February, 1883.]
FREYER ON LITHOLAPAXY.
ORIGINAL COMMUNICATIONS.
J
than,
A SECOND SERIES OF TEN CASES OF '
LITHOTRITY AT ONE SITTING.' By Surgeon P.
J. Freyer, a.m., Bengal Medical Service, Civil Surgeon, J\Ioradabad.
my first I have
article of mine
an
of
lithotrity completed a second
ten cases now
at a
appeared on single sitting. series of
ten
cases, and in the
present article I propose givbrief notes of these, together with a few pracing tical observations illustrative of my experience of the operation taken from notes jotted down from time
time whilst the incidents
to
or
sub-
which they refer were fresh in my meMy experience of the operation of 'litholapaxy' now extends to twenty cases, all of which were performed in adult males, varying between the ages of 20 and 85. Amongst these there was only one death, and this, as I mentioned in my previous article, occurred in an old man suffering from atony of the bladder and of the prostate, and who was great enlargement practically moribund when the operation was un-
jects
to
mory.
All the others made
dertaken.
excellent
re-
coveries. I may mention that I have not specially selected favorable cases for the operation of
litholapaxy, dividual to
ing
as a
cases
practise from
reference
to
the notes of the in-
will show. Since I first commenced
this
stone
operation, 23 adults sufferthe in bladder have come under
Twenty of these I have sublitholapaxy, and the remaining three jected to lithotomy. In two of these latter I attempted the crushing operation, but after introducing the lithotrite in each instance and grasping the my observation.
was
too hard to be dis-
posed of in this way. In the third case there a stricture of the urethra, so that lithowas could
be
fit to return home,
were
cases.
operation of litholapaxy is particularly adapted for calculi of small size, very large ones are amenable to treatment in this way, provided they are not extremely hard. I desire to call especial attention to Case the
Though
No. 16, in which I removed 3*^ ounces of hard uric acid calculus from the bladder at one sit-
ting
in
who
was
to in
hour and six minutes.
one
in
a
miserable condition
left it
hospital,
ten
aware, the
largest
This is,
as
operation
far
calculus that has
patient,
admission
on
the bladder
from
The
after the
days
excellent health.
as
ever
I
am
been
the
crushing by operation at one sitting, the largest removed by Sir Henry Thompson being 2^ ounces. The amount of manual labour required in crushing a large and hard stone of this kind, is something excessive. I don't remember having ever felt so exhausted before as I was after the completion of this operation, and the muscles of my right arm ached for two or three days subsequently. removed
It will be noticed from the notes of my cases,
that in all instances the calculus
ly
removed at
sitting.
one
was
This
complete-
I believe to
be the most essential consideration in the operation.
It is very much better that the operation prolonged, and the whole
should be somewhat
of the stone removed stone is
performed. All these three lapaxy cases I cut successfully, so that the previous attempt at the crushing operation had no detri-
the meantime
mental effect.
bladder and
The operation of litholapaxy is especially effective in cases of very small calculi, weighing less
No. 16 is
not
they
under observation for
were
in such
to
calculus, I found that it
that
a longer kept period merely for a reason which I purpose referring to hereafter. Contrast the condition of these patients with the lengthened periods they would have had to remain in hospital had lithotomy been performed, not to talk of the increased danger to life from the latter operation
and
In the December number of the Indian Medical Gazette
of my cases, it will be seen that in three or four instances, in which the stone was very small, the patients were so well in a day or two after the
operation,
m.d.,
From the notes
of drachms.
couple
a
say,
29
a
large
at
be left behind for future
time
once,
one, than that
a
when
the
should
portion disposal, constituting
source
to
even
a
of irritation rise to
to
in
the Case
likely give cystitis. good illustration of the length of instruments may be manipulated in the a
THE INDIAN MEDICAL GAZETTE.
3?
bladder be
with
completely
ted, allowed In all
the calculus
impunity, provided
to
removed and the organ, unirritaregain its normal condition.
allowing the patients to go home, I have satisfied myself that there were no fragments left behind by the introduction of
sound.
a
to
previous
cases
The sound I
for this purand I cannot
use
pose, is Sir Henry Thompson's, speak of this instrument in terms of too and
praise. Large be easily detected by very small calculi
arc
by them, especially
high
moderate sized calculi the
can
ordinary sounds,
but
almost certain to be missed
when
they
lie close behind
For the detection of these, Sir Thompson's sound is essential. I have
the prostate.
