been decided on, the a full sized staff patient passed; the stone was at once felt, but the staff could not be moved about freely. On making the deep incision, some very offensive stuff welled out. When the left forefinger was passed into the wound, the deep parts gave way like so much rotten material; and it almost felt as if the bladder had split right up. The finger now lay in a cavity about the size of a walnut with thick leathery corrugated walls, and containing horribly offensive stuff, together with a stone ; this latter, which was easily removed with the forceps, weighed about 2 drachms, and was of an Lateral
lithotomy having
was an
anaasthetised and
irregular quadrilateral shape ;
SOME COMPLICATED CASES OF STONE IN THE BLADDER. By Surgeon-Major M. D.
MORIARTY, M.B., F.R.C.S.I.
Aliau, agea years, was aumittea into the Ghazipur Dispensary on 23rd September 1884. He first got symptoms of stone when about 10 years old. In 1879 he was lithotomised in this hospital; the cicatrix was apparent, but the hospital records for the year in question were zo
1.
not
forthcoming. year's freedom the symptoms recurred ; lie had recently suffered much and looked very ill. On passing a No. 10 sound, urethral narrowing was detected at the root of the scrotum. It was now observed that the anterior perineum After a
swollen and thickened in the middle line ; there was no fluctuation. Passing on through what appeared to be the prostatic urethra, the sound grated against some rough substance, as if a concretion. Further on, it entered what appeared to be the bladder, and at once a stone was felt with its apex projecting from, or rather pointing at, the neck ; the sound could not be manipulated freely ; however, the stone appeared A lithotrite was to be central and anterior. the anterior cleared it now passed; narrowing with little difficulty, and soon impinged ou a stone, but on depressing the handle, the instrument could not be made to enter any cavity like the bladder; the finger in the rectum seemed to shew that the point of the lithotrite had passed the prostate in front of it; and inclined to the left (patient's right) was felt a soft Ihe lithotrite tumor, apparently the bladder. was now withdrawn, and the sound again passed with the result as above. With the sound in situ and held an assistant, the bladder was was
by manipulated bimanually. Whereupon,a quantity of stinking bloody stuff containing much phos-
phatic
sabulous matter welled from the urethra.
one
angle
or nose
It would appear, it was 011 this nose the sound had impinged. On further digital exploration, at the very apex of the cavity was felt a small, soft, wrinkled and easily dilatable opening. Aided by firm pressure above the pubes, the finger entered a cavity which felt like an ordinary bladder, contracted, but not markedly thickened, and empty save for a small rounded stone, which appeared to be lodged right above the pubes, and which was easily removed with the scoop. The lower cavity was washed out with a one per cent, carbolic solution. There was no bleeding to speak of; both stones appeared to be urates, The patient made well coated with phosphates. a o-ood recovery, and was discharged cured ou the 22nd day. It would appear that the first stone lay in the dilated prostatic urethra; the membranous urethra was doubtless somewhat contracted as a result of the first lithotomy ; behind this the prostatic urethra became dilated, and here lodged a small stone which gradually increased in size, the urethra expanding likewise. Litholapaxy was
markedly prominent.
was
obviously impossible.
II. Bharosa, aged 25 years, was admitted into the Ghazipur Dispensary on 11th April 1885. He had bad cystitis and general symptoms of The Assistant-Surgeon passed a No. 10 stone. Thompson's sound, but found nothing. On the 16th April the patient appeared very ill; he had a distinct septic look, high fever, and a constant dribbling of stinking puriform urine. A No. 10 common steel sound was now passed; in the membranous urethra a slight but distinct narrowing was observed. Passing ou, the sound at once struck a stone, which felt hard and rough ; but the instrument could not be manipulated so as to gauge the size of the stone. Thompson's souud was then tried ; not only could it not be manipulated, but the stone could not be felt at all with it. The bladder (?) was now washed out through a double catheter, aud a purgative and an enema ordered. The patient now also stated that when about tea years of age, he had symptoms of stone, which that were, for a time, subdued by medicines, aud
Aug., 1887.]
COMPLICATED CASES OF STONE.
for the last three mouths he had suffered very much. Next day, 17th April, lateral lithotomy was performed. When the staff, a No. 9, was passed, foul urine trickled out by its side, hut the stone could not be felt. It being obvious that the patient would soon die if not relieved, the operation was proceeded with. On making the deep incision, a quantity of stinking urine and pus welled out. The finger entered a large cavity extending on either side beyond reach, and distinctly marked off into two apparently equal parts by a medium ridge on its floor. Above aud beyond this, was a soft, relaxed, circular opening, from which projected the point of a stone. The stone was pear-shaped; it was not readily seized with the forceps, but with the scoop was at once brought away in its proper axis; the cavity from which it was removed felt like an ordinary empty bladder. The lower cavity was well washed out with The stone, a two per cent, carbolic solution. which weighed close on 7 drachms, was urate, coated with phosphates ; the projecting nose appeared to be entirely phosphatic. For a few days the patient did very well; the improvement was most marked, and the urine, as expressed from the bladder, became perfectly clear. On 20th, he got high fever and the old septic look; and was in a critical state for some days. The wound was, of course, carefully attended to, and the deep parts kept as aseptic as possible. Salicylic acid with acetate of potash, aud decoction of limes were given, then quinine and bromide of sodium?all in full doses, but the condition did not improve. At length, at 9 A.M. on 23rd his temperature being then 105?, and bis state altogether critical, gi*. of nitrate of was injected hypodermically. In a pilocarpine few minutes he was bathed in profuse perspiration,?up to tlieu the skin had been dry ;?and, soon after, two large liquid motions were passed in quick succession; the pulse now got very low, and the patieut became very weak and semicollapsed. Rum and water were given, with little apparent benefit; and Atli gr. of sulphate of atropin was then injected hypodermically. At once the pulse improved, and the patieut said lie felt better. Half an hour afterwards the temperature was 99?, aud at 5 p.m. it had not risen above 101?. Moderate fever continued for some days; on 29th aud 30th it increased somewhat, but was cut down by a 15-gr. dose of quinine. The patient was discharged oil 13th IVIay, the wound being then quite healed ; he was not very strong; aud was still subject to irregular attack of slight He had a narrow escape. lever. The bad symptoms in this case were obviously due to the condition of the fiiSt cavity, rather than to the presence of the stone. Was this cavity the dilated prostatic urethra? Cau the prostatic urethra be dilated to such
227
as in the first case, there of the membranous urethra, but there was uo stone around which the walls of the cavity had perforce to expand. Here, too, litholapaxy was not to be thought of. III. Ramdanu, aged 20 years, was admitted into the Ghazipur Dispensary on 27th April 1885. He had slight urethral discharge of whitish foetid stuff, and general symptoms of stone. A No. 10 sound stuck in the membranous urethra, as did a No. 8. A lateral lithotomy scar was now observed ; and the patient, in reply to questioning, stated that he had been cut twelve years ago, and remained well for eight years, after which symptoms of stone reappeared. Also that he had been sounded two years ago with a negative result. A No. 6 silver catheter was now passed, and a large hard stone was struck. The patient was forthwith anaesthetised and cut in an ordiThe urethra yielded readily nary No. 6 staff. to the knife and finger; not with the resistance of healthy tissue. Off the prostatic urethra, on its right superior aspect, was a small cul de sac containing a small oblong flattened stone. But no collection of offensive matter as in the two first cases. The neck of the bladder was soft and dilatable. From the bladder a facetted stone, shaped like the prostatic one, but about three times the size, was easily removed. A larger stone was then discovered ; it appeared to be partly encapsuled. With a lithotrite introduced through the wound a futile attempt was made to break it in situ. Finally, it was removed with the forceps. When it came, there was a distinct sensation as of something having given way. It may have been caught between hypertrophied fasciculi. There was no haemorrhage. The bladder was washed out with a two per cent, carbolic solution. The patient never had a bad symptom, and was discharged cured on 26th day. The stones appeared to be urates, and together weighed a little over If ounces. Had the means been at hand (which they were not) to dilate the stricture, it is obvioua litholapaxy would have been a dangerous operation in this case. Even were it possible to remove every particle of stone-?which is very doubtful?the after consequences might well have been dreaded. Whereas, by lithotomy, the stricture was divided and given a chance of healing, an unhealthy cavity was drained, and the stones were removed, with a minimum of danger. In this case also, it is fair to credit the stricture in the membranous urethra as being the cause of the prostatic dilatation. Why the latter should have been partial instead of general, is not so clear. But for the stricture, too, it is reasonable to suppose the stones might have been, in the first instance, expelled altogether. IV. Kishen Dyal, aged 40 years,was admitted into the Ghazipur Dispensary on 24th May 1885. an
was
extent?
