Notes on Litholapaxy, with Special Reference to

NOT&

ON LITHOLAPAXY, WITH SPECIAL REFERENCE TO THE OPERATION AS PER FORMED ON MALE CHILDREN. By Subgeon G.

DENNYS, Surgeon, Jalandhar. (Continued from page 325.) Civil

recorded my experience in the of this operation on male children, I should like to make a few remarks regarding the operation in general on both adults and children, illustrating them, as far as possible, by notes on some interesting cases that have occured in my own practice : (1.) Surgeon Freyer, at page 46 of his excellent work on Litholapaxy, very rightly draws attention to the difficulties attending the performance of the operation, which he says, is " perhaps the most difficult in the whole range of operative surgery, and should not be lightly undertaken by inexperienced hands." Now, though by no means wishing to detract from the truth of this remark, I cannot help thinking that it is apt to make many surgeons fearful of undertaking the operation at all till they have first had the opportunity of witnessing its performance. I fully agree with Dr. Freyer in his remarks on page 48 of his work, that " more information will be gained by seeing the operation once well performed than from any amount " but I do not think of theoretical knowledge ; that any surgeon in this country who has had a fair amount of experience in operative surgery and has gained some confidence in himself, need be afraid of undertaking the operation single handed and for the first time, simply because he has not had the opportunity of seeing the operation performed, provided only that before doing Dr. Freyer's work so he has carefully studied on the subject. I would eveu say more than this, for if a beginner will only select his first few cases, i.e., make certain that the stone is small, and not very hard, that the urethra is capacious, the bladder healthy and not irritable, the prostate not enlarged, and the patient strong and able to stand a somewhat prolonged administration of chloroform: he will be quite surprised at the simplicity of the operation, how anxious the stone appears to be to wet between the blades of the lithotrite and ?be crushed, and how easy is the process of evacuat-

Haying

now

performance

?

356

THE INDIAN MEDICAL GAZETTE.

the debris. It is often impossible for surgeons in India to get an opportunity of witnessing the operation before undertaking "it themselves, and my advice to such is, provide yourselves with- the necessary instruments of the latest and best patterns, make yourselves thoroughly acquainted with the method of operating and the complications likely to be met with, carefully select your first few cases, and attack the stones with perfect confidence of success." If one waits till one has had the opportunity of seeing the operation performed by some one else, one may have to wait a long time and thereby loose the chance of saving many lives and alleviating much suffering. JFreyer's description of the operation, witli the difficulties and complications that may be met with, is so explicit and thorough, that any one who studies the same carefully ought to find no difficulty whatever in disposing of si small stone in the bladder unattended by any of the complications so carefully pointed out by him. I notice that neither JFreyer nor Keegan enter very clearly into the best method of holding and manipulating the lithotrite during the process of searching for and crushing the stone or its fragments, and as this is, in my opinion, quite the most difficult part of the operation, I venture to give here a description and drawing of the method of holding and working the lithotrite, a careful observance of which I have found, in my own practice, to greatly facilitate the operation. I have already endeavoured to point out that prolonged influence of chloroform is the main danger in most cases of litholapaxy, and to avoid this it is obvious that the stone should be disposed of with the least possible A definite understanding as to the delay. method of holding and manipulating the lithotrite will greatly hasten the completion of the operation and tend to avoid much fruitless search for fragments, and the slipping away of the same from between the blades of the lithotrite after they have been caught. I have over and over again seen a fragment of stone, after being caught between the blades of a lithotrite, slip away again before the blades could be locked, simply due to clumsy handling of the instru-

iug

ment.

1 represents the method I have found useful of holding the lithotrite during the process of searching for and crushing the stone and its fragments. The woodcut represents the hauds as viewed from the right side of the patient, or in other words, as viewed by the operator himself. The left hand grasps the cylindrical portion of the instrument between the fingers and palm, the back of the hand facing away from the operator aud towards the left side of the patient. This leaves the thumb

Fig.

most

[Dec.,

1888.

work the button on the upper part of the which locks and unlocks the blades, while at the same time the grasp on the cylinder is never relaxed for a moment. The right hand now grasps the wheel on the upper part of the instrument between the bases of the thumb and index finger, the middle finger being flexed on to the under part of the wheel as a support. The points of the thumb and index finger should remain free. TIjus, when the blades are unlocked, by applying the points of the thumb and index finger against the upper part of the cylinder (as shown in the fig.) and gently extending them, the blades of the lithotrite cau be opened, while gentle pressure downwards on the wheel shuts them again. When a fragment of stone has been caught between the blades and they have been locked by pushing the nut upwards with the thumb of the left hand, the wheel can be rotated with the right hand and the fragment crushed, without shifting The nut can then the position of either hand. be drawn down again, the blades unlocked, and another fragment seized and crushed in the It may occasionally happen that same way. the stone is so hard that the grasp obtained on the wheel by the right hand (as shown in the fig.) is not sufficiently strong to enable one to crush the stone. If such be the case, of course, the position of the right hand can be changed in order to obtain a firmer purchase on the wheel; but I may ssiy that since I have adopted this method of holding the instrument, I have never found it necessary to alter the position of the right hand. The lithotrite depicted in the fig. is one of the ordinary Weiss and Thompson's pattern. I have never worked with any other pattern of lithotrite, nor have I ever seeu one of Bigelow's lithotrites as described at page 13 of Freyer's work. The locking and unlocking of this instrument is effected by simply a quarter rotation of the right wrist. When using this instrument, therefore, there would be 110 necessity for the position of the left hand as shown in my fig. in which the thumb is free for pushing the nut up and down. The working of I imagine, Bigelow's lithotrite would, however, " be facilitated by holding the ball," instead " wheel," in the right hand as shown of the If the male blade works at all in my fig. the within female (as is often the case) stiffly the point of the female blade is apt to shift its position inside the bladder during the process of pulling up the male blade, thereby uecessitating another search for the fragments after This shifting each piece lias been crushed. be female blade can easily avoided by of the the of the right hand as observing position There cau be no truer sayshown iu the fig. ing than that of Sir Henry Thompson who compares the finding of fragments to fishing for

free

to

cylinder,

Dec., 1888.]

DENNYS ON LITHOLAPAXY.

where one is found there many will be caught, and it is, therefore, especially necessary when the female blade has found a home for itself among a quantity of fragments, that it be not removed therefroiu till they have all been caught and crushed.

perch, viz.,

wheel, for it will bits, with little or

357 at no

begin to crumble to cracking sound. Scarcely

once

any force is required to crush these stones, and the first turn of the wheel often breaks them into dozens of small fragments. After this the and are the point to up; picked fragments remember now is that half a turn of the wheel will probably crush each fragment into a dozen more pieces, so that it is never necessary to If the male blade screw the male blade home. be screwed home in a non-fenestrated lithotrite when dealing with a soft stone clogging is Should the blades almost certain to occur. become clogged, however, it should be an invariable rule never to attempt withdrawal of the instrument till the ddbris is removed, and the blades become capable of being screwed well home. The female blade should then be lifted off the base of the bladder, well into the centre of the organ, and, the instrument being unlocked, the male blade should be brought down sharply with the sliding action on to the female blade and withdrawu again immediately. By this means, I have never yet failed to remove the impacted debris sufficiently to enable me to screw the blades home. Never attempt to screw the blades home with a view to removing the Fig. Tie. I. clogging, for this only makes matters worse, and impacts the debris the more firmly between the blades. The harder the stone, the less will be the chance of clogging, and iu fact with very hard Dr. Keegan has laid great stress on the stones it seems impossible to impact fragments necessity of the litholapaxist bein