Henry
several occasions detected
on
sizx of failed
a
to
this instrument, when I had with the ordinary sounds.
by
pea,
do
calculus, the
a
so
larger the evacuating catheter used the less necessity there will be for crushing the calculus into fine debris, and, consequently, the less time will the operation require for its performance. It is, therefore, advisable to make into use of the largest catheter that will pass The
the bladder easily. The use of any force in passing the catheter, or indeed any of the instru-
used, is
ments
deprecated as likely to lead results. The largest evacuating used is No. 18, and this passed
to be
to mischievous
catheter I have
nine of my cases. No. 16 was used in ten of the cases, and No. 14 in two. Case //.?Amroh, a Hindoo male, aged 40, in
easily
was
admitted into the Moradabad
Hospital
on
October, 1882, suffering from symptoms of stone in the bladder. During the previous the 16th
pain in the the glans penis,
suffered from
he had
two years
region of the bladder, as also in frequency of micturition, sudden stoppage the flow of urine, and occasional discharge
of of
These symptoms had increased very during the last three months. He had never
blood. much
passed gravel,
General
mucus.
October,
a
of a stone once
and there
sound
health
confirmed.
anaesthetised by It
no
fair.
discharge of the 17th
On
and the presence
passed
was
lapaxy performed.
was
The
patient
chloroform and was
not
was
at
litho-
necessary
to
[February, 1883.
slit up the floor of the urethra. Evacuating catheter No. 16 was at first used, and some de-
lay
occurred
sticking tried,
and
to
owing its eye.
in
a
large fragment
No.
passed easily.
18 catheter
of stone
then The lithotrite had to
be introduced three times
during
the
was
operation,
which lasted 25 minutes. The debris of the calculus weighed 7 drachms, and its composition oxalate of lime.
was
washed acid
out
with
a
The bladder
was
finally
weak solution of carbolic
100). Ten grains of quinine were internally as soon as the patient regained consciousness, and a morphia suppository by the rectum. Barley water with liquor potassse was given freely. On the 20th October the urine contained a slight mucoid deposit on standing. The bladder was washed out with a solution containing one grain of acetate of lead to four ounces of water. The mucoid discharge and the man was disgradually disappeared, charged quite well on the 26th October, a sound having been previously passed to see that there were no fragments of stone left in the bladder. Case 12.?A Hindoo male, named Bidah, aged 20, was admitted on the 22nd October in
(1
administered
with the usual symptoms of stone in the bladder, which had existed for four years. Patient's health
was
Presence of
fair.
the sound.
On
a
stone confirmed
23rd October the patient anaesthetised,and with the kind assistance of Dr. Moran of the 6th B. N. I., I performed litholapaxy. The calculus was phosphatic, with a small oxalate of lime nucleus. It weighed 170 grains. The operation lasted only 11 minutes, the lithotrite being only once introduced. Evacuating catheter No. 16 was used, and the floor of the urethra slightly slit up to by
the
was
admit of its passage. The usual after-treatment was adopted. The man recovered without bad symptom, and wras discharged in health on the 30th October. a
Case
j.?Lukhie,
1
a
Hindoo
male,
resident of Bhudaru in the Moradabad was
admitted
from the
on
the 2nd November,
penis.
of These
aged 50, District,
suffering
stoppage of urine, and pain in the glans symptoms had only existed
painful micturition, flow
sudden
perfect
February, 1883.] for
3*
FREYER ON LITHOLAPAXY.
The internally and externally. he in his urine, but that man was extremely thin and weak, and was never inconvenienced thereby. Presence was almost in a dying state. The presence of a of a small stone detected by the sound after a stone was detected by the sound. Bowels ordered good deal of difficult)-. Chloroform was at to be cleared out by a dose of castor oil. On the once given, and litholapaxy performed. The cal20th November I performed litholapaxy. Consiculus was a very hard oxalate of lime one, and derable difficulty was at first experienced in was lithotrite The 12 weighed only grains. grasping the stone, but once grasped it was easily was stone indeed the : once introduced only crushed, being phosphatic. The fragments crushed in four or five seconds. No. 18 evacuatweighed 235 grains. Time occupied by the withease the catheter with greatest ing passed operation, 23 minutes. Lithotrite introduced out slitting the urethra. The operation lasted 3 times. Evacuating catheter No. 16 used only six minutes. Usual after-treatment. Pa- ; after slitting the floor of the urethra. Usual aftertient was quite well next day, but was not j treatment. 2gth November-. Urine passing allowed to leave Hospital till the 5th November. | freely with slight pains and slight tinge of blood, Case 14.?Wazir Alii, a Mahomedan, aged 35, This j Vomited a good deal yesterday afternoon. shoe-maker by trade, admitted into the MoradaI was controlled by 5 drop doses of dilute hybad Hospital on the 17th November, suffering drocyanic acid every two hours. From this from the usual symptoms of stone in the bladder, time the patient rapidly improved, and was diswhich had lasted 12 years. The man was very charged in good health on the 7th December. thin and worn out from the constant pain, which There was not a bladder symptom present, and 10
days or passed gravel
so.
States that he
frequently
very severe whenever he took exercise of any kind. Presence of a calculus detected by the sound. The patient was allowed to rest
was
for
a
ment was
days, during which preparatory treatwas adopted ; on the 20th November he
few
put under the influence
of chloroform and
The calculus
litholapaxy performed.
was
very
of lime, and the fragments 225 grains. The operation lasted 20 minutes, the lithotrite being introduced four times. No. 16 evacuating catheter was used
hard, of weighed
after
oxalate
slitting
the floor of the urethra.
after-treatment. with Pain
blood, over
castor oil
and
21st some
the
region
one
ouncri
November-.
of the stomach. laudanum
22nd November-. Bowels moved last he is This
quite well to-day and wishes man was discharged in good
tinged
micturition.
pain during and
Usual
Urine
Ordered
drops. night. Says
to
20
go health
home. on
the
25th November. Case
ij.?Futteh,
Mahomedan, aged
both
piles,
the
piles
had
disappeared
This
treatment.
case
without any
made
a
most
special rapid and
wonderful recovery, and well illustrates the great superiority of litholapaxy over lithotomy. The
extremely
man
was
so
pain
and
loss of
blood,
exhausted and
from
the
also from the
hemorrhoidal
complication that I could not lithotomy, and in 10 days after the operation of litholapaxy he left hospital in perfect health. Case 16.? Illahi Buksh, a Mahomedan, aged dream of performing
60 years, resident of Sumbhul in the Moradabad district, was admitted into the Moradabad hos-
pital
on
toms
of
for
11
the
3rd
December with all the sympbladder, which had existed
stone in the
years.
He had suffered and
in the
from
glans penis region frequent and painful micturition,
pain
in the
of the bladder, and
passing
of
blood and pus in the urine. All the symptoms had increased rapidly during the last 3 years. On admission the
patient could only pass urine in drops continuously throughout the day and on the 27th November, suffering fiom painful and difficult night, and the passage of urine was attended micturition, occasional passage of blood and with great pain. The penis and foreskin were mucus. These symptoms had existed for two hypertrophied from the patient's constantly rubHe was also suffering from severe bing the organ to relieve the pain and irritation ; years. a
resident of Moradabad, admitted
40,
THE INDIAN MEDICAL GAZETTE.
32
a
urethral
calculus The
navicularis.
in
felt
was
the
stated that
man
fossa
when he
desired to pass urine he had to rub and pull the penis, and in this way push the urine past the calculus in the urethra. The urine was mixed with pus, and there was a muco-purulent discharge from the urethra. Patient was, as ageneral
rule, constipated, passing only of
ribbon-shaped
fasces
at a
time
times suffered from diarrhoea. into the rectum
finger
felt in the
was
to be
large
a
small
a
On
bladder, which large size.
general health
was
Tne
very bad. He and anaemic, and had a
weak,
anxious The
was
expression, the patient having
result been
some-
passing
and hard
calculus of
a
quantity
but he
:
was
the
tumour
diagnosed patient's very thin
pinched and of long suffering. subjected to pre-
paratory treatment, on the 5th December chloro. form was administered, the floor of the end of the urethra slit up slightly, and the urethral calculus removed by forceps. A sound was then into the
passed calculus
bladder,
the
litholapaxy, and 3^ ounces
operation lasting
66
minutes,
of hard uric acid calculus
removed in that time. be introduced
and the presence of a I then performed
there.
detected
being had
to
times, and after crushing large quantity of debris was removed by the aspirator through a No. 18 evacuating cathetcr. Considerable difficulty was at first experienced in catching the calculus with the lithotrite owing to its large size and the walls of the bladder grasping it tightly. This difficulty was overcome by first injecting at
each
a
ounces
dozen
passing
of water into the the lithotrite.
walls of the bladder calculus and
room
lithotrite allowed. the
a
a
few
then
least
The lithotrite
aspirator
some
were
for After
bladder and
In this way the separated from the
manipulation by each evacuation
water Was left
the
by
behind, and by
this arrangement the larger fragments were easily grasped and disposed of. The calculus was a very and required very severe manual labour in its crushing. After the fragments were com-
hard
one
pletelv removed,the bladder was washed out with weak solution of carbolic acid, a morphia suppository introduced into the rectum, and ten grains
a
[February, 1883.
of quinine administered
patient regained December 5th,
internally
the
as soon as
consciousness.
4. p.m.?Slight fever present. Urine mixed with blood, passing freely and with some pain. Patient taking copious
draughts
of
barley
water and
liquor potassaj.
December 6th.?No fever.
passed without pain purulent deposit.
Urine clear and
; urinal
contains
a
Bladder washed
solution of acetate of lead
muco-
out
with
to 4
(1 grain ounces.) Jth.?Patient much better in every bladder again washed out.
December
way : December St/i.?The
mucus
from the urine
appeared
health much
has almost disGeneral
standing.
on
improved.
