for

impacted

ureteral calculus which have recent-

ly fallen to m}T lot, each in its way, I venture to think, possessing some features of interest. Lieut. D., Royal Artillery, cet. 28, sent by Dr. Blood, of Woolwich, consulted me on July 19th, 1808. He had suffered, off and

for nineteen months from renal colic and The symptoms first set in at Malta in January, 1897, in the form of colic}' pains in both loins, extending across the abdomen, whenever he rode on horseback. These were at first considered to be due to indigestion; but on the third or fourth day on dismounting he found that his urine contained blood, so he went on the sick list. The symptoms passed off in a few days with rest and treatment. Three weeks later, his duties being heavy and involving much riding, the symptoms returned, and he had again to go on the sick list. The pain at this period was mainl}7 confined to the left side, commencing in the loin, shooting down to the groin, and sometimes across the abdomen, giving rise to the sensation of a string being tied tightly round the body. At no period did the pain shoot down into the testicles, nor was the organ retracted. The symptoms continuing, he came to England in May, 1897, and placed himself under the care of a well-known London physician. The renal attacks with hematuria continued to oti,

hematuria.

come

on

periodically every fortnight or so, and, to say, two of his worst attacks seemed to have been brought on b}' short sailing trips, though he did not suffer from sea-sickness. Getting no better he returned to Malta in August, 1897, and during the voyage painless hematuria set in, which continued off and on, till September, when another severe attack of pain in the left loin occurred, and the hematuria suddenly ceased. He was then seen by Major Swabey, R.A.M.C., who diagnosed the case as one of stone in the kidney. Unable to continue fit duty he went to Sicil}', but the strange

TWO RECENT CASES OF

SUCCESSFUL

OPERATION FOR IMPACTED STONE URETER, f M.Ch., -By P. J. FREYER, M.A., M.D.,

IN THE

LT.-COL. I.M.S., llETIllEI),

Surgeon to St. Peter's Hospital. attenThe short paper to which I invite youra mere as be to is regarded tion this evening of contribution to the surgery fragment?a brieflatter during which, is a subject the ureter. This of the attention the last few years, lias engaged of operastill,'how few instances surgeons ; and ureter have been placed tion for stone in the with me think I you will agree upon record. meets who that it is incumbent on every surgeon details to his publish practice with such cases in we may have accumulaso that, in time, a thereof, and varied number, as ted a sufficiently large concluauthoritative

basis from which to draw of dealing with sions as to the best methods part of the urestone impacted in any that I venture to teral canal. It is in this spirit of operation cases of two place before you details British his case to the

particular

*

of I have'sent a full account

Assocmuun. Medical "Association. aieaicai

ivoriaou, ' * -t? TiTpfUoal Society of London, Medical t Paper read before the nuary 23rd, 1899.

v?3?age again brought on hematuria, accompanied by fever, which, after lasting a week, again wound up with severe colic. He returned to duty at Malta at the end of the month of October, but had to lie down for several hours in the middle ot the daj^ to relieve the pain. The redrilling commenced on November 1st, and the first route march brought on pain and hemorrhage. He was excused marching and rode in a carriage, but though the pain was less the hemorrhage continued. In December he passed two stones by the urethra, cylindrical in shape and like red sand-stone. The acute pain up to this was in the left side ; and from that period till July, 1898, though there was occasional hematuria and the urine contained albumen, there was no severe pain, merely a dull aching in"botli loins. In May 1898, he returned to England"for duty j at Woolwich. On July 10th he took a lot of exer-

158

THE INDIAN MEDICAL GAZETTE.

