THE

VOL. XIII.

JULY, 1893.

No. 1.

ORIGINAL ARTICLES.

INDIVIDUAL EXPERIENCE IN THE TREATMENT OF VESICAL CALCULUS.

BY JOHN ASHHURST, JR., M. D.

Professor of Clinical Surgery in the University of Pennsylvania.

I find in looking over my records that I have removed calculi from the human body in fifty-one cases. One case was that of a female child, on whom I performed lithectasy, or rapid dilatation of the urethra, but the remaining fifty were in male subjects. In thirtyfive of these fifty cases, the patients were operated on by lateral lithotomy, which is the cutting operation that I prefer. I recognize that there are cases in which the median operation is to be preferred, and that there are other cases in which the supra-pubic operation is the best, but where the surgeon has the choice of operation, I think he should select lateral lithotomy. Of the thirty-five cases operated on by the lateral method, twenty were in children under the age of puberty, and in every case the patient recovered. In males beyond. the age of puberty, including a fair proportion of quite old persons, I have had fifteen cases with three deaths, but only one of these three was really the result of the operation. That occurred in a case operated on in a neighboring town this winter. Secondary hemorrhage occurred on the ninth or tenth day, and the attempts made by the attending physician to control it were not successful.

I have six cases of the median operation, with one death, to report. In one case, the operation was done for the removal of a foreign body—the end of a catheter. In this case I succeeded not only in removing the foreign body, on which there was a small

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calcareous deposit, but also in relieving the chronic retention of urine, from which the patient had long suffered, by tearing off the median lobe of the prostate with the forceps. This was fully ten years ago; the patient is still living, and I believe has not had occasion to use a catheter since. The case which proved fatal was in a patient in the last stages of cystitis and chronic renal disease, and in which the presence of the stone was simply a complication. An interesting feature in this case was that, in addition to the presence of a stone, there was a large quantity of that semi-organized material which has been described by Vandyke Carter as the animal basis of calculi.

I have one case of the supra-pubic operation, in which the stone was a small one, this particular operation being chosen because the case was really one of villous tumor of the bladder, and the presence of the stone was simply a complication. The patient was in a critical condition from hemorrhage at the time of the operation, but made a good recovery.

I have no case of the old-fashioned lithotrity. The operation had already come to be rarely practised before I had occasion to resort to the crushing method. The early portion of my practice was largely with children, and Bigelow's modification had already become the operation of preference when I first felt I had a case adapted to its performance. I have performed this operation eight times, with six satisfactory recoveries and two deaths. Both of the deaths were from uremia, dependent upon chronic disease of the kidney.

I have brought here a number of calculi which I have removed. The largest weighs three ounces and some drachms. It was removed by the ordinary lateral operation. It was not necessary to enlarge the wound by dividing the right side of the prostate, nor was it necessary to crush the stone. By making a large external wound, by grasping the stone with sufficiently powerful forceps, and by patience in manipulation, this stone was removed without difficulty, and the patient made an excellent convalescence.

The largest number of stones which I have removed from one

patient is fifty-four. These were removed by lateral lithotomy. The patient made a good recovery, but returned in a year or so with recurrence of the symptoms from a descent of more stones from the kidney. On that occasion I determined to perform the operation of litholapaxy. The patient did pretty well for a few days, but then the urine became turbid, containing a large quantity of ropy mucus and pus, uræmia developed, and the patient died in convulsions. This was a forcible illustration of the risk attending litholapaxy in cases of cystitis, and since the occurrence of that case, I make it a rule, where the patient presents cystitis in an advanced degree, to recommend the cutting rather than the crushing operation.

With regard to the results that I have reached from my own experience, I would say, in the first place, that I have never seen any reason to wish for a better operation than lateral lithotomy in children, Litholapaxy has been resorted to successfully a number of times, and with the improved instruments which we now have the operation is a feasible one, while it could hardly be considered such a few years ago. Until within a short time it has not been possible to get instruments of sufficient strength and delicacy for use in the urethras and bladders of children. Even now, the operation of litholapaxy in children seems to me to be a more severe one than lithotomy. The results of cutting for stone in children. are so satisfactory that I think we want nothing better. The great advantage of litholapaxy, it seems to me, is the short time required for after-treatment. If all goes well, litholapaxy will allow the patient to go about his business in five or six days. This is a great advantage in adults who are engaged in active business; but in young children it is a matter of no importance. At the same time, I am willing to admit that the operation has been improved to such an extent that it is one which may be legitimately resorted to in children if the surgeon thinks it is preferable.

The median operation seems to me to have a very limited field. Cases of foreign body in the bladder, and cases of very small stone, are those to which this operation is adapted. In some of my cases the operation was not begun with the knowledge that a stone was