From this time the
patient gradually
im-
proved in
general health, and the bladder symptoms disappeared, and on the 15th, when he was
the
discharged,
in my note
following entry
describes his condition :?" Patient
book
now
rid of all the bladder symptoms. Urine quite clear : bladder retains a large quantity at a time. Has grown quite fat and strong : says he has not been so well for several years. This man was a
ten
miserable wretch
days ago, and
on
now
admission to
hospital
leaves it in excellent
health." Case
17.?Sayid Uddin, a Mahomcdan, aged 36, resident of Sumbhul, was admitted into the Moradabad hospital on the 4th December, suffering from the usual symptoms of stone in bladder, which
the
lasted
had
11
months.
The presence of stone was confirmed by the sound. The man was in had health, being very thin and anaemic. this
case on
but I
morning
of the
operating on 5th December,
tired after the manual exertion
was so
required operation At 4 culus
the
I had intended
in Case
16,
that
I had to defer
till the afternoon.of the
l'. M. was a
I
performed litholapaxy.
soft
phosphatic
same
the
day.
The cal-
one, and the debris
grains. The operation lasted only 8 minutes, during which the lithotrite was twice introduced. Evacuating catheter No. 16 was used. This patient recovered without a bad symptom, and wanted to go home on the 8th, as he felt quite well. Discharged on the 13th December.
weighed
120
Case 18.?A Hindoo
broker,
ceased at
resident of Chan-
dausi, aged
35, came to me on the 19th Decemthe usual symptoms of stone in the which had existed four years. All the
ber, with
bladder,
symptoms had much increased 6 months.
where,
This I
but failed
passed to
a
during
the last
had been sounded else-
man
and told that there
bladder.
was
full-sized
detect
stone.
a
no
stone in his
ordinary sound, I then passed
Sir
Henry Thompson's sound, and detected a slight grating sensation behind the prostate by turning the point of the sound in that direction. On the same day chloroform was administered, and a lithotrite introduced. No stone a
could be detected till the end of the lithotrite was
turned towards the prostate, and on openposition, a small calculus
the blades in that
ing
caught and crushed. The debris, which was phosphatic and weighed 45 grains, was removed through an evacuating catheter No. 16. The operation only lasted 5 minutes, the lithotrite being only once introduced. This gentleman was
recovered without
a
allowed to return home Case
symptom, and
bad on
\vas
the 28th December.
Mahomedan, aged p.?Umaid Alii, Sabespore, in the Bijnour district, admitted into the Moradabad hospital on the 26th December, suffering from the usual sympa
1
40, resident of
toms of stone in the 11 or 12
years. had suffered from
bladder, which had existed
Previous
to
their
colic.
kidney
setting in,
The
man
he
was
very weak, and found great difficulty in moving about owing to the pain in the bladder. Pur-
gative ordered. presence
of
a
On the calculus
27th
was
December the
confirmed
sound, and litholapaxy performed. lus
by
the
The calcu-
and the
fragments weighed appeared much larger than it eventually turned out to be. This was probably due to its being ovoid in shape, and being grasped at first by its long was
10
phosphatic,
drachms.
diameter
At first the calculus
between the blades of the lithotrite.
operation lasted 35 minutes, the lithotrite being introduced 4 times. Evacuating catheter No. 16 was the largest used. A considerable portion of this time was occupied in administering artificial respiration, as the breathing The
33
FREYER ON LITHOLAPAXY.
February, 1883.]
;
during the operation. There was a considerable amount of bleeding from the urethra, the mucous membrane of which seemed to have a peculiar hemorrhagic tendency.
one
time
There
was a
considerable admixture of
blood with the urine for the first three
days operation: disappeared completely on the 30th December. The patient suffered from severe fever also for some days after the operation, but on the morning of the 31st December seemed to be quite free from fever. On the evening of that day, however, the patient became extremely violent, singing songs, &c., and I was afraid acute mania was setting in. I ordered a mixture containing grs. xv of Chloral Hydrate and grs. xxx Potass. Bromidi, to be repeated every two hours till sleep should be produced. After the third dose sleep was produced, and all these untoward symptoms had vanished on the 2nd January. I am after the
inclined Cinchona
this
to
attribute these symptom.1: to Febrifuge which the patient
the was
taking. As soon as the symptoms were noticed drug was dropped and Liquor Arscnicalis substituted. The patient is now quite well, and all the bladder symptoms have disappeared. Case 20.?Ram Dutt, a Hindoo male, aged 40, resident of Manoopur in the Moradabad district, came to the hospital on the 31st this
December, 1882, with all the symptoms in the bladder, which had lasted
stone
month.
Patient
draught.
On the
and detected
a
was
1st
ordered
January
small calculus
of one
purgative passed a sound lying behind the a
I
was administered and prostate. litholapaxy performed, the operation only lasting two minutes. The calculus was of oxalate of lime, and weighed only 10 grains. Lithotrite only introduced once, and catheter No. 16 used. The usual after treatment adopted. Patient had slight fever next day, but no other bad symptom has supervened, and he is now well enough to be discharged. Moradabad, 5th January, 1883.
Chloroform
FREYER ON LITHOLAPAXY.
ORIGINAL COMMUNICATIONS.
J
than,
A SECOND SERIES OF TEN CASES OF '
LITHOTRITY AT ONE SITTING.' By Surgeon P.
J. Freyer, a.m., Bengal Medical Service, Civil Surgeon, J\Ioradabad.
my first I have
article of mine
an
of
lithotrity completed a second
ten cases now
at a
appeared on single sitting. series of
ten
cases, and in the
present article I propose givbrief notes of these, together with a few pracing tical observations illustrative of my experience of the operation taken from notes jotted down from time
time whilst the incidents
to
or
sub-
which they refer were fresh in my meMy experience of the operation of 'litholapaxy' now extends to twenty cases, all of which were performed in adult males, varying between the ages of 20 and 85. Amongst these there was only one death, and this, as I mentioned in my previous article, occurred in an old man suffering from atony of the bladder and of the prostate, and who was great enlargement practically moribund when the operation was un-
jects
to
mory.
All the others made
dertaken.
excellent
re-
coveries. I may mention that I have not specially selected favorable cases for the operation of
litholapaxy, dividual to
ing
as a
cases
practise from
reference
to
the notes of the in-
will show. Since I first commenced
this
stone
operation, 23 adults sufferthe in bladder have come under
Twenty of these I have sublitholapaxy, and the remaining three jected to lithotomy. In two of these latter I attempted the crushing operation, but after introducing the lithotrite in each instance and grasping the my observation.
was
too hard to be dis-
posed of in this way. In the third case there a stricture of the urethra, so that lithowas could
be
fit to return home,
were
cases.
operation of litholapaxy is particularly adapted for calculi of small size, very large ones are amenable to treatment in this way, provided they are not extremely hard. I desire to call especial attention to Case the
Though
No. 16, in which I removed 3*^ ounces of hard uric acid calculus from the bladder at one sit-
ting
in
who
was
to in
hour and six minutes.
one
in
a
miserable condition
left it
hospital,
ten
aware, the
largest
This is,
as
operation
far
calculus that has
patient,
admission
on
the bladder
from
The
after the
days
excellent health.
as
ever
I
am
been
the
crushing by operation at one sitting, the largest removed by Sir Henry Thompson being 2^ ounces. The amount of manual labour required in crushing a large and hard stone of this kind, is something excessive. I don't remember having ever felt so exhausted before as I was after the completion of this operation, and the muscles of my right arm ached for two or three days subsequently. removed
It will be noticed from the notes of my cases,
that in all instances the calculus
ly
removed at
sitting.
one
was
This
complete-
I believe to
be the most essential consideration in the operation.
It is very much better that the operation prolonged, and the whole
should be somewhat
of the stone removed stone is
performed. All these three lapaxy cases I cut successfully, so that the previous attempt at the crushing operation had no detri-
the meantime
mental effect.
bladder and
The operation of litholapaxy is especially effective in cases of very small calculi, weighing less
No. 16 is
not
they
under observation for
were
in such
to
calculus, I found that it
that
a longer kept period merely for a reason which I purpose referring to hereafter. Contrast the condition of these patients with the lengthened periods they would have had to remain in hospital had lithotomy been performed, not to talk of the increased danger to life from the latter operation
and
In the December number of the Indian Medical Gazette
of my cases, it will be seen that in three or four instances, in which the stone was very small, the patients were so well in a day or two after the
operation,
m.d.,
From the notes
of drachms.
couple
a
say,
29
a
large
at
be left behind for future
time
once,
one, than that
a
when
the
should
portion disposal, constituting
source
to
even
a
of irritation rise to
to
in
the Case
likely give cystitis. good illustration of the length of instruments may be manipulated in the a
THE INDIAN MEDICAL GAZETTE.
3?
bladder be
with
completely
ted, allowed In all
the calculus
impunity, provided
to
removed and the organ, unirritaregain its normal condition.
allowing the patients to go home, I have satisfied myself that there were no fragments left behind by the introduction of
sound.
a
to
previous
cases
The sound I
for this purand I cannot
use
pose, is Sir Henry Thompson's, speak of this instrument in terms of too and
praise. Large be easily detected by very small calculi
arc
by them, especially
high
moderate sized calculi the
can
ordinary sounds,
but
almost certain to be missed
when
they
lie close behind
For the detection of these, Sir Thompson's sound is essential. I have
the prostate.
Henry
several occasions detected
on
sizx of failed
a
to
this instrument, when I had with the ordinary sounds.
by
pea,
do
calculus, the
a
so
larger the evacuating catheter used the less necessity there will be for crushing the calculus into fine debris, and, consequently, the less time will the operation require for its performance. It is, therefore, advisable to make into use of the largest catheter that will pass The
the bladder easily. The use of any force in passing the catheter, or indeed any of the instru-
used, is
ments
deprecated as likely to lead results. The largest evacuating used is No. 18, and this passed
to be
to mischievous
catheter I have
nine of my cases. No. 16 was used in ten of the cases, and No. 14 in two. Case //.?Amroh, a Hindoo male, aged 40, in
easily
was
admitted into the Moradabad
Hospital
on
October, 1882, suffering from symptoms of stone in the bladder. During the previous the 16th
pain in the the glans penis,
suffered from
he had
two years
region of the bladder, as also in frequency of micturition, sudden stoppage the flow of urine, and occasional discharge
of of
These symptoms had increased very during the last three months. He had never
blood. much
passed gravel,
General
mucus.
October,
a
of a stone once
and there
sound
health
confirmed.
anaesthetised by It
no
fair.
discharge of the 17th
On
and the presence
passed
was
lapaxy performed.
was
The
patient
chloroform and was
not
was
at
litho-
necessary
to
[February, 1883.
slit up the floor of the urethra. Evacuating catheter No. 16 was at first used, and some de-
lay
occurred
sticking tried,
and
to
owing its eye.
in
a
large fragment
No.
passed easily.
18 catheter
of stone
then The lithotrite had to
be introduced three times
during
the
was
operation,
which lasted 25 minutes. The debris of the calculus weighed 7 drachms, and its composition oxalate of lime.
was
washed acid
out
with
a
The bladder
was
finally
weak solution of carbolic
100). Ten grains of quinine were internally as soon as the patient regained consciousness, and a morphia suppository by the rectum. Barley water with liquor potassse was given freely. On the 20th October the urine contained a slight mucoid deposit on standing. The bladder was washed out with a solution containing one grain of acetate of lead to four ounces of water. The mucoid discharge and the man was disgradually disappeared, charged quite well on the 26th October, a sound having been previously passed to see that there were no fragments of stone left in the bladder. Case 12.?A Hindoo male, named Bidah, aged 20, was admitted on the 22nd October in
(1
administered
with the usual symptoms of stone in the bladder, which had existed for four years. Patient's health
was
Presence of
fair.
the sound.
On
a
stone confirmed
23rd October the patient anaesthetised,and with the kind assistance of Dr. Moran of the 6th B. N. I., I performed litholapaxy. The calculus was phosphatic, with a small oxalate of lime nucleus. It weighed 170 grains. The operation lasted only 11 minutes, the lithotrite being only once introduced. Evacuating catheter No. 16 was used, and the floor of the urethra slightly slit up to by
the
was
admit of its passage. The usual after-treatment was adopted. The man recovered without bad symptom, and wras discharged in health on the 30th October. a
Case
j.?Lukhie,
1
a
Hindoo
male,
resident of Bhudaru in the Moradabad was
admitted
from the
on
the 2nd November,
penis.
of These
aged 50, District,
suffering
stoppage of urine, and pain in the glans symptoms had only existed
painful micturition, flow
sudden
perfect
February, 1883.] for
3*
FREYER ON LITHOLAPAXY.
The internally and externally. he in his urine, but that man was extremely thin and weak, and was never inconvenienced thereby. Presence was almost in a dying state. The presence of a of a small stone detected by the sound after a stone was detected by the sound. Bowels ordered good deal of difficult)-. Chloroform was at to be cleared out by a dose of castor oil. On the once given, and litholapaxy performed. The cal20th November I performed litholapaxy. Consiculus was a very hard oxalate of lime one, and derable difficulty was at first experienced in was lithotrite The 12 weighed only grains. grasping the stone, but once grasped it was easily was stone indeed the : once introduced only crushed, being phosphatic. The fragments crushed in four or five seconds. No. 18 evacuatweighed 235 grains. Time occupied by the withease the catheter with greatest ing passed operation, 23 minutes. Lithotrite introduced out slitting the urethra. The operation lasted 3 times. Evacuating catheter No. 16 used only six minutes. Usual after-treatment. Pa- ; after slitting the floor of the urethra. Usual aftertient was quite well next day, but was not j treatment. 2gth November-. Urine passing allowed to leave Hospital till the 5th November. | freely with slight pains and slight tinge of blood, Case 14.?Wazir Alii, a Mahomedan, aged 35, This j Vomited a good deal yesterday afternoon. shoe-maker by trade, admitted into the MoradaI was controlled by 5 drop doses of dilute hybad Hospital on the 17th November, suffering drocyanic acid every two hours. From this from the usual symptoms of stone in the bladder, time the patient rapidly improved, and was diswhich had lasted 12 years. The man was very charged in good health on the 7th December. thin and worn out from the constant pain, which There was not a bladder symptom present, and 10
days or passed gravel
so.
