PERINEAL LITHOLAPAXY (KEITH'S OPERATION). 



By A. HoOTON.' 

 {Rajlcot, India.) 



The trend of general surgical opinion, with reference to the treat- 

 ment of stone in the urinary bladder, is, I suppose, more and more in 

 favor of the employment of crushing operations in almost all cases 

 in which they are practi-cable, and while admitting that very large 

 stones usually are best dealt with by suprapubic lithotomy, and that 

 certain cases associated with cystitis or suppuration about the neck of 

 the bladder derive benefit from the drainage which is most easily 

 afforded by a perineal lithotomy, I take it that everyone will agree that 

 any safe procedure which enables litholapaxy to be applied to stones 

 which would otherwise have to be removed by serious cutting operations 

 is worthy of consideration. Keith's operation has this application, and 

 it is with the view of bringing it to the notice of surgeons who perhaps 

 may not previously have heard of it that this short account has been 

 written. 



It may first be noted that several procedures involving a combination of 

 crushing with a larger or smaller incision in the perineum have from time to 

 time been advocated by various authorities. Dolbeau was the first surgeon, 

 so far as I am aware, to publish an account of such a combined operation, but 

 his operation, which in essentials is that still described in the text-books under 

 the name of perineal lithotrity or litholapaxy, differs from Keith's in the important 

 fact that a much larger opening is made in the urethra to allow of the passage 

 of large instruments designed merely to break up the calculus roughly, and not 

 to crush it completely; and, indeed, it may be said that this method has more 

 in common with lithotomy than litholapaxy pure and simple. Dolbeau's operation 

 apparently was practiced intermittently by various surgeons for many years, but 

 it was not until Dr. Keith of the Indian Medical Service introduced his modifica- 

 tion that any large number of cases of crushing through a perineal incision were 

 published, and that the operation — so changed in its details as to be practically 

 new — acquired almost all the advantages of an uncomplicated litholapaxy. Dr. 

 Keith, in his capacity of Civil Surgeon of Hyderabad, Scinde, with its five 

 hundred cases of stone a year, had imrivaled opportunities of demonstrating the 

 value of the procedure, and recorded a series of fifty-three cases in men, with 

 three deaths, and one hundred and six cases in children, with no deaths. Surgeon- 

 General Stevenson, Colonels W. H. Henderson and R. Baker, I. M. S., and other 



^ Major, I. M. S. 



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