March, 1884.]
-
FREYER ON LITHOLAPAXY.
-
ORIGINAL COMMUNICATIONS.
the stone
size, grasped,
was so
61
extremely hard no impression cut successfully.
that the instrument could make
A FURTHER SERIES OF 57 CASES OF DUR-
PERFORMED
LITHOLAPAXY
ING THE YEAR 1883. By Surgeon P.
J.
Freyer, a.m., m.d.,
Bengal Medical Service, Civil In
the
Surgeon,
Moradabad. Indian
number of the
December
Medical Gazette of 1882 and the
February
number of 1883 two papers of mine appeared on my first twenty cases of litholapaxy. These cases represented my experience of the operation up to the end of 1882. During the year 1883 I performed litholapaxy in 57cases, and in the present paper I propose reviewing these, and making some further practical observations which increased
experience
of
the
operation
has taught me. My previous papers contain a detailed account of each of the twenty' cases, with the mode of
In the present article I shall give in detail only a few of the most important cases,? pursued.
those which differ from the ordinary or
which illustrate
particularly to reader?adding,
some
direct
point
the
to which I wish
cessfully operated
on
giving
connected
cases
of stone were were
came cases suc-
by urethrotomy. There or boys under were all operated on by death. In the remaining
in male children
the age of 15, these lithotomy, with one 61 cases, all of which occurred in adult males with the exception of 3 instances in female
children, litholapaxy
was
attempted
;
but, for
various reasons, in four of the cases the operation could not be performed. In two of these cases the calculous disorder was complicated
by
case
paper, so that it may be clearly understood that the operation of litholapaxy was given a fair
trial, having been performed in every possible instance in the adult without reference to age, state of
It is in this way true estimate of the value of the
only that a operation can be obtained, not by a selection of particular I have to add that of the lithotomy and cases. urethrotomy cases sixteen were operated on by my Assistant-Surgeon, Jawala Pershad, an ex&c.
health,
cellent lithotomist.
Turning
to the immediate
subject of the append-
now
this paper, it will be observed from ed table that amongst the 57 cases of litholapaxy two deaths only occurred. These two cases
are
given
in
detail in the
sequel.
In
Case 24, death resulted from peritonitis, evidently by extension of inflammation from the neck It is difficult to say whether due to the operation or to the impac-
of the bladder. this
under my observation. Of these 6 of urethral calculus, all of which were 40 cases
of the
table
appendix, important points a
with each of the 57 cases. During the year 107
of cases,
attention
as an
some of the most
run
cases were
the calculus was exremaining tremely large and hard, weighing over twelve This was removed by the supra-pubic ounces. operation, the patient dying six hours afterwards from exhaustion. I have thought it advisable to mention the foregoing facts preliminary to entering on the immediate subject of this In the
and after-treatment
operating
These three
it.
on
was
tion of the calculus at the neck of the bladder and force necessary to ed to think the latter no
difficulty
in the
the calculus
only
displace
was
the
I
it.
cause.
performance
am
inclin-
There
was
of the operation,
very small and the operation lasted 8 minutes. The bladder was healthy
except
was
at the
neck, where the calculus had lain days. The kidneys also were probable that the calculus, forced
for two
impacted healthy. It is on by the accumulation of urine and efforts to empty the bladder, acted as an irritant to the mucous membrane, thereby causing inflammawhich was no doubt increased tion, by the force
stricture of the urethra, so that the smallest lithotrite would not pass into the bladder; and in one instance, the lithotrite was
necessary to return the calculus into the bladder. In case 44, the cause of death was pyaemia, the
passed and
and caused
severe
though the calculus, which
was
of moderate
result of
cystitis supervening
by
on
the irritation of
a
the
operation, large fragment
62
THE INDIAN MEDICAL GAZETTE,
of calculus which it the first
move at
This last
found
was
impossible
to
re-
sitting. teaches
case
us
that in lasted tion
of the
several
was
prolonged
to
an
the
operation
one case
the opera-
cases
hour ; and in
over an
a
which I
on
a
hour and
half, 1,015 being success-
of hard uric acid calculus
grains fully removed.
operation
The essential
to be lost
one
of
sight
in
a
even
of the
removal of
complete sitting. This fact by some operators,
have noticed in accounts of their cond and
a
principle
consists in the
the calculus at
"
third
cases
sitting "_was
of their
seems
that
for I a
se-
necessary
An
operation large proportion prolonged over several sittings" in this way involves all the dangers attending the old operation of lithotrity. It will be noticed that large calculi were removed successfully by litholapaxy from three patients aged 85, and in case 69, full details of drachms of a very hard uric which follow, acid calculcus were removed from a patient aged 96, the operation lasting one hour, with complete success. It is wonderful how well very old patients stand the operation, and I have noticed that in them the operation is less likely to be attended by urethral fever than in the a
cases.
"
of young and strong men. In fact my experience is, that the older the patient the greater case
is the
compared
with
Case 30 is neous
from
litholapaxy
as
lithotomy.
as
a
far
as
occurring
quacks stone
success
remarkable instance of spontadisintegration of a calculus in the bladder,
and is, case
of
prospect
who
by
I
am
in the
profess
In
aspirator.
a
previous
article
alluded to the great value of Sir Thompson's sound in detecting small cal-
of mine I
practical lesson point strongly insisted in a the importance of reprevious article, namely, moving the whole of the calculus at one sitting, no matter how long the operation may take. A reference to the appended table will show on
of the
means
[March, 1884.
aware,
unique. of
be
a
of those
able to
dissolve
practice to
Such
one
the internal administration of secret
remedies would certainly be the
means
of mak-
ing his fortune, had the urethral orifice been sufficiently large to permit the fragments to pass out. In case 54, a new method of diagnosis of stone in the bladder is indicated, namely, by
Henry
ordinary sounds fail to bring to notice. I find from experience, however,that, even with the aid of Sir Henry Thompson's sound, we may fail to detect a small calculus lying in some peculiar position in the bladder. In the case referred to a most careful search was made by means of sounds of various kinds, but no calculus could be detected till the aspirator was employed, when a distinct click was at once felt during exhaustion of the water from the bladder, and due to the calculus being carried with force against the eye of the canula by the outward The sound of the fragments clicking stream. against the eye of the canula during the evacuation of the fragments of a calculus in the operation of litholapaxy suggested this mode of diagnosis, and I am now in the habit of having which the
culi,
are
it when
the symptoms of stone well marked and the sound fails to detect to
recourse
the presence of one in the bladder. Not only may the aspirator be employed with
advantage for diagnostic purposes, but, as illustrated by case 76, it may be used for the evacuation of a calculus entire, when the calculus is very small, without the aid of any crushing instrument whatever.
plated
the
I had for some time contem-
of
possibility
removing
a
small
calculus in this way, but this was the earliest instance in which an opportunity presented itself of
my idea to
practical test. Since then, 5th January last, I had a similar case, in which a calculus weighing 13 grains was removed by means of the aspirator and canula alone and with similar success, the patient having gone to his work the day after the operation, and having suffered no inconvenience whatever. Sir Henry Thompson objects to the word litholapaxy," employed by Bigelow for the operation invented by him, and suggests "lithotrity at one sitting" as a more suitable name. It is putting on
a
the
"
obvious thatt his latter
name cannot
the two cases just referred to, as there
ing
whatever
which
means
practised,
whereas
"
evacuation of stone, is
be
applied
was no
to
crush-
litholapaxy," applicable.