States that he
frequently
very severe whenever he took exercise of any kind. Presence of a calculus detected by the sound. The patient was allowed to rest
was
for
a
ment was
days, during which preparatory treatwas adopted ; on the 20th November he
few
put under the influence
of chloroform and
The calculus
litholapaxy performed.
was
very
of lime, and the fragments 225 grains. The operation lasted 20 minutes, the lithotrite being introduced four times. No. 16 evacuating catheter was used
hard, of weighed
after
oxalate
slitting
the floor of the urethra.
after-treatment. with Pain
blood, over
castor oil
and
21st some
the
region
one
ouncri
November-.
of the stomach. laudanum
22nd November-. Bowels moved last he is This
quite well to-day and wishes man was discharged in good
tinged
micturition.
pain during and
Usual
Urine
Ordered
drops. night. Says
to
20
go health
home. on
the
25th November. Case
ij.?Futteh,
Mahomedan, aged
both
piles,
the
piles
had
disappeared
This
treatment.
case
without any
made
a
most
special rapid and
wonderful recovery, and well illustrates the great superiority of litholapaxy over lithotomy. The
extremely
man
was
so
pain
and
loss of
blood,
exhausted and
from
the
also from the
hemorrhoidal
complication that I could not lithotomy, and in 10 days after the operation of litholapaxy he left hospital in perfect health. Case 16.? Illahi Buksh, a Mahomedan, aged dream of performing
60 years, resident of Sumbhul in the Moradabad district, was admitted into the Moradabad hos-
pital
on
toms
of
for
11
the
3rd
December with all the sympbladder, which had existed
stone in the
years.
He had suffered and
in the
from
glans penis region frequent and painful micturition,
pain
in the
of the bladder, and
passing
of
blood and pus in the urine. All the symptoms had increased rapidly during the last 3 years. On admission the
patient could only pass urine in drops continuously throughout the day and on the 27th November, suffering fiom painful and difficult night, and the passage of urine was attended micturition, occasional passage of blood and with great pain. The penis and foreskin were mucus. These symptoms had existed for two hypertrophied from the patient's constantly rubHe was also suffering from severe bing the organ to relieve the pain and irritation ; years. a
resident of Moradabad, admitted
40,
THE INDIAN MEDICAL GAZETTE.
32
a
urethral
calculus The
navicularis.
in
felt
was
the
stated that
man
fossa
when he
desired to pass urine he had to rub and pull the penis, and in this way push the urine past the calculus in the urethra. The urine was mixed with pus, and there was a muco-purulent discharge from the urethra. Patient was, as ageneral
rule, constipated, passing only of
ribbon-shaped
fasces
at a
time
times suffered from diarrhoea. into the rectum
finger
felt in the
was
to be
large
a
small
a
On
bladder, which large size.
general health
was
Tne
very bad. He and anaemic, and had a
weak,
anxious The
was
expression, the patient having
result been
some-
passing
and hard
calculus of
a
quantity
but he
:
was
the
tumour
diagnosed patient's very thin
pinched and of long suffering. subjected to pre-
paratory treatment, on the 5th December chloro. form was administered, the floor of the end of the urethra slit up slightly, and the urethral calculus removed by forceps. A sound was then into the
passed calculus
bladder,
the
litholapaxy, and 3^ ounces
operation lasting
66
minutes,
of hard uric acid calculus
removed in that time. be introduced
and the presence of a I then performed
there.
detected
being had
to
times, and after crushing large quantity of debris was removed by the aspirator through a No. 18 evacuating cathetcr. Considerable difficulty was at first experienced in catching the calculus with the lithotrite owing to its large size and the walls of the bladder grasping it tightly. This difficulty was overcome by first injecting at
each
a
ounces
dozen
passing
of water into the the lithotrite.
walls of the bladder calculus and
room
lithotrite allowed. the
a
a
few
then
least
The lithotrite
aspirator
some
were
for After
bladder and
In this way the separated from the
manipulation by each evacuation
water Was left
the
by
behind, and by
this arrangement the larger fragments were easily grasped and disposed of. The calculus was a very and required very severe manual labour in its crushing. After the fragments were com-
hard
one
pletelv removed,the bladder was washed out with weak solution of carbolic acid, a morphia suppository introduced into the rectum, and ten grains
a
[February, 1883.
of quinine administered
patient regained December 5th,
internally
the
as soon as
consciousness.
4. p.m.?Slight fever present. Urine mixed with blood, passing freely and with some pain. Patient taking copious
draughts
of
barley
water and
liquor potassaj.
December 6th.?No fever.
passed without pain purulent deposit.
Urine clear and
; urinal
contains
a
Bladder washed
solution of acetate of lead
muco-
out
with
to 4
(1 grain ounces.) Jth.?Patient much better in every bladder again washed out.
December
way : December St/i.?The
mucus
from the urine
appeared
health much
has almost disGeneral
standing.
on
improved.
