ON URETHRAL LITHOTRITY.
By
Dr. Cahours
{Paris).
for 1870, (p. 178), Dr. Cahours reports several cases of urethral calculus occurring iu the practice of Dr. Amussat (Junior). He remarks that the presence of a foreign body in the urethra is usually due to one of three causes. Either it has been introduced from without, it has descended from the bladder from within, or it has been found in situ. In the first case, the diagnosis is easy from the history, except when shame induces an individual, addicted to solitary vice, to conceal from the surgeon the true cause of the accident. Secondly, the foreign body may be impacted gravel which has come down from the kidneys, or else portions of a vesical calculus after lithotrity. In the latter case, the sharp angles of the fragments easily catch in the folds of the urethral mucous membrane, and render their extraction as painful as it is difficult. Lastly, calculous concretions may form in the sinuses of the prostate, and even, according to Louis, in the " cavities communicating with the urethra ; such calculi not coming from the bladder, but being formed of deposits of sediment from the urine." Anatomical peculiarities arrest such foreign bodies usually either in the prostatic portion, the bulbous portion, the usual site of stricture, or the fossa navicularis of the urethra. Case I. ?M. D., aged 46 years, was sent to Dr. Amussat in January 1868, complaining of having some gravel impacted in the urethra for some time past. The patieqt stated that he had suffered from attacks of nephritic colic for years, always followed by the discharge of more or less red gravel. The day after a recent attack, he noticed a foreign body in the urethra, about 5 centimetres (=1'96 inch) down, which he supposed to be a piece of gravel. External examination and the introduction of a bougie proved the patient to be right in his surmise. He was placed in an arm-chair and told to press firmly on the urethra behind the foreign body, which was very moveable. Dr. Amussat then introduced into the urethra a small three bladed forceps, seized and removed a small uric acid concretion, the size of a pea. After this, there was not the slightest difficulty in micturition. Full sized elastic bougies were afterwards In the Gazette des
Hopitaux
easily passed.
In this case a smooth ovoid body was probably arrested in its of the muscular fibres of the passage down the canal, by spasm urethra caused by the actual presence and irritation of the
foreign body.
Case II.?In September 1867, a butcher's-assistant, aged 5S, and very robust, came as out-patient to Dr. Amussat's dispensary, and complained of difficulty in passing water. The urethra was examined with a small bougie, and the presence of a foreign body behind a stricture in the bulbous portion ascertained. Very marked phymosis also was present, and," as a preliminary measure, circumcision was performed. In October, gradual dilatation of the stricture was commenced, but proceeded with very slowly, as the patient, being very poor, could not afford to discontinue his daily work. On the 16th December, the urethra admitted a bougie of 6 millimetres ( = 25- inch) in diameter with ease. Employing the same means as in Case No. I, but with more difficulty, Dr. Amussat extracted a phosphatic calculus, about the size of a pea, but elongated. The stricture was further dilated, and the bladder explored, when a second calculus was found lyinc behind the neck, about the size of a flattened walnut. Dr. Amussat wished to crush this; but as it caused no inconvenience, the patient would not consent, and did not again return to the dispensary. This case was more complicated. ?The mode of origin is easy to imagine : a small piece of gravel is arrested
54
THE INDIAN MEDICAL GAZETTE.
in the dilatation behind the stricture and forms the nucleus for
phosphatic deposits. Being under very favourable conditions for growth, the calculus probably increases rapidly. The instrument used, as in Case No. I, was a forceps with three blades. This is preferable to Hunter's forceps, as, by the opening of the blades, the walls of the urethra are more widely separated, and the calculus can be more securely seized and held. In case he had failed to extract the calculus whole, Dr. Amussat was prepared to crush the stone, with the small urethral lithotrite of Amussat, found in nearly every box of lithotrity instruments. Case III.?In August 1853, a child, aged 10 years, was sent to Dr. Amussat, in whose urethra, eight hours previously, a calculus had become impacted, on a level with the bulb. There The stone was complete obstruction to the passage of urine. could neither be pushed back into the bladder nor extracted with
[Febettaey 2,
1874.