March, 1884.] It
will
table that
instances 4 years
be
FREYER ON LITHOLAPAXY.
observed
litholapaxy in
female
respectively.
was
appended
the
from
in
three
aged
about
performed
children,
given only
I have
one
of
results
55, in detail. Similar good followed in the others. There was no real dilatation of the urethra necessary and no disturb-
these,
case
of the part. There was no incontinence that urine, that filthy and disgusting sequel dilataby results from the
litholapaxy,
63
in skilful
hands, involves practically
danger than the passage of a catheter. only to the reduction of mortality that litholapaxy can claim is the comparatively short time in hospital which the operation involves and -a disease which formerly required weeks of no
more
Second
and confinement to bed for its cure, is disposed of in as many days. As yet no
suffering
ance
now
of
instruments have been invented
operation
frequently
tion, and which would marriage,?a matter
an
effective bar
prove which amongst
to
natives
Japaxy
can
be
performed
with
by which safety in
lithomales
below the age of puberty, but in such cases lithotomy should be, as a rule, successful. With
importance than the litholapaxy in the adult male and females inconvenience caused by the dribbling of urine. of all ages, and lithotomy in males below Illustrative of the extraodinary ideas natives the age of puberty, the mortality from operasometimes get into their heads about surgical tions for stone should be comparatively very
would be considered of more
operations, I may mention that some of my small. Case 24..?Bholoo, a Mahomedan male aged patients at first objected to the new operation of litholapaxy, on the ground that, though they 48, admitted into the Moradabad Civil Hospital should get rid of the culculous disease, permanent
impotence
of the
of
on
9th January with retention of urine which existed 36 hours. Had suffered from the
the
I have had the had this pointof several usual symptoms of stone in the bladder for Much exhausted, with pinched seen at varying nine months.
would result !
curiosity tomake enquiries
on
litholapaxy, subjects intervals after the operation, and
1 need
scarcely anxious expression
of face.
On
passing
a
full-
add that there were no grounds whatever for the sized catheter a small calculus was detected at ridiculous idea referred to. On the contrary, the neck of the bladder, blocking up the passage. This was pushed back with considerable force an old gentleman of 55 informed me that in virile and the retention of urine relieved by the cathepower as in other respects he felt twenty years i The patient was anaesthetised and litholater. younger than before the operation was performed. | The operation only In concluding these remarks I cannot speak paxy at once performed. 8 minutes, the lithotrite being only once I in terms of too high praise of Bigelow's operation. lasted calculus weighed only 20 grains. % its introduction the operative surgery ofintroduced. The catheter No. 18 passed easily without slitting stone has truly been revolutionised, and the the urethra. removal of calculus, which was regarded as January 10th.?Passed very little urine since a hazardous operation in the adult and extremeof pain in the region of ly dangerous in old age, is now, thanks to theyesterday. Complains the; bladder, catheter parsed and a small quannew operation, shorn of most of its perils. of urine drawn off. Hot fomentations to I have now, at the time of writing, com-tity the hypogastrium with hot poultices ordered, pleted seventy-nine cases of litholapaxy, of also 1 grain of opium internally every 3 hours. which 76 were in adult male and 3 in female 11th.?Well-marked peritonitis prechildren. Amongst these only 3 deaths occur- January sent. Temperature 102? F. Respirations 44 per red, all the others having been completely sucminute. No urine passed: drawn off by cessful. Compare this result with the mortacatheter twice daily. lity of 1 in 4 or 5 from lithotomy in the adult, January 12th.? Pain less. Passed about two acknowledged to be the average by the greatest ounces of urine without the use of the catheter ; lithotomists ! It is no exaggeration to say that stool, black in colour. of when the calculus is very small the operation scanty
THE INDIAN MEDICAL GAZETTE.
64
January 13th.?No pain
great distension of
:
the abdomen, which is very distressing. Patient very weak. Passsd 4 ounces of urine without the catheter.
Died
quietly in the evening. January 14th.?Post-mortem examination.? On opening the abdominal cavity it was^ found distended with clear was
embedded in
of amber-coloured
mass
a
The bladder
fluid.
serous
which broke like cold
gelatinous lymph, on application of the fingers. Congestion
of the
cellular tissue at the base and
of the
neck'
bladder.
The
thra
the neck of the bladder
near
membrane of the
mucous
inflamed, presenting
jelly
a
dark
was
ure-
highly
red
appearance. of the bladder, and
There
was no congestion kidneys were healthy. Case 30.?Jehan Khan, a Mahomedan, aged 35, resident of the Terai, admitted 19th March
the
with the usual symptoms of stone, which had existed years. Thirteen days previous to admission all the symptoms became aggravated, since which date urine had
suddenly only been On plac-
passed with great difficulty in drops. ing the patient on the operating table with a view to passing the sound, I noticed an elongated hard thickening along the course of the urethra, and my first impression was that there was a severe stricture. Dr. Moran, 6th N. I., who kindly assisted me at the operation, remarked that the feeling was like that of urethral calculus, and on passing the sound, his idea was proved to be correct. The floor of the meatus was
slit up and
no
less than
debris of calculus removed
by
one
drachm of
urethral
forceps
small scoop. The whole length of the urethra was filled with pulverised calculus. A
and
a
sound
was
then
the bladder.
passed
and
fragments
The lithotrite
was
detected in
introduced and
litholapaxy performed. The fragments removed from the bladder weighed 125 grains, exclusive of 60 grains from the urethra : No. 16 catheter was used. On inspection of the fragments it was evident that they belonged to one large phosphatic calculus, not of several small The patient recovered without a bad ones. symptom, and was discharged on the 27th March,
[March, 1884.
33.?Daiby Dass, a Hindoo, aged 50 hospital on the 7th April with the usual symptoms of stone, the most prominent of which was excruciating pain in walking and during micturition. The symptoms had existed two years. On the 12th April I performed and had the honor of doing the litholapaxy, operation in the presence of Surgeon-General Case
camc
to
W. Walker. The urethral orifice so
its base
was
ed in
slightly
slit up
Considerable
director.
passing
was
by difficulty
very narrow, the scalpel on a
experiencowing partly in the
was
the lithotrite into the bladder
to the calculus
lying
close
to
and
The stone was, however,, and crushed. The calculus was
neck of the urethra. soon
grasped
very hard, composed of oxalate of debris weighed just one ounce. The
lime, and the operation oc-
45 minutes, a long time for this size of stone ; but only No. 16 catheter could be
cupied
passed, and, owing urethra
at
siderable the
the
to the
neck
of
manipulation through
instruments
irregularity
of the
the
was
bladder, required to
this
part
of
con-
pass the
canal.
April \3tJ1.?Passed some blood with the urine last evening. Urine clear this morning. Slight fever present. April 14th.?Patient doing well ; no fever. Urine passing freely and clear. The man made cured on a rapid recovery and was discharged the 20th April. Case jj.?Emam Bux, aMahomedan, aged 85, resident of Chandausi, came to hospital on the 13th April with symptoms of stone, which had existed two years. The man was extremely feeble, emaciated, and almost in a dying state. There was great enlargement of the prostate, owing to which the bladder was never completely emptied after micturition, which was very painful. A calculus was detected by the sound. On the 15th April I performed litholapaxy, removing 6^ drachms of hard uric acid calculus, the operation lasting 20 minutes. April 16th.?Urine only passed by means of catheter, which is used every 6 hours. Had high fever last evening, which is much less this morninCf.
March, 1884.]
dribbles away when the
April iSth.?Urine bladder
Fever
gets half full.
patient
gone:
stronger. April 19th.?On passing the catheter it grated against a fragment of stone. Chloroform administered and the fragment crushed and removed by the aspirator : weighed 40 grains. April 21st.?Much better. Urine clear, but still drawn off by catheter. are
being
bladder
Quinine
and belladonna
for the atony of the The patient now rapidly
administered
that exists.
April could pass urine without the use of the catheter, though, owing to the great enlargement of the prostate, the bladder could not be completely emptied by regained strength,
and
by
the 26th
the natural effort. The man was able to walkabout the hospital, and his generaj health had
greatly improved.
As
there
were
no
urinary
symptoms except those due to the enlarged prostate, which will permanently remain, he was allowed to go home. Case
39.?This was hillman, a
A young
aged 32,
came
to
a
in
private practice. Ramnugger, 25th April complain-
case
zemindar of
me on
the
ing
of the usual symptoms of stone which had existed one year. Had passed gravel previous-
ly.
On the 28th
April I performed litholapaxy, removing grains of uric acid calculus in 12 minutes. Not a drop of blood was lost the during operation, No. 16 catheter passing easily. April 29th.?Patient has high fever with delirium : stomach wont retain any food. Order160
ed fever mixture
and
epigastrium
calves of
and
mustard
plasters
to the
Patient
was legs. day and gradually improved. go home on the 2nd May quite
much better next
Was allowed well.
to
I have since had several letters from him
and he has not suffered from any tom since the
urinary
symp-
operation. 42.?Jaffir, a Mahomedan, aged 45, came hospital on the 18th May suffering from the
Case to
usual symptoms of stone, which had existed several The man was thin but in years. fair health : slight trace of albumen in the
urine. ation
65
FREYER ON LITHOLAPAXY.
.
Litholapaxy was performed, the operlasting one hour and ten minutes, two
and-a-half culus and
of
ounces
removed.
being catching
the stone,
blades would not close
stone,
that I
so
extremely
On
passing
it
was
owing
er
found that the
to the size of the
operation By manipulation,
the calculus
was
grasped across
axis and
was
eventually crushed. extremely hard, composed of
bonate
with
an
cal-
afraid the crushing
was
would have to be abandoned.
however,
hard
the lithotrite
oxalate of lime
a
short-
The calculus calcium
nucleus,
car-
and
resembled white marble in appearance. No. 16 catheter was the largest that would pass easily, fact that retarded the
a
blood
was
lost
operation; not a drop of during the operation. This
patient recovered without a bad symptom, and discharged cured on the 29th May. Case 44..?Nihal, a Hindu, aged 45, admitted 23rd May with symptoms of stone, the most prominent of which were agonising pain in the region of the bladder and passing of blood and
was
pus with the urine. The symptoms had existed 8 years, and the patient was in very bad health. A
large
calculus
detected
was
I
On the
by the sound. performed litholapaxy. experienced owing to
25th May difficulty was the large size and hardness of the stone and the operation progressed very slowly, 14 drachms being removed in 75 minutes. No more fragments could be detected by the lithotrite, but on passing a sound a large fragment was deGreat
high up at the fundus of the bladder. As the patient was very much exhausted I was afraid to keep him longer under chloroform, so I had, unwillingly, to postpone the completion of the operation for another day. The usual tected
after-treatment Mav 26th.
was
ordered.
Had great
pain
in the
region
of
the bladder all
yesterday, which was controlled grain opium administered every 3 hours. Urine scanty and blood-stained. Temp. I04?F.; great thirst. Fever mixture ordered and opium
by
1
continued.
rigor last evening. Fever continued till midnight; patient anxious and depressed. Ten grains of quinine ordered ; to be repeated in the evening. No pain in abdomen, but great pain in the left hip. May 2/th.?Had
a
severe
THE INDIAN MEDICAL GAZETTE.
66
presence quite normal in appearance. There was no incontinence of urine. Discharged on
in left hip ; all May 28th.?Abscess forming the symptoms of blood poisoning present.
Carbonate of ammonia
Patient died at
ordered.
the
14th August.
Case 68.?Oomaida,
10 P.M.
examination.? Walls
of
the
greatly thickened, sacculated
and
con-
Post-mortem
bladder
bark
and
[March, 1884.
-
resident of
Rampur,
Hindoo
a
to
came
male, aged hospital on
55, the
the usual symptoms of stone, which had existed 6 months. On the 26th October 1 performed litholapaxy in pre20th October
Large fragment of calculus, about one ounce in weight, in a sacculum at the fundus of the bladder ; several small patches of inflammation in the mucous membrane in the vicinity of the fragment of stone. Some milky looking
tracted.
suffering from
Sanitary Commissioner, Dr. Planck. operation lasted 34 minutes, the calculus It was of was very tough, and hard to crush. the mixed variety, and the debris weighed one urine in the bladder. The tissues of the left ounce and 35 grains. Catheter No. 18 passed gluteal region and round the hip joint swollen easily without slitting the floor of the orifice of and infiltrated with dark red fluid. Cause of the urethra. Next day the patient was walking death, pyaemia. 1 aboutthe hospital as if no operation had been perCase 34.?On the 1st of August a Hindoo, aged 50, came to hospital with symptoms of stone, formed. On the 30th October, the day on which the most marked of which were sudden stoppage j the man was discharged, he presented himself at of the
sence
The
!
of the flow of urine and increased
micturition. After
a
most careful
various
the bladder
by Henry Thompson's, no
frequency exploration
sounds, including
of of
Sir
calculus could be detect-
I felt certain, however, from the symptoms was a small stone present, and deter-
ed.
that there
mined of
to
employ
the
aspirator
I introduced
diagnosis.
a
for the purpose No. 14 catheter
Dr. Planck's camp. Dr. Planck was very much by the rapidity of the cure, having seen
struck the
operated on only 4 days before. patient was in high spirits, and gave us an amusing account of the expedients he had man
The
to in order to
recourse
operation. then
his
on
used
belly,
sometimes
aspirator. After going through performance of pumping water into the bladder and exhausting it once or twice, a distinct click was heard. The catheter was withdrawn, the lithotrite introduced, the calculus and crushed. The fragments weighed
legs in the air, and could not pass water !
applied
the
the
to
on
side and
one
the other, but frequently without avail. When these positions failed to give him relief> then
and
pass urine before the lie on his back,
He
on
he had
recourse
to
standing
his
Case
69.?This
on
his head
then he
even
with
frequently
in
private practice, sake, was perday walking only 11 grains. about quite well, and was discharged on the 4th formed at the Civil Hospital. The patient, a Mahomedan of Moradabad, stated that he was August. on 100 years of age, and by calculacase was close that of a Hindoo Case 55 ?This seem to be 96. He was a driedgirl, aged 4^ years, who had been suffering with tion he would
grasped
the
Next
symptoms
man
A up, withered old creature, without a tooth in his On the head, and consisting almost of skin and bone.
of stone almost from her birth.
by the sound. 1 oth August performed litholapaxy, the urethra being dilated, merely sufficiently to allow calculus
detected
was
I
the
lithotrite
calculus,
to
which
grains. No. 14 operation only
The debris of pass. uric acid, weighed
was
catheter lasted
8
girl was running quite well, and passed
the
was a case
but the operation, for convenience
was
was
used, and
minutes. about urine
the
Next
sons were
in
attendance,
and
one
of them looked about 70 years of age. Till the about a month before coming under my treatment 86 he had
enjoyed good health,
the about the bazaar
day hospital
in my
Several of his
daily.
and used
to walk
Since then he has had
symptoms of stone, especially great pain in passing urine. He was very weak and unable
own to
leave his bed.
A
large
calculus
was
detected
March, 1884.] by
VENERAL DISEASE IN THE EUROPEAN ARMY.
On the 28th October I
the sound.
performed
The calculus, the debris of which
litholapaxy.
9 drachms and 35 grains, was very hard, consisting of uric acid. The operation lasted
weighed
hour, great difficulty having been experigrasping the last fragments. October 29th.?No fever. No urine passed since the operation : 3 ounces drawn off by the
one
enced in
catheter.
30th.?Passing
urine with considerable
No fever.
$ist.?Urine passing freely.
passing freely.
November 2nd.?Urine clear and
Patient
much
Walking tion
:
improved, sitting
about the house ;
urine
quite
no
pain.
up in bed. 6th.? pain in micturi-
clear.
November \$th.? Patient quite well; able walk about.
walking
about
troubled by Case
I have since
no
the
Ihe old
seen
of
to
man
Moradabad and
city urinary symptom.
76.?Gholam Hussain,
Mahomedan,
a
aged 5?> Warder in the Moradabad Jail, had been passing gravel for years, but suffered no
inconvenience
during
till
within the last 3
which he had
months,
stoppage of
occasional
water. On the 26th December he had retention of urine, which the Native Doctor relieved the passage of a catheter. On the 27th he again had retention, when he came to me. I and on my arrisent him to the Civil
by
Hospital,
val there put him at once under the influence of chloroform and passed a No. 18 evacuating
catheter with the greatest
ease.
The
aspirator
then applied and the click of the calculus distinctly heard as, with each successive exhaustion of the water, it was carried to the eye of the catheter. The catheter was suddenly withwas
drawn during 'exhaustion,' carrying the calculus with it in its eye. The calculus was uiic
acid, elongated
and oval in
shape,
15 grains. The man went to j ail next day, quite well, and no
unpleasant symptoms. Moradabad,
8th Feb. 1884.
and
weighed
his work
having
at the
suffered
67,
f
..
.'
S3
showing particulars of Litholapaxy on daring 1883, By Surgeon P.
No.
Name.
Date of
Operation.
21
Mohun
1st
22
Kulloo
23 24
Sawanthy
3rd
25
Madari
27 28
Bhaloo
Najjoo Gopi Nath
9th 17th 17th
19th 22nd
18
?
35
?
50
M M M M M M M M M M M M M
?
85
M
January
6th
Age. Sex.
?
55
?
41
?
48
?
Feb. ?
32 17 40 40
33
Ditto Jai Sukh' Jehan Khan Jai Lall Goord Sahoy Daby Dass
34
Emam Bux
I5th
35
Sookha
36
Nihal Ali Shah Kullon Ditto Kunna
M 20th 65 M ,, 2ISt 40 M ,, 36 M 24th ,, 28th 52 M ? 50 M 27th ,, 16 M Sth May 18th 45 M ? 17 M 19th ,, 45 M 25th >> 28th 19 M ,, 35 M 3rd June Sth 65 M ? 21st 85 M ,, 36 M 24 th ? 55 M 3rd July 8th 65 M ? 10th 65 M ,, 18 M 27th ? 1st August 50 M 10th ,, 4^ F 12 th ,, 85 M 65 M 14th ? 22nd 3o M ,, 32 Ai 23rd ,, 60 M 24th ? 25th ? 45 M 3rd Sept. 50 M 16th 36 M ,, 16th 42 M ,, 20th ,, 3h F F 2nd Oct. 4 65 M 15th ? 26th ? 55 M 28th 96 M ,, 80 M 21st Nov. 50 M 4th Dec. I 35 M 5th ? nth ? 50 M 13th ,, | 60 M 26 M 14th 45 M 27th
29 30 31 32
37
38 39 40 41 42 43 44 45
Choonu
Jaffir
59 60 61 62
Toolsia N ihal Mai la Kareem Ali Mooni Ram Kalloo (junga Ram Mull 00 Goor Buksh Bhola Nath Bhalloo Hatim Sing Sundria Md. Hussain Kaieem Kuksh Mohurthan Allum Oollah Ditto Khaili M agia
63 64 65
Budha Ditto
46 47
4S 49 5? 51 52
53 54 55
56 57
58
Rohmi
66
Haheebun
67
Nihal Oomaida Ditto Kayam Ali Mokarul
68
69 70 71 72 73 74 75
76
''
j
THE INDIAN MEDICAL GAZETTE.
Table
26
'1
?
Soojan
Fuzal Hussain Poosa Luchman Ghulam Hussain
5th.
19th'
,,
March. ,,
4th April
12th 12th
16th
,,
46 35 32
J. FREYER,
Weight 6 % 2 =
Variety.
50 grains. 995
Uric.
540 340
Oxalate. Uric. Oxalate. Uric
!75
Phosphate.
120
Uric.
i85
Phosphate.
35 480
( 400 + 40 80 240 140
)?
Uric.
20
3} 5
36 20
5 12 20
Oxalate. 195 2/4 Ozs. Carb of Lime. i
40
1
S40
Uric. Oxalate.
520
Phosphate.
ns.
12
U ric.
12
70 7
75
Died.
14 6
Successful.
870
Oxalate.
35
540 750
Uric.
20
57
ICO
310
12 10
| j
Oxalate, Uric.
10
6
25 2
86
8
824 804
55 56 35
340 19 270
Phosphate.
Uric.
10
5
32
146 90
10
3o
I25 206
Phosphate. Uric.
Phosphate.
10 20
15
57
10
85
5 34 60
5i5 575 1,015
Uric.
85
Phosphate.
90 6
165
Phosphate.
3 8
11
106
155 15
Died. Successful.
20
35 6
33o
90 66
Successful.
10
45
5J
160
8
35 25 25
Uric.
Phosphate.
10
minutes.
5
Oxalate. Uric.
=4+o
10
Result
25
1*
39o
occupied by Operation.
25
J5
130
14 18
operated
Time
of
15
55
cases
m.d.
Calculus.
20
I
[March, 1884.
J5
Uric.
10 20
Uric.
1
-
FREYER ON LITHOLAPAXY.
-
ORIGINAL COMMUNICATIONS.
the stone
size, grasped,
was so
61
extremely hard no impression cut successfully.
that the instrument could make
A FURTHER SERIES OF 57 CASES OF DUR-
PERFORMED
LITHOLAPAXY
ING THE YEAR 1883. By Surgeon P.
J.
Freyer, a.m., m.d.,
Bengal Medical Service, Civil In
the
Surgeon,
Moradabad. Indian
number of the
December
Medical Gazette of 1882 and the
February
number of 1883 two papers of mine appeared on my first twenty cases of litholapaxy. These cases represented my experience of the operation up to the end of 1882. During the year 1883 I performed litholapaxy in 57cases, and in the present paper I propose reviewing these, and making some further practical observations which increased
experience
of
the
operation
has taught me. My previous papers contain a detailed account of each of the twenty' cases, with the mode of
In the present article I shall give in detail only a few of the most important cases,? pursued.
those which differ from the ordinary or
which illustrate
particularly to reader?adding,
some
direct
point
the
to which I wish
cessfully operated
on
giving
connected
cases
of stone were were
came cases suc-
by urethrotomy. There or boys under were all operated on by death. In the remaining
in male children
the age of 15, these lithotomy, with one 61 cases, all of which occurred in adult males with the exception of 3 instances in female
children, litholapaxy
was
attempted
;
but, for
various reasons, in four of the cases the operation could not be performed. In two of these cases the calculous disorder was complicated
by
case
paper, so that it may be clearly understood that the operation of litholapaxy was given a fair
trial, having been performed in every possible instance in the adult without reference to age, state of
It is in this way true estimate of the value of the
only that a operation can be obtained, not by a selection of particular I have to add that of the lithotomy and cases. urethrotomy cases sixteen were operated on by my Assistant-Surgeon, Jawala Pershad, an ex&c.
health,
cellent lithotomist.
Turning
to the immediate
subject of the append-
now
this paper, it will be observed from ed table that amongst the 57 cases of litholapaxy two deaths only occurred. These two cases
are
given
in
detail in the
sequel.
In
Case 24, death resulted from peritonitis, evidently by extension of inflammation from the neck It is difficult to say whether due to the operation or to the impac-
of the bladder. this
under my observation. Of these 6 of urethral calculus, all of which were 40 cases
of the
table
appendix, important points a
with each of the 57 cases. During the year 107
of cases,
attention
as an
some of the most
run
cases were
the calculus was exremaining tremely large and hard, weighing over twelve This was removed by the supra-pubic ounces. operation, the patient dying six hours afterwards from exhaustion. I have thought it advisable to mention the foregoing facts preliminary to entering on the immediate subject of this In the
and after-treatment
operating
These three
it.
on
was
tion of the calculus at the neck of the bladder and force necessary to ed to think the latter no
difficulty
in the
the calculus
only
displace
was
the
I
it.
cause.
performance
am
inclin-
There
was
of the operation,
very small and the operation lasted 8 minutes. The bladder was healthy
except
was
at the
neck, where the calculus had lain days. The kidneys also were probable that the calculus, forced
for two
impacted healthy. It is on by the accumulation of urine and efforts to empty the bladder, acted as an irritant to the mucous membrane, thereby causing inflammawhich was no doubt increased tion, by the force
stricture of the urethra, so that the smallest lithotrite would not pass into the bladder; and in one instance, the lithotrite was
necessary to return the calculus into the bladder. In case 44, the cause of death was pyaemia, the
passed and
and caused
severe
though the calculus, which
was
of moderate
result of
cystitis supervening
by
on
the irritation of
a
the
operation, large fragment
62
THE INDIAN MEDICAL GAZETTE,
of calculus which it the first
move at
This last
found
was
impossible
to
re-
sitting. teaches
case
us
that in lasted tion
of the
several
was
prolonged
to
an
the
operation
one case
the opera-
cases
hour ; and in
over an
a
which I
on
a
hour and
half, 1,015 being success-
of hard uric acid calculus
grains fully removed.
operation
The essential
to be lost
one
of
sight
in
a
even
of the
removal of
complete sitting. This fact by some operators,
have noticed in accounts of their cond and
a
principle
consists in the
the calculus at
"
third
cases
sitting "_was
of their
seems
that
for I a
se-
necessary
An
operation large proportion prolonged over several sittings" in this way involves all the dangers attending the old operation of lithotrity. It will be noticed that large calculi were removed successfully by litholapaxy from three patients aged 85, and in case 69, full details of drachms of a very hard uric which follow, acid calculcus were removed from a patient aged 96, the operation lasting one hour, with complete success. It is wonderful how well very old patients stand the operation, and I have noticed that in them the operation is less likely to be attended by urethral fever than in the a
cases.
"
of young and strong men. In fact my experience is, that the older the patient the greater case
is the
compared
with
Case 30 is neous
from
litholapaxy
as
lithotomy.
as
a
far
as
occurring
quacks stone
success
remarkable instance of spontadisintegration of a calculus in the bladder,
and is, case
of
prospect
who
by
I
am
in the
profess
In
aspirator.
a
previous
article
alluded to the great value of Sir Thompson's sound in detecting small cal-
of mine I
practical lesson point strongly insisted in a the importance of reprevious article, namely, moving the whole of the calculus at one sitting, no matter how long the operation may take. A reference to the appended table will show on
of the
means
[March, 1884.
aware,
unique. of
be
a
of those
able to
dissolve
practice to
Such
one
the internal administration of secret
remedies would certainly be the
means
of mak-
ing his fortune, had the urethral orifice been sufficiently large to permit the fragments to pass out. In case 54, a new method of diagnosis of stone in the bladder is indicated, namely, by
Henry
ordinary sounds fail to bring to notice. I find from experience, however,that, even with the aid of Sir Henry Thompson's sound, we may fail to detect a small calculus lying in some peculiar position in the bladder. In the case referred to a most careful search was made by means of sounds of various kinds, but no calculus could be detected till the aspirator was employed, when a distinct click was at once felt during exhaustion of the water from the bladder, and due to the calculus being carried with force against the eye of the canula by the outward The sound of the fragments clicking stream. against the eye of the canula during the evacuation of the fragments of a calculus in the operation of litholapaxy suggested this mode of diagnosis, and I am now in the habit of having which the
culi,
are
it when
the symptoms of stone well marked and the sound fails to detect to
recourse
the presence of one in the bladder. Not only may the aspirator be employed with
advantage for diagnostic purposes, but, as illustrated by case 76, it may be used for the evacuation of a calculus entire, when the calculus is very small, without the aid of any crushing instrument whatever.
plated
the
I had for some time contem-
of
possibility
removing
a
small
calculus in this way, but this was the earliest instance in which an opportunity presented itself of
my idea to
practical test. Since then, 5th January last, I had a similar case, in which a calculus weighing 13 grains was removed by means of the aspirator and canula alone and with similar success, the patient having gone to his work the day after the operation, and having suffered no inconvenience whatever. Sir Henry Thompson objects to the word litholapaxy," employed by Bigelow for the operation invented by him, and suggests "lithotrity at one sitting" as a more suitable name. It is putting on
a
the
"
obvious thatt his latter
name cannot
the two cases just referred to, as there
ing
whatever
which
means
practised,
whereas
"
evacuation of stone, is
be
applied
was no
to
crush-
litholapaxy," applicable.
March, 1884.] It
will
table that
instances 4 years
be
FREYER ON LITHOLAPAXY.
observed
litholapaxy in
female
respectively.
was
appended
the
from
in
three
aged
about
performed
children,
given only
I have
one
of
results
55, in detail. Similar good followed in the others. There was no real dilatation of the urethra necessary and no disturb-
these,
case
of the part. There was no incontinence that urine, that filthy and disgusting sequel dilataby results from the
litholapaxy,
63
in skilful
hands, involves practically
danger than the passage of a catheter. only to the reduction of mortality that litholapaxy can claim is the comparatively short time in hospital which the operation involves and -a disease which formerly required weeks of no
more
Second
and confinement to bed for its cure, is disposed of in as many days. As yet no
suffering
ance
now
of
instruments have been invented
operation
frequently
tion, and which would marriage,?a matter
an
effective bar
prove which amongst
to
natives
Japaxy
can
be
performed
with
by which safety in
lithomales
below the age of puberty, but in such cases lithotomy should be, as a rule, successful. With
importance than the litholapaxy in the adult male and females inconvenience caused by the dribbling of urine. of all ages, and lithotomy in males below Illustrative of the extraodinary ideas natives the age of puberty, the mortality from operasometimes get into their heads about surgical tions for stone should be comparatively very
would be considered of more
operations, I may mention that some of my small. Case 24..?Bholoo, a Mahomedan male aged patients at first objected to the new operation of litholapaxy, on the ground that, though they 48, admitted into the Moradabad Civil Hospital should get rid of the culculous disease, permanent
impotence
of the
of
on
9th January with retention of urine which existed 36 hours. Had suffered from the
the
I have had the had this pointof several usual symptoms of stone in the bladder for Much exhausted, with pinched seen at varying nine months.
would result !
curiosity tomake enquiries
on
litholapaxy, subjects intervals after the operation, and
1 need
scarcely anxious expression
of face.
On
passing
a
full-
add that there were no grounds whatever for the sized catheter a small calculus was detected at ridiculous idea referred to. On the contrary, the neck of the bladder, blocking up the passage. This was pushed back with considerable force an old gentleman of 55 informed me that in virile and the retention of urine relieved by the cathepower as in other respects he felt twenty years i The patient was anaesthetised and litholater. younger than before the operation was performed. | The operation only In concluding these remarks I cannot speak paxy at once performed. 8 minutes, the lithotrite being only once I in terms of too high praise of Bigelow's operation. lasted calculus weighed only 20 grains. % its introduction the operative surgery ofintroduced. The catheter No. 18 passed easily without slitting stone has truly been revolutionised, and the the urethra. removal of calculus, which was regarded as January 10th.?Passed very little urine since a hazardous operation in the adult and extremeof pain in the region of ly dangerous in old age, is now, thanks to theyesterday. Complains the; bladder, catheter parsed and a small quannew operation, shorn of most of its perils. of urine drawn off. Hot fomentations to I have now, at the time of writing, com-tity the hypogastrium with hot poultices ordered, pleted seventy-nine cases of litholapaxy, of also 1 grain of opium internally every 3 hours. which 76 were in adult male and 3 in female 11th.?Well-marked peritonitis prechildren. Amongst these only 3 deaths occur- January sent. Temperature 102? F. Respirations 44 per red, all the others having been completely sucminute. No urine passed: drawn off by cessful. Compare this result with the mortacatheter twice daily. lity of 1 in 4 or 5 from lithotomy in the adult, January 12th.? Pain less. Passed about two acknowledged to be the average by the greatest ounces of urine without the use of the catheter ; lithotomists ! It is no exaggeration to say that stool, black in colour. of when the calculus is very small the operation scanty
THE INDIAN MEDICAL GAZETTE.
64
January 13th.?No pain
great distension of
:
the abdomen, which is very distressing. Patient very weak. Passsd 4 ounces of urine without the catheter.
Died
quietly in the evening. January 14th.?Post-mortem examination.? On opening the abdominal cavity it was^ found distended with clear was
embedded in
of amber-coloured
mass
a
The bladder
fluid.
serous
which broke like cold
gelatinous lymph, on application of the fingers. Congestion
of the
cellular tissue at the base and
of the
neck'
bladder.
The
thra
the neck of the bladder
near
membrane of the
mucous
inflamed, presenting
jelly
a
dark
was
ure-
highly
red
appearance. of the bladder, and
There
was no congestion kidneys were healthy. Case 30.?Jehan Khan, a Mahomedan, aged 35, resident of the Terai, admitted 19th March
the
with the usual symptoms of stone, which had existed years. Thirteen days previous to admission all the symptoms became aggravated, since which date urine had
suddenly only been On plac-
passed with great difficulty in drops. ing the patient on the operating table with a view to passing the sound, I noticed an elongated hard thickening along the course of the urethra, and my first impression was that there was a severe stricture. Dr. Moran, 6th N. I., who kindly assisted me at the operation, remarked that the feeling was like that of urethral calculus, and on passing the sound, his idea was proved to be correct. The floor of the meatus was
slit up and
no
less than
debris of calculus removed
by
one
drachm of
urethral
forceps
small scoop. The whole length of the urethra was filled with pulverised calculus. A
and
a
sound
was
then
the bladder.
passed
and
fragments
The lithotrite
was
detected in
introduced and
litholapaxy performed. The fragments removed from the bladder weighed 125 grains, exclusive of 60 grains from the urethra : No. 16 catheter was used. On inspection of the fragments it was evident that they belonged to one large phosphatic calculus, not of several small The patient recovered without a bad ones. symptom, and was discharged on the 27th March,
[March, 1884.
33.?Daiby Dass, a Hindoo, aged 50 hospital on the 7th April with the usual symptoms of stone, the most prominent of which was excruciating pain in walking and during micturition. The symptoms had existed two years. On the 12th April I performed and had the honor of doing the litholapaxy, operation in the presence of Surgeon-General Case
camc
to
W. Walker. The urethral orifice so
its base
was
ed in
slightly
slit up
Considerable
director.
passing
was
by difficulty
very narrow, the scalpel on a
experiencowing partly in the
was
the lithotrite into the bladder
to the calculus
lying
close
to
and
The stone was, however,, and crushed. The calculus was
neck of the urethra. soon
grasped
very hard, composed of oxalate of debris weighed just one ounce. The
lime, and the operation oc-
45 minutes, a long time for this size of stone ; but only No. 16 catheter could be
cupied
passed, and, owing urethra
at
siderable the
the
to the
neck
of
manipulation through
instruments
irregularity
of the
the
was
bladder, required to
this
part
of
con-
pass the
canal.
April \3tJ1.?Passed some blood with the urine last evening. Urine clear this morning. Slight fever present. April 14th.?Patient doing well ; no fever. Urine passing freely and clear. The man made cured on a rapid recovery and was discharged the 20th April. Case jj.?Emam Bux, aMahomedan, aged 85, resident of Chandausi, came to hospital on the 13th April with symptoms of stone, which had existed two years. The man was extremely feeble, emaciated, and almost in a dying state. There was great enlargement of the prostate, owing to which the bladder was never completely emptied after micturition, which was very painful. A calculus was detected by the sound. On the 15th April I performed litholapaxy, removing 6^ drachms of hard uric acid calculus, the operation lasting 20 minutes. April 16th.?Urine only passed by means of catheter, which is used every 6 hours. Had high fever last evening, which is much less this morninCf.
March, 1884.]
dribbles away when the
April iSth.?Urine bladder
Fever
gets half full.
patient
gone:
stronger. April 19th.?On passing the catheter it grated against a fragment of stone. Chloroform administered and the fragment crushed and removed by the aspirator : weighed 40 grains. April 21st.?Much better. Urine clear, but still drawn off by catheter. are
being
bladder
Quinine
and belladonna
for the atony of the The patient now rapidly
administered
that exists.
April could pass urine without the use of the catheter, though, owing to the great enlargement of the prostate, the bladder could not be completely emptied by regained strength,
and
by
the 26th
the natural effort. The man was able to walkabout the hospital, and his generaj health had
greatly improved.
As
there
were
no
urinary
symptoms except those due to the enlarged prostate, which will permanently remain, he was allowed to go home. Case
39.?This was hillman, a
A young
aged 32,
came
to
a
in
private practice. Ramnugger, 25th April complain-
case
zemindar of
me on
the
ing
of the usual symptoms of stone which had existed one year. Had passed gravel previous-
ly.
On the 28th
April I performed litholapaxy, removing grains of uric acid calculus in 12 minutes. Not a drop of blood was lost the during operation, No. 16 catheter passing easily. April 29th.?Patient has high fever with delirium : stomach wont retain any food. Order160
ed fever mixture
and
epigastrium
calves of
and
mustard
plasters
to the
Patient
was legs. day and gradually improved. go home on the 2nd May quite
much better next
Was allowed well.
to
I have since had several letters from him
and he has not suffered from any tom since the
urinary
symp-
operation. 42.?Jaffir, a Mahomedan, aged 45, came hospital on the 18th May suffering from the
Case to
usual symptoms of stone, which had existed several The man was thin but in years. fair health : slight trace of albumen in the
urine. ation
65
FREYER ON LITHOLAPAXY.
.
Litholapaxy was performed, the operlasting one hour and ten minutes, two
and-a-half culus and
of
ounces
removed.
being catching
the stone,
blades would not close
stone,
that I
so
extremely
On
passing
it
was
owing
er
found that the
to the size of the
operation By manipulation,
the calculus
was
grasped across
axis and
was
eventually crushed. extremely hard, composed of
bonate
with
an
cal-
afraid the crushing
was
would have to be abandoned.
however,
hard
the lithotrite
oxalate of lime
a
short-
The calculus calcium
nucleus,
car-
and
resembled white marble in appearance. No. 16 catheter was the largest that would pass easily, fact that retarded the
a
blood
was
lost
operation; not a drop of during the operation. This
patient recovered without a bad symptom, and discharged cured on the 29th May. Case 44..?Nihal, a Hindu, aged 45, admitted 23rd May with symptoms of stone, the most prominent of which were agonising pain in the region of the bladder and passing of blood and
was
pus with the urine. The symptoms had existed 8 years, and the patient was in very bad health. A
large
calculus
detected
was
I
On the
by the sound. performed litholapaxy. experienced owing to
25th May difficulty was the large size and hardness of the stone and the operation progressed very slowly, 14 drachms being removed in 75 minutes. No more fragments could be detected by the lithotrite, but on passing a sound a large fragment was deGreat
high up at the fundus of the bladder. As the patient was very much exhausted I was afraid to keep him longer under chloroform, so I had, unwillingly, to postpone the completion of the operation for another day. The usual tected
after-treatment Mav 26th.
was
ordered.
Had great
pain
in the
region
of
the bladder all
yesterday, which was controlled grain opium administered every 3 hours. Urine scanty and blood-stained. Temp. I04?F.; great thirst. Fever mixture ordered and opium
by
1
continued.
rigor last evening. Fever continued till midnight; patient anxious and depressed. Ten grains of quinine ordered ; to be repeated in the evening. No pain in abdomen, but great pain in the left hip. May 2/th.?Had
a
severe
THE INDIAN MEDICAL GAZETTE.
66
presence quite normal in appearance. There was no incontinence of urine. Discharged on
in left hip ; all May 28th.?Abscess forming the symptoms of blood poisoning present.
Carbonate of ammonia
Patient died at
ordered.
the
14th August.
Case 68.?Oomaida,
10 P.M.
examination.? Walls
of
the
greatly thickened, sacculated
and
con-
Post-mortem
bladder
bark
and
[March, 1884.
-
resident of
Rampur,
Hindoo
a
to
came
male, aged hospital on
55, the
the usual symptoms of stone, which had existed 6 months. On the 26th October 1 performed litholapaxy in pre20th October
Large fragment of calculus, about one ounce in weight, in a sacculum at the fundus of the bladder ; several small patches of inflammation in the mucous membrane in the vicinity of the fragment of stone. Some milky looking
tracted.
suffering from
Sanitary Commissioner, Dr. Planck. operation lasted 34 minutes, the calculus It was of was very tough, and hard to crush. the mixed variety, and the debris weighed one urine in the bladder. The tissues of the left ounce and 35 grains. Catheter No. 18 passed gluteal region and round the hip joint swollen easily without slitting the floor of the orifice of and infiltrated with dark red fluid. Cause of the urethra. Next day the patient was walking death, pyaemia. 1 aboutthe hospital as if no operation had been perCase 34.?On the 1st of August a Hindoo, aged 50, came to hospital with symptoms of stone, formed. On the 30th October, the day on which the most marked of which were sudden stoppage j the man was discharged, he presented himself at of the
sence
The
!
of the flow of urine and increased
micturition. After
a
most careful
various
the bladder
by Henry Thompson's, no
frequency exploration
sounds, including
of of
Sir
calculus could be detect-
I felt certain, however, from the symptoms was a small stone present, and deter-
ed.
that there
mined of
to
employ
the
aspirator
I introduced
diagnosis.
a
for the purpose No. 14 catheter
Dr. Planck's camp. Dr. Planck was very much by the rapidity of the cure, having seen
struck the
operated on only 4 days before. patient was in high spirits, and gave us an amusing account of the expedients he had man
The
to in order to
recourse
operation. then
his
on
used
belly,
sometimes
aspirator. After going through performance of pumping water into the bladder and exhausting it once or twice, a distinct click was heard. The catheter was withdrawn, the lithotrite introduced, the calculus and crushed. The fragments weighed
legs in the air, and could not pass water !