and next day an acute attack of pain set in in the right side, which lasted seveny-two hours continuously, during which he was kept under the influence of morphia by Dr. Blood. The pain was excruciating, accompanied by restlessness, nausea, and vomiting, with constant desire to micturate, only a small quantity of highcoloured urine passing each time. For two days after this attack the urine was clear, but after that became thick and bloody again. I found that there was a slightly movable tumour in the region of the right kidney as large as two fists, extremely tender on palpation both in the loin and in front. There was no stabbing pain on pressure at the back, but distinct tenderness at one spot in front, midway between the navel and the anterior superior spine of the ilium. Urine, colour of Madeira wine, acid, sp. blood corpuscles and crystals gr. 1015, containing of oxalate of lime, also albumen. The left kidney was normal. My diagnosis was?stone in the pelvis of the kidney, trying to pass down the ureter and causing obstruction of urine. On July 30th the patient entered a surgical home, and on August 1st I operated, Mr. W. Braine giving the ancesthetic and Mr. B. Smeaton assisting. Drs. A. M. MacDonnell and H, T. Griffiths were also present. The

cise,

kidney rapidly exposed through an oblique lumbar incision four-half inches long, and the fatty capsule opened. No stone was detected on feeling it all over. The kidney, which was much enlarged and congested, was stripped of its fatty capsule and brought out on to the loin through the wound. I felt it carefully all over, but could detect no stone. The kidney was then opened through the convex border by means of a scalpel, and my finger passed into the pelvis, a rush of urine taking place through the wound, and the kidney collapsing much in size. No stone could be found, though my finger passed easily into the calyces, which, with the pelvis, formed a large, smooth-walled cavity. I then passed a was

catheter down the ureter as far as four inches from the pelvis, where it was obstructed. A long silver probe was then passed, and a stone felt in the ureter at this point. The incision in the loin was at once extended downwards and inwards for four or five inches, and the peritoneum raised inwards from off the ureter by my fingers, till I could grasp the stone (which felt the size of a filbert), lying in the ureter between my finger and thumb? I made several attempts to push the stone upwards into the kidney, but it was too firmly impacted in the ureter, so the ureter was incised

longitudinally over the stone, which was pushed through the wound by the point of my finger. A bougie was then passed into the bladder through the ureter from the pelvis. I did not

suture the

wound in the ureter

because (1)

suturing of the ureter when a stone is removed extra-peritoneally is a debatable proceeding ;

(2)

the ureter

would and

probably

[May

was

so

narrow

that

1899.

suturing

contraction of the canal ; I could extract the stone

cause

(3) though

with the limited incision already indicated, the successful suturing of the ureter at the bot-

tom of a deep wound was impossible without a much more extended dissection. I contended

myself, therefore, by placing

a

large drainage

tube down to the opening in the ureter, along the back of the kidney, bringing the muscles together by buried silk sutures, and the superficial parts by silk-worm gut. The wound in the kidney was partially closed by two sutures, the middle portion being left open so that the urine might flow freely through the loin, and thus avoid tension on the ureter till the wound in it should have healed. Bloody urine was passed freely by the urethra in the evening, showing that the ureter was patent; and bloody urine by both loin and urethra for several days. On the third day I began-to shorten the drainage tube daily, and this was completely removed on August 7th. On the 8th the wound was firmly united, save in the track of the drainage tube. On the 9th urine ceased to flow by the loin. The patient made a rapid recovery; was sitting up on August 28th ; went for a walk on September 2nd ; and left the home on September 7th, travelling by train to Margate. Soon after he began to bicycle ; he started to rejoin his battery at Gibraltar on November 15th. He is now in excellent health, and wrote to me in the end of December last that he does five or six hours work daily with his battery, ascending the rock 1,300 feet. It may be of interest to mention, as bearing on the hereditary tendency of stone, that owing to the successful result in this case, the patient's mother, who for seventeen years had suffered from stone in the kidney, placed herself in my hands. On September 28th, 1898,1 performed a lumbar nephrolithotomy. Dr. Dudley Buxton, anzesthetist, and Mr. Swinford Edwards assisting me, removing one largish oxalate of limestone from the pelvis and several smaller ones from the calyces. The kidney, which was extremely large, was sutured. No urine passed by the wound, and the patient made a rapid and successful recovery. Furthermore, this lady's father suffered severely from gravel for many years before his death. