NOTES ON LITHOTOMY. By G.
HENDERSON, M.D., Lahore.
Punjab stone is so common that in many dispensaries scarcely a week passes without a case of lithotomy. I have had as many as five cases in one day, and as many as thirteen cases in Hospital at one time. I have never had more than thirty-five cases running without a death, and that occurred only once. In May last, Dr. Murray, Inspector-General of Hospitals, described to me his mode of operating for stone, which is much more simple than that usually practised. No case of stone being in Hospital at the time, I was unable to see Dr. Murray operate, but since then I have had a good many cases, in all of which I have adopted Dr. Murray's operation, and I am so jdeased with it that I intend never to perIn the
form any other. The operation of lithotomy, usually so easy in adults, is not unfrcquently attended with difficulties in the cases of children as is well described by Sir "W. Ferguson in the Mcdical and Gazette for
Times
July 2nd, 1864, and I have more than once seen inexperienced operators meet with difficulties, even in the Dr. Murray's operation differs case of adults. very slightly from the ordinary lateral operation, but is very much more easy to perform. Instead of dissecting towards the bladder, and making the finger prccede the knife, he at once pushes the knife into the groove of the staff, having first ascertained the position of the latter by means of the thumb-nail of the left hand ; the operation is similar to that recommended by Professor Buchanan of Glasgow, except that an ordinary staff is used instead of a rectangular one. The steps of the operation are as follows A staff is chosen with a large central groove, the latter so constructed at its extremity as to catch the point of the knife and prevent its leaving the staff, and thus endangering the
bladder. The staff having been introduced, the thumb of the left hand is to be placed on the spot wnere it is proposed to enter the knife, and the skin is then drawn over, if necessary, until this spot is exactly opposite the groove of the staff ; then feeling the groove with the thumb-nail, the point of the knife is at once pushed along the nail into the groove, and on, into the bladder.
By depressing the handle of the knife as the bladder is entered, the wound of the prostate is made sufficiently large. It now only remains to enlarge the external wound, which is done
NOTES OX LITHOTOMY.?BY G. HENDERSON, M.D.
February 1, 1867.]
by one sweep of the knife, as this is withdrawn. The whole proceeding does not occupy half a minute, and the facility with which it is effected is quite surprising to those who witness the operation for the first time. Dr. Murray recommends that a probe-pointed knife should bo used after the urethra is fairly entered ; but if the groove of the staff is properly constructed at its extremity, the bladder can hardly be injured, I also understood Dr Murray to even by a careless operator. say that he enlarged the wound of the prostate, by passing the finger over the back of the knife, but I find that, by depressing the handle, as the knife enters the bladder, the wound is at once enlarged sufficiently, and if on examination it is found to be too small, the knife can be re-introduced. I have generally observed that students operating on the dead body for the first time, meet with difficulties in dissect-
ing towards the bladder, but since they have adopted the operation above described, the bladder is reached with the utmost facility. Since I have adopted the new mode of operating, I have removed the stones with unusual facility. In two of my cases one of the students happened to note the time, and from first entering the knife, until the stone was on the table, occupied in
one
80, in the other 65 seconds.
case
haemorrhage is little more free than usual at operation, but it soon ceases. advantages of the operation are the facility of perform-
I think that the time of
The ance, and from the fact that all the tissues are cleanly cut, in their natural positions, without any laceration, the wound heals
rapidly.
very In
case, aged 3, healing occurred by the first intention alurine ever came by the wound.
one
most, for
no
In another case, also aged 3, a few drops of urine came day after the operation, but none afterwards.
wound the
by
the
And
operated on by Dr. Brown, only by the wound the day after the operation, but none subsequently. I have observed that the majority of operators seem to consider it necessary to introduce the forceps into the bladder over the finger, and often considerable force is necessary to effect this. It does not seem to be known that once the finger lias fairly entered the bladder and touched the stone, any forceps of moderate dimensions, if passed in the proper direction and slightly rotated, will freely pass into the bladder without using the finger as a guide. And in the case of small calculi, if the forceps is passed aver the finger, the internal wound must be unnecessarily lacerated by this proceeding. If the wound is too small, I always prefer to enlarge it with the knife, rather than to tear it. ^ In the Punjab, where our hospitals are so open, I find it a good rule never to operate during wet weather, as the patients in
a
a
few
are
third case, aged 60, lately drops of urine came
almost
sure
to
get fever.
I never operate on adults until servation for at least a week, as a other disease under which he
some
operated
on
In the
tlicy have been under obpatient will often conceal is laboring, if anxious to be
at once.
case
of
children,
I
usually operate
the
day
after
admission. In all
eases
chloroform,
or
I
give as
a
full dose of
soon
as
the
opium before administering patient is removed from the
table. cases, a week or so after operation, diarrhoea comes patient gets obstinate fever or some other complication, and begins steadily to go down-hill in spite of treatment. In such cases ought we to trust to treatment in Hospital, or yield to the urgent request of the patient and his relatives to allow him to be carried to his home ? At first I was strongly opposed to this practice, but some years ago a moribund patient was carried off by his relatives during the night without my consent,
In
on,
some
or
the
and lie
was
wards lie
41
entered in the register as dead ; but six months afterto thank me for having relieved him of the
appeared
Since that time I have made it a rule that as soon as reasonable liope of recovery after the operation of lithotomy, and after all resources have failed, to suggest to the relatives that he should be carried home, provided he lives within twenty miles and wishes to be removed. Such a case stone.
I see
no
I enter in my notes as fatal, unless I afterwards get evidence to the contrary. The effect of the change is quite wonderful in most cases.
And only the other day 11 strong healthy man who was operated on by me, got diarrhoea on the 8th day ; all remedies failed to check it, he began to despond, and I suggested that he should be taken home, a distance of five miles, and I gave him some astringents to take with him ; four days afterwards his wife returned to tell me that from the time he left the he began to improve, and was then quite well. It is certain that the air of a crowded hospital, in the heart of a
hospital
populous native city, is unfavourable for recovery. The plan adopted by me will probably be opposed by many surgeons, but in a certain proportion of cases?and the number is very small?I feel certain that it will save lives that would otherwise lost. The same good effect is sometimes seen when a moribund prisoner is released from jail and made over to his relatives to be carried to his home : the effect is magical. be
HENDERSON, M.D., Lahore.
Punjab stone is so common that in many dispensaries scarcely a week passes without a case of lithotomy. I have had as many as five cases in one day, and as many as thirteen cases in Hospital at one time. I have never had more than thirty-five cases running without a death, and that occurred only once. In May last, Dr. Murray, Inspector-General of Hospitals, described to me his mode of operating for stone, which is much more simple than that usually practised. No case of stone being in Hospital at the time, I was unable to see Dr. Murray operate, but since then I have had a good many cases, in all of which I have adopted Dr. Murray's operation, and I am so jdeased with it that I intend never to perIn the
form any other. The operation of lithotomy, usually so easy in adults, is not unfrcquently attended with difficulties in the cases of children as is well described by Sir "W. Ferguson in the Mcdical and Gazette for
Times
July 2nd, 1864, and I have more than once seen inexperienced operators meet with difficulties, even in the Dr. Murray's operation differs case of adults. very slightly from the ordinary lateral operation, but is very much more easy to perform. Instead of dissecting towards the bladder, and making the finger prccede the knife, he at once pushes the knife into the groove of the staff, having first ascertained the position of the latter by means of the thumb-nail of the left hand ; the operation is similar to that recommended by Professor Buchanan of Glasgow, except that an ordinary staff is used instead of a rectangular one. The steps of the operation are as follows A staff is chosen with a large central groove, the latter so constructed at its extremity as to catch the point of the knife and prevent its leaving the staff, and thus endangering the
bladder. The staff having been introduced, the thumb of the left hand is to be placed on the spot wnere it is proposed to enter the knife, and the skin is then drawn over, if necessary, until this spot is exactly opposite the groove of the staff ; then feeling the groove with the thumb-nail, the point of the knife is at once pushed along the nail into the groove, and on, into the bladder.
By depressing the handle of the knife as the bladder is entered, the wound of the prostate is made sufficiently large. It now only remains to enlarge the external wound, which is done
NOTES OX LITHOTOMY.?BY G. HENDERSON, M.D.
February 1, 1867.]
by one sweep of the knife, as this is withdrawn. The whole proceeding does not occupy half a minute, and the facility with which it is effected is quite surprising to those who witness the operation for the first time. Dr. Murray recommends that a probe-pointed knife should bo used after the urethra is fairly entered ; but if the groove of the staff is properly constructed at its extremity, the bladder can hardly be injured, I also understood Dr Murray to even by a careless operator. say that he enlarged the wound of the prostate, by passing the finger over the back of the knife, but I find that, by depressing the handle, as the knife enters the bladder, the wound is at once enlarged sufficiently, and if on examination it is found to be too small, the knife can be re-introduced. I have generally observed that students operating on the dead body for the first time, meet with difficulties in dissect-
ing towards the bladder, but since they have adopted the operation above described, the bladder is reached with the utmost facility. Since I have adopted the new mode of operating, I have removed the stones with unusual facility. In two of my cases one of the students happened to note the time, and from first entering the knife, until the stone was on the table, occupied in
one
80, in the other 65 seconds.
case
haemorrhage is little more free than usual at operation, but it soon ceases. advantages of the operation are the facility of perform-
I think that the time of
The ance, and from the fact that all the tissues are cleanly cut, in their natural positions, without any laceration, the wound heals
rapidly.
very In
case, aged 3, healing occurred by the first intention alurine ever came by the wound.
one
most, for
no
In another case, also aged 3, a few drops of urine came day after the operation, but none afterwards.
wound the
by
the
And
operated on by Dr. Brown, only by the wound the day after the operation, but none subsequently. I have observed that the majority of operators seem to consider it necessary to introduce the forceps into the bladder over the finger, and often considerable force is necessary to effect this. It does not seem to be known that once the finger lias fairly entered the bladder and touched the stone, any forceps of moderate dimensions, if passed in the proper direction and slightly rotated, will freely pass into the bladder without using the finger as a guide. And in the case of small calculi, if the forceps is passed aver the finger, the internal wound must be unnecessarily lacerated by this proceeding. If the wound is too small, I always prefer to enlarge it with the knife, rather than to tear it. ^ In the Punjab, where our hospitals are so open, I find it a good rule never to operate during wet weather, as the patients in
a
a
few
are
third case, aged 60, lately drops of urine came
almost
sure
to
get fever.
I never operate on adults until servation for at least a week, as a other disease under which he
some
operated
on
In the
tlicy have been under obpatient will often conceal is laboring, if anxious to be
at once.
case
of
children,
I
usually operate
the
day
after
admission. In all
eases
chloroform,
or
I
give as
a
full dose of
soon
as
the
opium before administering patient is removed from the
table. cases, a week or so after operation, diarrhoea comes patient gets obstinate fever or some other complication, and begins steadily to go down-hill in spite of treatment. In such cases ought we to trust to treatment in Hospital, or yield to the urgent request of the patient and his relatives to allow him to be carried to his home ? At first I was strongly opposed to this practice, but some years ago a moribund patient was carried off by his relatives during the night without my consent,
In
on,
some
or
the
and lie
was
wards lie
41
entered in the register as dead ; but six months afterto thank me for having relieved him of the
appeared
Since that time I have made it a rule that as soon as reasonable liope of recovery after the operation of lithotomy, and after all resources have failed, to suggest to the relatives that he should be carried home, provided he lives within twenty miles and wishes to be removed. Such a case stone.
I see
no
I enter in my notes as fatal, unless I afterwards get evidence to the contrary. The effect of the change is quite wonderful in most cases.
And only the other day 11 strong healthy man who was operated on by me, got diarrhoea on the 8th day ; all remedies failed to check it, he began to despond, and I suggested that he should be taken home, a distance of five miles, and I gave him some astringents to take with him ; four days afterwards his wife returned to tell me that from the time he left the he began to improve, and was then quite well. It is certain that the air of a crowded hospital, in the heart of a
hospital
populous native city, is unfavourable for recovery. The plan adopted by me will probably be opposed by many surgeons, but in a certain proportion of cases?and the number is very small?I feel certain that it will save lives that would otherwise lost. The same good effect is sometimes seen when a moribund prisoner is released from jail and made over to his relatives to be carried to his home : the effect is magical. be
