L IT H 0 T 0 M Y.
By Surgeon
"W. P.
Hahkis, M.D.,
Civil
Surgeon, ShahjeJianpore.
The following notes give the result of my experience derived from 359 cases of stone in the bladder, operated upon by myself, and upon
also from the observation of many other by my subordinates :?
cases
operated
Section I. Cause
of stone.?About
this I havo not much information.
observation has led me to think it likely that inflammatory and congestive conditions of tho bladder and kidneys, causing deposits of blood or mucus, may lead to the aggregation of tho particles of gravel together, so as to form a calculous mass.
My
This pre-supposes the existence of a calculous diathesis. This idea of the probable frequency of inflammation and congestion of tho kidney or bladder being tho origin of the
aggregation of the lithic deposit into a calculus in the kidney or bladder, especially in children, receives confirmation from the fact, that calculus is more common in cold than hot climates, as well as inoro so in the colder parts of hot climates, such as tho North-^V
estern Provinces, than in the southern part of India. In old persons this hypothesis of an inflammatory origin is not required, for in them stagnation of tho urine in the bladder readily takes place in consequence of paralysis, or hypertrophy of that organ, as well as from disease of tho prostate or urethra.
Prophylaxis,
or
means
of preventing
the
formation of
stone.
in the North-Western Provinces of India, where the winters aro severe, have been principally among people who live in a half-naked state, and in most cases with only the
?My patients eastern
girdle round therefore,
who must, organs.
the bo
loins, subject
both winter and summer, and to congestions of the internal
The prophylaxis should then in calculous districts consist in extra
clothing,
in addition to
hygienic precautions connected
with diet.
Section II. Examination of urinary organs and general condition of patient.?Tho examination of tho stato of the kidneys and all the other organs of the body should be carefully made bofoi?
June 2,
LITHOTOMY.?BT W. P- HARRIS.
1873.]
to tho operation of lithotomy; for, as 'when the patient is greatly emaciated, his says, constitution broken down, and his kidneys evidently disorgan-
subjecting
patient
a
"
Erichsen
Dr. Johnson writes:?"The mode of using the table is to ascertain the specific gravity of the urine, and to multiply the number which represents the amount of solids contained in
ized
urine of that
and
24 hours.
extensively, lithotomy would be attended by an inevitably rapidly fatal result, and the performance of an operation ?would be an useless act of cruelty." An examination of the urine should be made by taking the re-action and determining 1 hough, as a the quantity of albumen by heat and nitric acid. rule, a large amount of albumen coutra-indicates the suitability of the case for operation, yet in childien I have operated sucit to the extent of onecessfully when tho urine has contained third or even half its bulk; and in a man, aged 40, of good conhad suffered only two months, but stitution, who stated that he
whose urine contained one-thiid of its bulk of albumen and no blood, I operated successfully, and found that the nucleus of
straw, and that the calculus had contracted adhesions to the coats of the bladder. In an adult, if the albumen amount to one-sixth of the bulk of the urine, it generally indicates serious disease of the kidneys; but even then no unfavorable prognosis should be expressed, until a thorough the stone
was
a
examination has been made of the of pus in the
urine,
state of
heart,
amount
of
solids, quantity
and other great organs of the
body. hand, it would be a great mistake if thought the kidneys healthy, where the urine by heat acid yielded only a trace of albumen or none at all. On the other
we
always
and nitric In several
instances I have found this to be the case, when the kidneys were greatly disorganized, as shown by the specific gravity of the urine
being only
a
degree
or
the amount of solids reduced to
a
two above that of water, and minimum.
Johnson, in his work on "Diseases of the Kidneys," page 245, explains the cause of the amount of albumen being some-
times very small in tho later the kidneys :?
periods
of
desquamative
disease of
"
It is not impossible that the thickened condition of the may offer some impediment to the free escape of serum ; but as I have several times seen the urine highly albuminous in connection with extreme thickening of
malpighian capillaries
vessels, I believe that a diminution in the number of the malpighian bodies is more influential than thickening of the capillary wall in lessening the secretion of albumen." The most important aid in prognosis is to ascertain tho amount of solids discharged in 24 hours, which should be done in the manner recommended by Dr. Johnson as follows :? The urine should be collected in a funnel-shaped vessel. The object of this being to show conveniently the quantity of mucus thrown down nfter standing, and to collect deposit in case a miscroscopical examination should be necessary. the
Then having taken the specific gravity, measure the total quantity of urine, and calculate the amount of solids by means of the following table (from p. 45 of Johnson's work), which shows the number of grains of solids in, and the weight of, a fluid ounce of urine of every density, from 1010 upwards :?