revealed the presence of a stricture at the bulbous portion, and a calcular in the prostatic portion of the urethra. There was also_ extreme phymosi's. Circumcision was first performed on the 11th July, by means of the galvanic cautery, Messrs. Revillout and Maublane assisting at the operation. When the prepuce had cicatrized, gradual dilatation of the stricture wa3 performed by means of gum elastic bougies. By this means the urethra became tolerant of the presence of instruments, and Dr. Amussat was enabled to introduce a lithotrite to crush the stone. The moclus operandi was as follows :?The patient was brought to the edge of the bed, the pelvis slightly raised, the feet on two chairs, and the bladder injected with A small duckwarm water. billed lithotrite was introduced, the stone seized in the prostatic portion of the urethra, and broksuccessive blows with en by Amussat's hammer. The lithotrite was withdrawn full of
Hunter's forceps; Dr. Amussat therefore broke it up in the urethra by means of a straight steel rod with a triangular point guided down to the stone in a small straight canula. Two fragments passed out on the child making water; and a third was extracted by a small curette. This case was more complicated, as the small calibre of the urethra prohibited the use of forceps with two or three blades. The method employed was that of Franco. Case IY.?In June 1869, a young man, aged 18, working as a market gardener, consulted Dr. Amussat for incontinence of urine, diurnal and nocturnal. At the age of six years, he had undergone the operation of lithotrity. Dr. Guersant in nine sittings had crushed and got rid of a stone of considerable size. Since then the patient had enjoyed good health. In 1S67 he suffered from pain in the scrotum while walking, and also noticed that his urine did not flow freely. In January 1869, he suffered from constipation, and noticed that on straining at the stool, a few drops of blood passed from the urethra. Shortly after this, nocturnal incontinence of urine supervened, followed a little later by diurnal incontinence.
detritus. This and on
process was repeated, making water the patient a quantity of debris. passed Judging by the separation of the blades, the stone must have had a diameter of 1 centimetre ( ?39 inch). No blood was lost during or after the operation. =
After
treatment consisted of bath, rest in bed, and light food. No bad symptoms followed and the remains of the calculus passed out with the urine. The patient was able to hold his water from the moment that the last fragments were ejected. Three subsequent explorations of both urethra and bladder proved the absence of any other a
warm
foreign body.
Dr. Cahours concludes by rethe above methods of extraction in preference to on the foreign down cutting bodies impacted in the urethra and removing them by the periHe also calls attention neum.
commending
A. Amussat's hammer. Amussat's
Amnssat's Amussat'.s duck-bill lithotrite. small sound with a bulbous introducing into the bladder aa small point, a scratching sensation was felt; and careful examination On
to the small duck-billed lithotrite of Amussat, ?which is ly adapted to operations within the urethra.
peculiar*
Charles H. Joubeert M.B., F.R.C.S., Assistant Surgeon, 17th Native Infantry.
By
Dr. Cahours
{Paris).
for 1870, (p. 178), Dr. Cahours reports several cases of urethral calculus occurring iu the practice of Dr. Amussat (Junior). He remarks that the presence of a foreign body in the urethra is usually due to one of three causes. Either it has been introduced from without, it has descended from the bladder from within, or it has been found in situ. In the first case, the diagnosis is easy from the history, except when shame induces an individual, addicted to solitary vice, to conceal from the surgeon the true cause of the accident. Secondly, the foreign body may be impacted gravel which has come down from the kidneys, or else portions of a vesical calculus after lithotrity. In the latter case, the sharp angles of the fragments easily catch in the folds of the urethral mucous membrane, and render their extraction as painful as it is difficult. Lastly, calculous concretions may form in the sinuses of the prostate, and even, according to Louis, in the " cavities communicating with the urethra ; such calculi not coming from the bladder, but being formed of deposits of sediment from the urine." Anatomical peculiarities arrest such foreign bodies usually either in the prostatic portion, the bulbous portion, the usual site of stricture, or the fossa navicularis of the urethra. Case I. ?M. D., aged 46 years, was sent to Dr. Amussat in January 1868, complaining of having some gravel impacted in the urethra for some time past. The patieqt stated that he had suffered from attacks of nephritic colic for years, always followed by the discharge of more or less red gravel. The day after a recent attack, he noticed a foreign body in the urethra, about 5 centimetres (=1'96 inch) down, which he supposed to be a piece of gravel. External examination and the introduction of a bougie proved the patient to be right in his surmise. He was placed in an arm-chair and told to press firmly on the urethra behind the foreign body, which was very moveable. Dr. Amussat then introduced into the urethra a small three bladed forceps, seized and removed a small uric acid concretion, the size of a pea. After this, there was not the slightest difficulty in micturition. Full sized elastic bougies were afterwards In the Gazette des
Hopitaux
easily passed.
In this case a smooth ovoid body was probably arrested in its of the muscular fibres of the passage down the canal, by spasm urethra caused by the actual presence and irritation of the
foreign body.
Case II.?In September 1867, a butcher's-assistant, aged 5S, and very robust, came as out-patient to Dr. Amussat's dispensary, and complained of difficulty in passing water. The urethra was examined with a small bougie, and the presence of a foreign body behind a stricture in the bulbous portion ascertained. Very marked phymosis also was present, and," as a preliminary measure, circumcision was performed. In October, gradual dilatation of the stricture was commenced, but proceeded with very slowly, as the patient, being very poor, could not afford to discontinue his daily work. On the 16th December, the urethra admitted a bougie of 6 millimetres ( = 25- inch) in diameter with ease. Employing the same means as in Case No. I, but with more difficulty, Dr. Amussat extracted a phosphatic calculus, about the size of a pea, but elongated. The stricture was further dilated, and the bladder explored, when a second calculus was found lyinc behind the neck, about the size of a flattened walnut. Dr. Amussat wished to crush this; but as it caused no inconvenience, the patient would not consent, and did not again return to the dispensary. This case was more complicated. ?The mode of origin is easy to imagine : a small piece of gravel is arrested
54
THE INDIAN MEDICAL GAZETTE.
in the dilatation behind the stricture and forms the nucleus for
phosphatic deposits. Being under very favourable conditions for growth, the calculus probably increases rapidly. The instrument used, as in Case No. I, was a forceps with three blades. This is preferable to Hunter's forceps, as, by the opening of the blades, the walls of the urethra are more widely separated, and the calculus can be more securely seized and held. In case he had failed to extract the calculus whole, Dr. Amussat was prepared to crush the stone, with the small urethral lithotrite of Amussat, found in nearly every box of lithotrity instruments. Case III.?In August 1853, a child, aged 10 years, was sent to Dr. Amussat, in whose urethra, eight hours previously, a calculus had become impacted, on a level with the bulb. There The stone was complete obstruction to the passage of urine. could neither be pushed back into the bladder nor extracted with
[Febettaey 2,
1874.
revealed the presence of a stricture at the bulbous portion, and a calcular in the prostatic portion of the urethra. There was also_ extreme phymosi's. Circumcision was first performed on the 11th July, by means of the galvanic cautery, Messrs. Revillout and Maublane assisting at the operation. When the prepuce had cicatrized, gradual dilatation of the stricture wa3 performed by means of gum elastic bougies. By this means the urethra became tolerant of the presence of instruments, and Dr. Amussat was enabled to introduce a lithotrite to crush the stone. The moclus operandi was as follows :?The patient was brought to the edge of the bed, the pelvis slightly raised, the feet on two chairs, and the bladder injected with A small duckwarm water. billed lithotrite was introduced, the stone seized in the prostatic portion of the urethra, and broksuccessive blows with en by Amussat's hammer. The lithotrite was withdrawn full of
Hunter's forceps; Dr. Amussat therefore broke it up in the urethra by means of a straight steel rod with a triangular point guided down to the stone in a small straight canula. Two fragments passed out on the child making water; and a third was extracted by a small curette. This case was more complicated, as the small calibre of the urethra prohibited the use of forceps with two or three blades. The method employed was that of Franco. Case IY.?In June 1869, a young man, aged 18, working as a market gardener, consulted Dr. Amussat for incontinence of urine, diurnal and nocturnal. At the age of six years, he had undergone the operation of lithotrity. Dr. Guersant in nine sittings had crushed and got rid of a stone of considerable size. Since then the patient had enjoyed good health. In 1S67 he suffered from pain in the scrotum while walking, and also noticed that his urine did not flow freely. In January 1869, he suffered from constipation, and noticed that on straining at the stool, a few drops of blood passed from the urethra. Shortly after this, nocturnal incontinence of urine supervened, followed a little later by diurnal incontinence.
detritus. This and on
process was repeated, making water the patient a quantity of debris. passed Judging by the separation of the blades, the stone must have had a diameter of 1 centimetre ( ?39 inch). No blood was lost during or after the operation. =
After
treatment consisted of bath, rest in bed, and light food. No bad symptoms followed and the remains of the calculus passed out with the urine. The patient was able to hold his water from the moment that the last fragments were ejected. Three subsequent explorations of both urethra and bladder proved the absence of any other a
warm
foreign body.
Dr. Cahours concludes by rethe above methods of extraction in preference to on the foreign down cutting bodies impacted in the urethra and removing them by the periHe also calls attention neum.
commending
A. Amussat's hammer. Amussat's
Amnssat's Amussat'.s duck-bill lithotrite. small sound with a bulbous introducing into the bladder aa small point, a scratching sensation was felt; and careful examination On
to the small duck-billed lithotrite of Amussat, ?which is ly adapted to operations within the urethra.
peculiar*
Charles H. Joubeert M.B., F.R.C.S., Assistant Surgeon, 17th Native Infantry.