Here,
narrowing
228
THE INDIAN MEDICAL GAZETTE.
[Aug.,
1887-
He had symptoms of stone for about twelve Had an accurate diagnosis been made, it is of water could years, and for two months had suffered much. doubtful if a sufficient quantity have been injected and retained to admit of The urine was and sanious. offensive highly No stricture was being performed. Still it is to be apparent. The sound struck litholapaxythe a stone about the neck of the bladder, but could regretted attempt was not made, as, had been not be feasible, it would probably have pushed in and manipulated, so as to ex- litholapaxy been the safer operation of the two. The paroin the rectum felt the The plore finger parts. tid swelling was probably pysemic. The condithe stone very distinctly, and very low down. tion of the urine was held to justify the free use considered unadvisable, Litholapaxy being of opium ; yet, it would have been interesting lateral lithotomy was performed on 25th May. A perineal artery spouted pretty freely ; but to have ascertained the condition of the kidneys and ureters, had an autopsy been allowed. a nip of an artery forceps soon stopped it. "V. Bijjub, aged 30 years, was admitted into There was also some deep venous haemorrhage which soon ceased; altogether, the loss of blood the Shahjihanpur Dispensary on 3rd April 1887. Symptoms of stone had commenced six was by no means excessive, or such as would and for the last six months had to previously, rise uneasiness. years The any ordinarily give been very severe. The urine was highly offenwas distinctly urethra dilated. The prostatic stone lay in the bladder, which was rough sive, the sound struck a stone, obviously in the and contracted. The stone was removed with- urethra, and could not be advanced or manipuIt weighed 410 grains, and lated in the slightest. Rectal examination disout difficulty. to be uric acid coated with phosphates. closed a round stone, the size of a large marble, appeared An hour after the operation, the patient was then a narrow neck, and then a larger round dumb-bell in fact, except that given the usual full dose of quiuine and opium stone?a perfect With the one sphere was larger than the other. tiuct. Next 15; gr. opii 3ss.). morning (quiuia in the of the still the sound rectum, point his pulse was 64; temperature 96*5?; tongue finger coated ; urine clear. On the 27th, the pulse was firmly pressed against the centre of the prewas very weak and compressible; temperature senting stone, but the latter could not be moved from its position. Litholapaxy and soft a little puffy; breath- in the slightest 101*2?; belly impossible, lateral lithotomy obviously Thin offensive stools were being ing rapid. passed transverse perineal artery The was performed. involuntarily ; tongue dry ; wound also dry ; and urine slightly bloody. A mixture of rum and bled viciously, and was twisted. The urethra? ammonia was given every hour, and one full passing the narrow neck of the dumb-bell?was dose of quinine. Towards evening the belly cautiously divided with a blunt pointed knife became more swollen and tympanitic, and the o-uided by the finger. It was hoped to remove but the neck way; the pulse was almost imperceptible. He rallied consi- the stone entire, then removedgave from a cavity was stone second derably after a hypodermic dose of sulphuric ether. On 28th, lie was much better : tongue which it about filled. On this stone a second moist; pulse 98 and temperature 98?; belly broken neck was observed. The finger was again soft; and wound a little moist. The improvement introduced, and, aided by firm pressure above did not long continue. The wound failed to re-act, the pubes, a soft and loose circular opening was and became sloughy throughout its whole ex- felt right behind the pubis, leading into a cavity, tent; thin offensive motions were constantly the walls of which were thick and corrugated, a quantity of sabulous passed involuntarily. On the evening of 31st and which contained the temperature was 103-2?; and a painful parotid matter, with an outer shell which had broken. swelling appeared. He went from bad to worse ; The greater part of this sabulous matter was the diarrhoea continued; lie vomited nearly removed with forceps, scoop, syringe, aspirator but some was left closely adhering everything that was given to him. Abed-sore and finger, mucous the membrane, and almost beyond to threatened ; wandering delirium set in, with substone was chiefly phosphatic, with The reach. on tendinum. He, 2nd June? sultus finally,sank probably an uric nucleus for each sphere of the ejcrht clear days after the operation. dumb-bell (they have not been cut). What was examination not allowed. ?fost-mortem of it weighed over If ounces ; but After the operation, the urine was always free, was collected of sabulous matter was lost. The a clear. As to treatment, quantity and, for the most part, second stones lay in smooth lined and first on and quinine reliance was chiefly placed opium, the third sac, as already mentioned, with stimulants, and as much nourishment as cavities, and wrinkled. The patient was was rough he could take. full dose of quinine and opium, both It will be observed, that here, again, the prosta- given a tic urethra was dilated. Can this be attributed to before and after the operation, and subsequentthe irritable,thickened,and contracted bladder? ly was ordered a mixture of dilute nitric acid, Prior to operation the condition of the bladder and quinine, and infusion of linseed. For a no sabulous matter was passed. After was not clearly recognised ; rather, a condition few days, that it began to come through the wound. Quite cases was the
resembling
preceding
suspected.
CASES OF HEPATIC ABSCESS.
Arc., 1887.] a
lump
of it entered the
urethra,
and advanced
to the front of the scrotum, where it stuck for
a
few days. It blunt curette.
a
was
ultimately
removed with
Recovery was slow; a troublesome diarrhoea brought on by errors in diet; there was also some irregular fever. He was, finall}', discharged on the 27th day. The urine was free
was
and clear; the wound healed save for a slight and he Avas daily putting on flesh. It would appear that the first stone lay in the membranous urethra, the second in the prostatic urethra, and the third in the bladder proper ; a rare condition, if this opinion be correct. Neither of the two anterior stones were tunnelled, or rather grooved, by the urine, as is sometimes observed in stones of lonsc which O O standing have almost filled the urethra. For the most part it is impossible to carry out in our dispensaries any preliminary treatment worthy of the name. Frequent soundings and washings of the bladder would probably convince the patient that his case was not understood, or was perhaps hopeless. Tortured by prolonged suffering and despairing of relief otherwise, he has at length screwed up conrtige If operation be delayed, to come to hospital. his faith is shaken, his courage oozes out, and he absconds, perhaps on the very day fixed for operation; hence immediate operation is the
superficial ulcer;
rule. It is matter for our
regret, too, that
patients again,
we
and in the fatal
seldom
see
cases are,
denied -post-mortem examinations. The records of our cases are, therefore, often
generally,
incomplete. Shahjehanpur, N.-W. P., June 25th, 1887.
229
lithotomy having
was an
anaasthetised and
irregular quadrilateral shape ;
SOME COMPLICATED CASES OF STONE IN THE BLADDER. By Surgeon-Major M. D.
MORIARTY, M.B., F.R.C.S.I.
Aliau, agea years, was aumittea into the Ghazipur Dispensary on 23rd September 1884. He first got symptoms of stone when about 10 years old. In 1879 he was lithotomised in this hospital; the cicatrix was apparent, but the hospital records for the year in question were zo
1.
not
forthcoming. year's freedom the symptoms recurred ; lie had recently suffered much and looked very ill. On passing a No. 10 sound, urethral narrowing was detected at the root of the scrotum. It was now observed that the anterior perineum After a
swollen and thickened in the middle line ; there was no fluctuation. Passing on through what appeared to be the prostatic urethra, the sound grated against some rough substance, as if a concretion. Further on, it entered what appeared to be the bladder, and at once a stone was felt with its apex projecting from, or rather pointing at, the neck ; the sound could not be manipulated freely ; however, the stone appeared A lithotrite was to be central and anterior. the anterior cleared it now passed; narrowing with little difficulty, and soon impinged ou a stone, but on depressing the handle, the instrument could not be made to enter any cavity like the bladder; the finger in the rectum seemed to shew that the point of the lithotrite had passed the prostate in front of it; and inclined to the left (patient's right) was felt a soft Ihe lithotrite tumor, apparently the bladder. was now withdrawn, and the sound again passed with the result as above. With the sound in situ and held an assistant, the bladder was was
by manipulated bimanually. Whereupon,a quantity of stinking bloody stuff containing much phos-
phatic
sabulous matter welled from the urethra.