applied
the
the
to
on
side and
one
the other, but frequently without avail. When these positions failed to give him relief> then
and
pass urine before the lie on his back,
He
on
he had
recourse
to
standing
his
Case
69.?This
on
his head
then he
even
with
frequently
in
private practice, sake, was perday walking only 11 grains. about quite well, and was discharged on the 4th formed at the Civil Hospital. The patient, a Mahomedan of Moradabad, stated that he was August. on 100 years of age, and by calculacase was close that of a Hindoo Case 55 ?This seem to be 96. He was a driedgirl, aged 4^ years, who had been suffering with tion he would
grasped
the
Next
symptoms
man
A up, withered old creature, without a tooth in his On the head, and consisting almost of skin and bone.
of stone almost from her birth.
by the sound. 1 oth August performed litholapaxy, the urethra being dilated, merely sufficiently to allow calculus
detected
was
I
the
lithotrite
calculus,
to
which
grains. No. 14 operation only
The debris of pass. uric acid, weighed
was
catheter lasted
8
girl was running quite well, and passed
the
was a case
but the operation, for convenience
was
was
used, and
minutes. about urine
the
Next
sons were
in
attendance,
and
one
of them looked about 70 years of age. Till the about a month before coming under my treatment 86 he had
enjoyed good health,
the about the bazaar
day hospital
in my
Several of his
daily.
and used
to walk
Since then he has had
symptoms of stone, especially great pain in passing urine. He was very weak and unable
own to
leave his bed.
A
large
calculus
was
detected
March, 1884.] by
VENERAL DISEASE IN THE EUROPEAN ARMY.
On the 28th October I
the sound.
performed
The calculus, the debris of which
litholapaxy.
9 drachms and 35 grains, was very hard, consisting of uric acid. The operation lasted
weighed
hour, great difficulty having been experigrasping the last fragments. October 29th.?No fever. No urine passed since the operation : 3 ounces drawn off by the
one
enced in
catheter.
30th.?Passing
urine with considerable
No fever.
$ist.?Urine passing freely.
passing freely.
November 2nd.?Urine clear and
Patient
much
Walking tion
:
improved, sitting
about the house ;
urine
quite
no
pain.
up in bed. 6th.? pain in micturi-
clear.
November \$th.? Patient quite well; able walk about.
walking
about
troubled by Case
I have since
no
the
Ihe old
seen
of
to
man
Moradabad and
city urinary symptom.
76.?Gholam Hussain,
Mahomedan,
a
aged 5?> Warder in the Moradabad Jail, had been passing gravel for years, but suffered no
inconvenience
during
till
within the last 3
which he had
months,
stoppage of
occasional
water. On the 26th December he had retention of urine, which the Native Doctor relieved the passage of a catheter. On the 27th he again had retention, when he came to me. I and on my arrisent him to the Civil
by
Hospital,
val there put him at once under the influence of chloroform and passed a No. 18 evacuating
catheter with the greatest
ease.
The
aspirator
then applied and the click of the calculus distinctly heard as, with each successive exhaustion of the water, it was carried to the eye of the catheter. The catheter was suddenly withwas
drawn during 'exhaustion,' carrying the calculus with it in its eye. The calculus was uiic
acid, elongated
and oval in
shape,
15 grains. The man went to j ail next day, quite well, and no
unpleasant symptoms. Moradabad,
8th Feb. 1884.
and
weighed
his work
having
at the
suffered
67,
f
..
.'
S3
showing particulars of Litholapaxy on daring 1883, By Surgeon P.
No.
Name.
Date of
Operation.
21
Mohun
1st
22
Kulloo
23 24
Sawanthy
3rd
25
Madari
27 28
Bhaloo
Najjoo Gopi Nath
9th 17th 17th
19th 22nd
18
?
35
?
50
M M M M M M M M M M M M M
?
85
M
January
6th
Age. Sex.
?
55
?
41
?
48
?
Feb. ?
32 17 40 40
33
Ditto Jai Sukh' Jehan Khan Jai Lall Goord Sahoy Daby Dass
34
Emam Bux
I5th
35
Sookha
36
Nihal Ali Shah Kullon Ditto Kunna
M 20th 65 M ,, 2ISt 40 M ,, 36 M 24th ,, 28th 52 M ? 50 M 27th ,, 16 M Sth May 18th 45 M ? 17 M 19th ,, 45 M 25th >> 28th 19 M ,, 35 M 3rd June Sth 65 M ? 21st 85 M ,, 36 M 24 th ? 55 M 3rd July 8th 65 M ? 10th 65 M ,, 18 M 27th ? 1st August 50 M 10th ,, 4^ F 12 th ,, 85 M 65 M 14th ? 22nd 3o M ,, 32 Ai 23rd ,, 60 M 24th ? 25th ? 45 M 3rd Sept. 50 M 16th 36 M ,, 16th 42 M ,, 20th ,, 3h F F 2nd Oct. 4 65 M 15th ? 26th ? 55 M 28th 96 M ,, 80 M 21st Nov. 50 M 4th Dec. I 35 M 5th ? nth ? 50 M 13th ,, | 60 M 26 M 14th 45 M 27th
29 30 31 32
37
38 39 40 41 42 43 44 45
Choonu
Jaffir
59 60 61 62
Toolsia N ihal Mai la Kareem Ali Mooni Ram Kalloo (junga Ram Mull 00 Goor Buksh Bhola Nath Bhalloo Hatim Sing Sundria Md. Hussain Kaieem Kuksh Mohurthan Allum Oollah Ditto Khaili M agia
63 64 65
Budha Ditto
46 47
4S 49 5? 51 52
53 54 55
56 57
58
Rohmi
66
Haheebun
67
Nihal Oomaida Ditto Kayam Ali Mokarul
68
69 70 71 72 73 74 75
76
''
j
THE INDIAN MEDICAL GAZETTE.
Table
26
'1
?
Soojan
Fuzal Hussain Poosa Luchman Ghulam Hussain
5th.
19th'
,,
March. ,,
4th April
12th 12th
16th
,,
46 35 32
J. FREYER,
Weight 6 % 2 =
Variety.
50 grains. 995
Uric.
540 340
Oxalate. Uric. Oxalate. Uric
!75
Phosphate.
120
Uric.
i85
Phosphate.
35 480
( 400 + 40 80 240 140
)?
Uric.
20
3} 5
36 20
5 12 20
Oxalate. 195 2/4 Ozs. Carb of Lime. i
40
1
S40
Uric. Oxalate.
520
Phosphate.
ns.
12
U ric.
12
70 7
75
Died.
14 6
Successful.
870
Oxalate.
35
540 750
Uric.
20
57
ICO
310
12 10
| j
Oxalate, Uric.
10
6
25 2
86
8
824 804
55 56 35
340 19 270
Phosphate.
Uric.
10
5
32
146 90
10
3o
I25 206
Phosphate. Uric.
Phosphate.
10 20
15
57
10
85
5 34 60
5i5 575 1,015
Uric.
85
Phosphate.
90 6
165
Phosphate.
3 8
11
106
155 15
Died. Successful.
20
35 6
33o
90 66
Successful.
10
45
5J
160
8
35 25 25
Uric.
Phosphate.
10
minutes.
5
Oxalate. Uric.
=4+o
10
Result
25
1*
39o
occupied by Operation.
25
J5
130
14 18
operated
Time
of
15
55
cases
m.d.
Calculus.
20
I
[March, 1884.
J5
Uric.
10 20
Uric.
1