Specific
gravity. 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020
Weight of one
fluid
411-8 442-3 442-7 44:3-1 413-0 441441-5 444-9 415-3 415-8 440-2
Solids in one ounce.
Grs. 10-283 11-330 12-337 13-421 14-170 15.517 IG'570 17-C22 18-671 19-735 20-792
of Specific Weight one fluid gravity. ounce.
1021 1022 1023 1021 1025 1026 1027 1028 1029 1030
446'6 447-1 417-5 448-0 448-4 448-8 419-3 419-7 450-1 450-6
Solids in one
ounce.
Grs. 21-852 22-918 23-981 25-051 26-119
27-118 28-265 29-338 30-413 31-496
153
"
the
density by
the number of fluid ounces passed in
Suppose, for instance, that the specific gravity is 1020, and quantity passed 30 ounces, then 20792 x 30 623'760 grains =
of solids."
According to Dr. Golding Bird, it appears from a large number of observations " that the average amount of work performed by the kidneys in the adult may be looked upon as affecting the secretion of from 600 to 700 grains of solids in 24 hours." I have known cases, however, in which the solids fell much below the above standard, although the men were free from, albumen in their
and other signs of kidney disease; Hindoo of ordinary size, whose arm was amputated for injury, the solids were only 503-464 grains. In another, a small anaemic man from a very malarious district, suffering from gravel, but without any other sign of kiduey disease, only 308'490 grains of solids were passed in
thus, in
one
urine,
instance,
a
24 hours. If the solids fall must be looked upon
as
low as
200 in
an
adult,
the
very unfavorable as far as is concerned; though, if the patient
case
as
the state of the kidneys appears otherwise in a favorable condition, the possibility of some
of the urine
been lost
having
by
the
patient
or
attend-
ants, and not confessed to by them, must be remembered. This no doubt took place in a case in which the solids were apparently
only 45 grains ; for, owing to the peculiar position of the stone lying partly in the bladder and partly in the prostate, there was complete incontinence of urine. The boy, a Hindoo, aged 11, made a good recovery. A small amount of solids is occasionally passed without extensive kidney disease in cases of anoemia and cachexia. In a patient, aged 40, who made a good recovery, but who passed only 1S6*71 of solids before the operation, I found the causes to be that he was in the habit of taking only 8 ounces of food daily ; that he had recently suffered from malarious fever, and had taken several strong purgatives. In other pateints, though the solids passed be double the amount of those of the last-mentioued case, yet, if they present a combiaation of all or most of the symptoms, such as the following, the operation would be "an useless act of cruelty ?Old age,
emaciation, aspect
weak voice like that of
yellowish-brown tinge alkal'ne, granular one
and
gait
of much
debility, husky
person in advanced consumption, of the conjunctiva, re-action of urine a
casts visible under the
microscope,
stone from
to two ounces in size.
If the urine contain a large amount of albumen, say, a quarter bulk, and the bladder be in a state of chronic irritation, the urine containing much mucus and pus, and being highly of it3
ammoniacal, the case is still more unfavorable. Besides the above-mentioned symptom, which all indicate extensive disease of the urinary organs, there is one other unfavorable state commonly met with in old patients, namely, such .extreme weakness of the sounds of the heart as to render tho first one inaudible, and the second one very feeble at the aortic orifice, the pathological condition being fatty degeneration of the muscular fibres of the heart. It is also important to determine the existence or not of any of the following diseases, as their presence might hinder the success of the operation? Enlarged prostate, phthisis, diarrhoea, dysentery, disease of the or the spleen, peritonitis, pericarditis, pleuritis, and uraemia. The above-mentioned precautions in the selection of cases for operation apply rather to adults than to children; for these when
liver
puberty, however weakly or diseased, may nearly always subjected to operation. If, indeed, the stone be so large as to form an almost complete cast of the inside of the bladder, the case should be rejected. {To be continued.') under
be
By Surgeon
"W. P.
Hahkis, M.D.,
Civil
Surgeon, ShahjeJianpore.
The following notes give the result of my experience derived from 359 cases of stone in the bladder, operated upon by myself, and upon
also from the observation of many other by my subordinates :?
cases
operated
Section I. Cause
of stone.?About
this I havo not much information.
observation has led me to think it likely that inflammatory and congestive conditions of tho bladder and kidneys, causing deposits of blood or mucus, may lead to the aggregation of tho particles of gravel together, so as to form a calculous mass.
My
This pre-supposes the existence of a calculous diathesis. This idea of the probable frequency of inflammation and congestion of tho kidney or bladder being tho origin of the
aggregation of the lithic deposit into a calculus in the kidney or bladder, especially in children, receives confirmation from the fact, that calculus is more common in cold than hot climates, as well as inoro so in the colder parts of hot climates, such as tho North-^V
estern Provinces, than in the southern part of India. In old persons this hypothesis of an inflammatory origin is not required, for in them stagnation of tho urine in the bladder readily takes place in consequence of paralysis, or hypertrophy of that organ, as well as from disease of tho prostate or urethra.
Prophylaxis,
or
means
of preventing
the
formation of
stone.
in the North-Western Provinces of India, where the winters aro severe, have been principally among people who live in a half-naked state, and in most cases with only the
?My patients eastern
girdle round therefore,
who must, organs.
the bo
loins, subject
both winter and summer, and to congestions of the internal
The prophylaxis should then in calculous districts consist in extra
clothing,
in addition to
hygienic precautions connected
with diet.
Section II. Examination of urinary organs and general condition of patient.?Tho examination of tho stato of the kidneys and all the other organs of the body should be carefully made bofoi?
June 2,
LITHOTOMY.?BT W. P- HARRIS.
1873.]
to tho operation of lithotomy; for, as 'when the patient is greatly emaciated, his says, constitution broken down, and his kidneys evidently disorgan-
subjecting
patient
a
"
Erichsen
Dr. Johnson writes:?"The mode of using the table is to ascertain the specific gravity of the urine, and to multiply the number which represents the amount of solids contained in
ized
urine of that
and
24 hours.
extensively, lithotomy would be attended by an inevitably rapidly fatal result, and the performance of an operation ?would be an useless act of cruelty." An examination of the urine should be made by taking the re-action and determining 1 hough, as a the quantity of albumen by heat and nitric acid. rule, a large amount of albumen coutra-indicates the suitability of the case for operation, yet in childien I have operated sucit to the extent of onecessfully when tho urine has contained third or even half its bulk; and in a man, aged 40, of good conhad suffered only two months, but stitution, who stated that he
whose urine contained one-thiid of its bulk of albumen and no blood, I operated successfully, and found that the nucleus of
straw, and that the calculus had contracted adhesions to the coats of the bladder. In an adult, if the albumen amount to one-sixth of the bulk of the urine, it generally indicates serious disease of the kidneys; but even then no unfavorable prognosis should be expressed, until a thorough the stone
was
a
examination has been made of the of pus in the
urine,
state of
heart,
amount
of
solids, quantity
and other great organs of the
body. hand, it would be a great mistake if thought the kidneys healthy, where the urine by heat acid yielded only a trace of albumen or none at all. On the other
we
always
and nitric In several
instances I have found this to be the case, when the kidneys were greatly disorganized, as shown by the specific gravity of the urine
being only
a
degree
or
the amount of solids reduced to
a
two above that of water, and minimum.
Johnson, in his work on "Diseases of the Kidneys," page 245, explains the cause of the amount of albumen being some-
times very small in tho later the kidneys :?
periods
of
desquamative
disease of
"
It is not impossible that the thickened condition of the may offer some impediment to the free escape of serum ; but as I have several times seen the urine highly albuminous in connection with extreme thickening of
malpighian capillaries
vessels, I believe that a diminution in the number of the malpighian bodies is more influential than thickening of the capillary wall in lessening the secretion of albumen." The most important aid in prognosis is to ascertain tho amount of solids discharged in 24 hours, which should be done in the manner recommended by Dr. Johnson as follows :? The urine should be collected in a funnel-shaped vessel. The object of this being to show conveniently the quantity of mucus thrown down nfter standing, and to collect deposit in case a miscroscopical examination should be necessary. the
Then having taken the specific gravity, measure the total quantity of urine, and calculate the amount of solids by means of the following table (from p. 45 of Johnson's work), which shows the number of grains of solids in, and the weight of, a fluid ounce of urine of every density, from 1010 upwards :?
Specific
gravity. 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020
Weight of one
fluid
411-8 442-3 442-7 44:3-1 413-0 441441-5 444-9 415-3 415-8 440-2
Solids in one ounce.
Grs. 10-283 11-330 12-337 13-421 14-170 15.517 IG'570 17-C22 18-671 19-735 20-792
of Specific Weight one fluid gravity. ounce.
1021 1022 1023 1021 1025 1026 1027 1028 1029 1030
446'6 447-1 417-5 448-0 448-4 448-8 419-3 419-7 450-1 450-6
Solids in one
ounce.
Grs. 21-852 22-918 23-981 25-051 26-119
27-118 28-265 29-338 30-413 31-496
153
"
the
density by
the number of fluid ounces passed in
Suppose, for instance, that the specific gravity is 1020, and quantity passed 30 ounces, then 20792 x 30 623'760 grains =
of solids."
According to Dr. Golding Bird, it appears from a large number of observations " that the average amount of work performed by the kidneys in the adult may be looked upon as affecting the secretion of from 600 to 700 grains of solids in 24 hours." I have known cases, however, in which the solids fell much below the above standard, although the men were free from, albumen in their
and other signs of kidney disease; Hindoo of ordinary size, whose arm was amputated for injury, the solids were only 503-464 grains. In another, a small anaemic man from a very malarious district, suffering from gravel, but without any other sign of kiduey disease, only 308'490 grains of solids were passed in
thus, in
one
urine,
instance,
a
24 hours. If the solids fall must be looked upon
as
low as
200 in
an
adult,
the
very unfavorable as far as is concerned; though, if the patient
case
as
the state of the kidneys appears otherwise in a favorable condition, the possibility of some
of the urine
been lost
having
by
the
patient
or
attend-
ants, and not confessed to by them, must be remembered. This no doubt took place in a case in which the solids were apparently
only 45 grains ; for, owing to the peculiar position of the stone lying partly in the bladder and partly in the prostate, there was complete incontinence of urine. The boy, a Hindoo, aged 11, made a good recovery. A small amount of solids is occasionally passed without extensive kidney disease in cases of anoemia and cachexia. In a patient, aged 40, who made a good recovery, but who passed only 1S6*71 of solids before the operation, I found the causes to be that he was in the habit of taking only 8 ounces of food daily ; that he had recently suffered from malarious fever, and had taken several strong purgatives. In other pateints, though the solids passed be double the amount of those of the last-mentioued case, yet, if they present a combiaation of all or most of the symptoms, such as the following, the operation would be "an useless act of cruelty ?Old age,
emaciation, aspect
weak voice like that of
yellowish-brown tinge alkal'ne, granular one
and
gait
of much
debility, husky
person in advanced consumption, of the conjunctiva, re-action of urine a
casts visible under the
microscope,
stone from
to two ounces in size.
If the urine contain a large amount of albumen, say, a quarter bulk, and the bladder be in a state of chronic irritation, the urine containing much mucus and pus, and being highly of it3
ammoniacal, the case is still more unfavorable. Besides the above-mentioned symptom, which all indicate extensive disease of the urinary organs, there is one other unfavorable state commonly met with in old patients, namely, such .extreme weakness of the sounds of the heart as to render tho first one inaudible, and the second one very feeble at the aortic orifice, the pathological condition being fatty degeneration of the muscular fibres of the heart. It is also important to determine the existence or not of any of the following diseases, as their presence might hinder the success of the operation? Enlarged prostate, phthisis, diarrhoea, dysentery, disease of the or the spleen, peritonitis, pericarditis, pleuritis, and uraemia. The above-mentioned precautions in the selection of cases for operation apply rather to adults than to children; for these when
liver
puberty, however weakly or diseased, may nearly always subjected to operation. If, indeed, the stone be so large as to form an almost complete cast of the inside of the bladder, the case should be rejected. {To be continued.') under
be