From this time the
patient gradually
im-
proved in
general health, and the bladder symptoms disappeared, and on the 15th, when he was
the
discharged,
in my note
following entry
describes his condition :?" Patient
book
now
rid of all the bladder symptoms. Urine quite clear : bladder retains a large quantity at a time. Has grown quite fat and strong : says he has not been so well for several years. This man was a
ten
miserable wretch
days ago, and
on
now
admission to
hospital
leaves it in excellent
health." Case
17.?Sayid Uddin, a Mahomcdan, aged 36, resident of Sumbhul, was admitted into the Moradabad hospital on the 4th December, suffering from the usual symptoms of stone in bladder, which
the
lasted
had
11
months.
The presence of stone was confirmed by the sound. The man was in had health, being very thin and anaemic. this
case on
but I
morning
of the
operating on 5th December,
tired after the manual exertion
was so
required operation At 4 culus
the
I had intended
in Case
16,
that
I had to defer
till the afternoon.of the
l'. M. was a
I
performed litholapaxy.
soft
phosphatic
same
the
day.
The cal-
one, and the debris
grains. The operation lasted only 8 minutes, during which the lithotrite was twice introduced. Evacuating catheter No. 16 was used. This patient recovered without a bad symptom, and wanted to go home on the 8th, as he felt quite well. Discharged on the 13th December.
weighed
120
Case 18.?A Hindoo
broker,
ceased at
resident of Chan-
dausi, aged
35, came to me on the 19th Decemthe usual symptoms of stone in the which had existed four years. All the
ber, with
bladder,
symptoms had much increased 6 months.
where,
This I
but failed
passed to
a
during
the last
had been sounded else-
man
and told that there
bladder.
was
full-sized
detect
stone.
a
no
stone in his
ordinary sound, I then passed
Sir
Henry Thompson's sound, and detected a slight grating sensation behind the prostate by turning the point of the sound in that direction. On the same day chloroform was administered, and a lithotrite introduced. No stone a
could be detected till the end of the lithotrite was
turned towards the prostate, and on openposition, a small calculus
the blades in that
ing
caught and crushed. The debris, which was phosphatic and weighed 45 grains, was removed through an evacuating catheter No. 16. The operation only lasted 5 minutes, the lithotrite being only once introduced. This gentleman was
recovered without
a
allowed to return home Case
symptom, and
bad on
\vas
the 28th December.
Mahomedan, aged p.?Umaid Alii, Sabespore, in the Bijnour district, admitted into the Moradabad hospital on the 26th December, suffering from the usual sympa
1
40, resident of
toms of stone in the 11 or 12
years. had suffered from
bladder, which had existed
Previous
to
their
colic.
kidney
setting in,
The
man
he
was
very weak, and found great difficulty in moving about owing to the pain in the bladder. Pur-
gative ordered. presence
of
a
On the calculus
27th
was
December the
confirmed
sound, and litholapaxy performed. lus
by
the
The calcu-
and the
fragments weighed appeared much larger than it eventually turned out to be. This was probably due to its being ovoid in shape, and being grasped at first by its long was
10
phosphatic,
drachms.
diameter
At first the calculus
between the blades of the lithotrite.
operation lasted 35 minutes, the lithotrite being introduced 4 times. Evacuating catheter No. 16 was the largest used. A considerable portion of this time was occupied in administering artificial respiration, as the breathing The
33
FREYER ON LITHOLAPAXY.
February, 1883.]
;
during the operation. There was a considerable amount of bleeding from the urethra, the mucous membrane of which seemed to have a peculiar hemorrhagic tendency.
one
time
There
was a
considerable admixture of
blood with the urine for the first three
days operation: disappeared completely on the 30th December. The patient suffered from severe fever also for some days after the operation, but on the morning of the 31st December seemed to be quite free from fever. On the evening of that day, however, the patient became extremely violent, singing songs, &c., and I was afraid acute mania was setting in. I ordered a mixture containing grs. xv of Chloral Hydrate and grs. xxx Potass. Bromidi, to be repeated every two hours till sleep should be produced. After the third dose sleep was produced, and all these untoward symptoms had vanished on the 2nd January. I am after the
inclined Cinchona
this
to
attribute these symptom.1: to Febrifuge which the patient
the was
taking. As soon as the symptoms were noticed drug was dropped and Liquor Arscnicalis substituted. The patient is now quite well, and all the bladder symptoms have disappeared. Case 20.?Ram Dutt, a Hindoo male, aged 40, resident of Manoopur in the Moradabad district, came to the hospital on the 31st this
December, 1882, with all the symptoms in the bladder, which had lasted
stone
month.
Patient
draught.
On the
and detected
a
was
1st
ordered
January
small calculus
of one
purgative passed a sound lying behind the a
I
was administered and prostate. litholapaxy performed, the operation only lasting two minutes. The calculus was of oxalate of lime, and weighed only 10 grains. Lithotrite only introduced once, and catheter No. 16 used. The usual after treatment adopted. Patient had slight fever next day, but no other bad symptom has supervened, and he is now well enough to be discharged. Moradabad, 5th January, 1883.
Chloroform
