments are caught which, in the judgment of the operator, are too large to pass through the largest evacuatiug catheter that he expects to get into the bladder. He may, it is true, in this way repeatedly grasp fragments that are small enough to have passed through the evacuator, and so take a little longer over the operation : but he will avoid the repeated passing of instruments to and fro through the neck of the bladder, and it is this more than the actual presence of an instrument in the bladder that sets up irritation and spasm.
1 to
I would strongly advise that the first step in the operation be the injection of a moderate quantity of tepid water into the bladder: I generally conclude that I have injected enough when the hand working the syringe experiences the slightest resistance. If the bladder be left with no fluid in it, it is likely to bruise itself by contracting upou the fragments of stone and the blades of the lithotrite: while, if it be moderately distended, the lithotrite has plenty of room to work in, the fragments of stone collect together on the floor of the bladder, and if spasm should come on, the organ has an elastic bag to contract upon which equalizes the strain 011 different parts. I have never yet met with a child's bladder that refused to retain some fluid: I have more than once in the course of a litholapaxy found, when the fluid first injected had leaked out, that a second injection allayed instead of increasing spasm.
Sometimes in the course of an operation the lithotrite grasps something soft which may be membraue or a fragment of stone mucous covered by mucous or blood clot: how is the difference to be determined ? In practice, this is If the mucous membrane has not difficult. been grasped, the operator will not be able to move his lithotrite at all freely, and a gentle attempt at rotating the instrument will soon show him what he has caught. I should hesitate at mentioning such an obvious point had I not been questioned upon the subject by those who have, perhaps, exaggerated notions concerning the difficulties and dangers of litho-
lapaxy.
Rewah, India, April, 1887.
Central