one
angle
or nose
It would appear, it was 011 this nose the sound had impinged. On further digital exploration, at the very apex of the cavity was felt a small, soft, wrinkled and easily dilatable opening. Aided by firm pressure above the pubes, the finger entered a cavity which felt like an ordinary bladder, contracted, but not markedly thickened, and empty save for a small rounded stone, which appeared to be lodged right above the pubes, and which was easily removed with the scoop. The lower cavity was washed out with a one per cent, carbolic solution. There was no bleeding to speak of; both stones appeared to be urates, The patient made well coated with phosphates. a o-ood recovery, and was discharged cured ou the 22nd day. It would appear that the first stone lay in the dilated prostatic urethra; the membranous urethra was doubtless somewhat contracted as a result of the first lithotomy ; behind this the prostatic urethra became dilated, and here lodged a small stone which gradually increased in size, the urethra expanding likewise. Litholapaxy was
markedly prominent.
was
obviously impossible.
II. Bharosa, aged 25 years, was admitted into the Ghazipur Dispensary on 11th April 1885. He had bad cystitis and general symptoms of The Assistant-Surgeon passed a No. 10 stone. Thompson's sound, but found nothing. On the 16th April the patient appeared very ill; he had a distinct septic look, high fever, and a constant dribbling of stinking puriform urine. A No. 10 common steel sound was now passed; in the membranous urethra a slight but distinct narrowing was observed. Passing ou, the sound at once struck a stone, which felt hard and rough ; but the instrument could not be manipulated so as to gauge the size of the stone. Thompson's souud was then tried ; not only could it not be manipulated, but the stone could not be felt at all with it. The bladder (?) was now washed out through a double catheter, aud a purgative and an enema ordered. The patient now also stated that when about tea years of age, he had symptoms of stone, which that were, for a time, subdued by medicines, aud
Aug., 1887.]
COMPLICATED CASES OF STONE.
for the last three mouths he had suffered very much. Next day, 17th April, lateral lithotomy was performed. When the staff, a No. 9, was passed, foul urine trickled out by its side, hut the stone could not be felt. It being obvious that the patient would soon die if not relieved, the operation was proceeded with. On making the deep incision, a quantity of stinking urine and pus welled out. The finger entered a large cavity extending on either side beyond reach, and distinctly marked off into two apparently equal parts by a medium ridge on its floor. Above aud beyond this, was a soft, relaxed, circular opening, from which projected the point of a stone. The stone was pear-shaped; it was not readily seized with the forceps, but with the scoop was at once brought away in its proper axis; the cavity from which it was removed felt like an ordinary empty bladder. The lower cavity was well washed out with The stone, a two per cent, carbolic solution. which weighed close on 7 drachms, was urate, coated with phosphates ; the projecting nose appeared to be entirely phosphatic. For a few days the patient did very well; the improvement was most marked, and the urine, as expressed from the bladder, became perfectly clear. On 20th, he got high fever and the old septic look; and was in a critical state for some days. The wound was, of course, carefully attended to, and the deep parts kept as aseptic as possible. Salicylic acid with acetate of potash, aud decoction of limes were given, then quinine and bromide of sodium?all in full doses, but the condition did not improve. At length, at 9 A.M. on 23rd his temperature being then 105?, and bis state altogether critical, gi*. of nitrate of was injected hypodermically. In a pilocarpine few minutes he was bathed in profuse perspiration,?up to tlieu the skin had been dry ;?and, soon after, two large liquid motions were passed in quick succession; the pulse now got very low, and the patieut became very weak and semicollapsed. Rum and water were given, with little apparent benefit; and Atli gr. of sulphate of atropin was then injected hypodermically. At once the pulse improved, and the patieut said lie felt better. Half an hour afterwards the temperature was 99?, aud at 5 p.m. it had not risen above 101?. Moderate fever continued for some days; on 29th aud 30th it increased somewhat, but was cut down by a 15-gr. dose of quinine. The patient was discharged oil 13th IVIay, the wound being then quite healed ; he was not very strong; aud was still subject to irregular attack of slight He had a narrow escape. lever. The bad symptoms in this case were obviously due to the condition of the fiiSt cavity, rather than to the presence of the stone. Was this cavity the dilated prostatic urethra? Cau the prostatic urethra be dilated to such
227
as in the first case, there of the membranous urethra, but there was uo stone around which the walls of the cavity had perforce to expand. Here, too, litholapaxy was not to be thought of. III. Ramdanu, aged 20 years, was admitted into the Ghazipur Dispensary on 27th April 1885. He had slight urethral discharge of whitish foetid stuff, and general symptoms of stone. A No. 10 sound stuck in the membranous urethra, as did a No. 8. A lateral lithotomy scar was now observed ; and the patient, in reply to questioning, stated that he had been cut twelve years ago, and remained well for eight years, after which symptoms of stone reappeared. Also that he had been sounded two years ago with a negative result. A No. 6 silver catheter was now passed, and a large hard stone was struck. The patient was forthwith anaesthetised and cut in an ordiThe urethra yielded readily nary No. 6 staff. to the knife and finger; not with the resistance of healthy tissue. Off the prostatic urethra, on its right superior aspect, was a small cul de sac containing a small oblong flattened stone. But no collection of offensive matter as in the two first cases. The neck of the bladder was soft and dilatable. From the bladder a facetted stone, shaped like the prostatic one, but about three times the size, was easily removed. A larger stone was then discovered ; it appeared to be partly encapsuled. With a lithotrite introduced through the wound a futile attempt was made to break it in situ. Finally, it was removed with the forceps. When it came, there was a distinct sensation as of something having given way. It may have been caught between hypertrophied fasciculi. There was no haemorrhage. The bladder was washed out with a two per cent, carbolic solution. The patient never had a bad symptom, and was discharged cured on 26th day. The stones appeared to be urates, and together weighed a little over If ounces. Had the means been at hand (which they were not) to dilate the stricture, it is obvioua litholapaxy would have been a dangerous operation in this case. Even were it possible to remove every particle of stone-?which is very doubtful?the after consequences might well have been dreaded. Whereas, by lithotomy, the stricture was divided and given a chance of healing, an unhealthy cavity was drained, and the stones were removed, with a minimum of danger. In this case also, it is fair to credit the stricture in the membranous urethra as being the cause of the prostatic dilatation. Why the latter should have been partial instead of general, is not so clear. But for the stricture, too, it is reasonable to suppose the stones might have been, in the first instance, expelled altogether. IV. Kishen Dyal, aged 40 years,was admitted into the Ghazipur Dispensary on 24th May 1885. an
was
extent?
Here,
narrowing
228
THE INDIAN MEDICAL GAZETTE.
[Aug.,
1887-
He had symptoms of stone for about twelve Had an accurate diagnosis been made, it is of water could years, and for two months had suffered much. doubtful if a sufficient quantity have been injected and retained to admit of The urine was and sanious. offensive highly No stricture was being performed. Still it is to be apparent. The sound struck litholapaxythe a stone about the neck of the bladder, but could regretted attempt was not made, as, had been not be feasible, it would probably have pushed in and manipulated, so as to ex- litholapaxy been the safer operation of the two. The paroin the rectum felt the The plore finger parts. tid swelling was probably pysemic. The condithe stone very distinctly, and very low down. tion of the urine was held to justify the free use considered unadvisable, Litholapaxy being of opium ; yet, it would have been interesting lateral lithotomy was performed on 25th May. A perineal artery spouted pretty freely ; but to have ascertained the condition of the kidneys and ureters, had an autopsy been allowed. a nip of an artery forceps soon stopped it. "V. Bijjub, aged 30 years, was admitted into There was also some deep venous haemorrhage which soon ceased; altogether, the loss of blood the Shahjihanpur Dispensary on 3rd April 1887. Symptoms of stone had commenced six was by no means excessive, or such as would and for the last six months had to previously, rise uneasiness. years The any ordinarily give been very severe. The urine was highly offenwas distinctly urethra dilated. The prostatic stone lay in the bladder, which was rough sive, the sound struck a stone, obviously in the and contracted. The stone was removed with- urethra, and could not be advanced or manipuIt weighed 410 grains, and lated in the slightest. Rectal examination disout difficulty. to be uric acid coated with phosphates. closed a round stone, the size of a large marble, appeared An hour after the operation, the patient was then a narrow neck, and then a larger round dumb-bell in fact, except that given the usual full dose of quiuine and opium stone?a perfect With the one sphere was larger than the other. tiuct. Next 15; gr. opii 3ss.). morning (quiuia in the of the still the sound rectum, point his pulse was 64; temperature 96*5?; tongue finger coated ; urine clear. On the 27th, the pulse was firmly pressed against the centre of the prewas very weak and compressible; temperature senting stone, but the latter could not be moved from its position. Litholapaxy and soft a little puffy; breath- in the slightest 101*2?; belly impossible, lateral lithotomy obviously Thin offensive stools were being ing rapid. passed transverse perineal artery The was performed. involuntarily ; tongue dry ; wound also dry ; and urine slightly bloody. A mixture of rum and bled viciously, and was twisted. The urethra? ammonia was given every hour, and one full passing the narrow neck of the dumb-bell?was dose of quinine. Towards evening the belly cautiously divided with a blunt pointed knife became more swollen and tympanitic, and the o-uided by the finger. It was hoped to remove but the neck way; the pulse was almost imperceptible. He rallied consi- the stone entire, then removedgave from a cavity was stone second derably after a hypodermic dose of sulphuric ether. On 28th, lie was much better : tongue which it about filled. On this stone a second moist; pulse 98 and temperature 98?; belly broken neck was observed. The finger was again soft; and wound a little moist. The improvement introduced, and, aided by firm pressure above did not long continue. The wound failed to re-act, the pubes, a soft and loose circular opening was and became sloughy throughout its whole ex- felt right behind the pubis, leading into a cavity, tent; thin offensive motions were constantly the walls of which were thick and corrugated, a quantity of sabulous passed involuntarily. On the evening of 31st and which contained the temperature was 103-2?; and a painful parotid matter, with an outer shell which had broken. swelling appeared. He went from bad to worse ; The greater part of this sabulous matter was the diarrhoea continued; lie vomited nearly removed with forceps, scoop, syringe, aspirator but some was left closely adhering everything that was given to him. Abed-sore and finger, mucous the membrane, and almost beyond to threatened ; wandering delirium set in, with substone was chiefly phosphatic, with The reach. on tendinum. He, 2nd June? sultus finally,sank probably an uric nucleus for each sphere of the ejcrht clear days after the operation. dumb-bell (they have not been cut). What was examination not allowed. ?fost-mortem of it weighed over If ounces ; but After the operation, the urine was always free, was collected of sabulous matter was lost. The a clear. As to treatment, quantity and, for the most part, second stones lay in smooth lined and first on and quinine reliance was chiefly placed opium, the third sac, as already mentioned, with stimulants, and as much nourishment as cavities, and wrinkled. The patient was was rough he could take. full dose of quinine and opium, both It will be observed, that here, again, the prosta- given a tic urethra was dilated. Can this be attributed to before and after the operation, and subsequentthe irritable,thickened,and contracted bladder? ly was ordered a mixture of dilute nitric acid, Prior to operation the condition of the bladder and quinine, and infusion of linseed. For a no sabulous matter was passed. After was not clearly recognised ; rather, a condition few days, that it began to come through the wound. Quite cases was the
resembling
preceding
suspected.
CASES OF HEPATIC ABSCESS.
Arc., 1887.] a
lump
of it entered the
urethra,
and advanced
to the front of the scrotum, where it stuck for
a
few days. It blunt curette.
a
was
ultimately
removed with
Recovery was slow; a troublesome diarrhoea brought on by errors in diet; there was also some irregular fever. He was, finall}', discharged on the 27th day. The urine was free
was
and clear; the wound healed save for a slight and he Avas daily putting on flesh. It would appear that the first stone lay in the membranous urethra, the second in the prostatic urethra, and the third in the bladder proper ; a rare condition, if this opinion be correct. Neither of the two anterior stones were tunnelled, or rather grooved, by the urine, as is sometimes observed in stones of lonsc which O O standing have almost filled the urethra. For the most part it is impossible to carry out in our dispensaries any preliminary treatment worthy of the name. Frequent soundings and washings of the bladder would probably convince the patient that his case was not understood, or was perhaps hopeless. Tortured by prolonged suffering and despairing of relief otherwise, he has at length screwed up conrtige If operation be delayed, to come to hospital. his faith is shaken, his courage oozes out, and he absconds, perhaps on the very day fixed for operation; hence immediate operation is the
superficial ulcer;
rule. It is matter for our
regret, too, that
patients again,
we
and in the fatal
seldom
see
cases are,
denied -post-mortem examinations. The records of our cases are, therefore, often
generally,
incomplete. Shahjehanpur, N.-W. P., June 25th, 1887.
229
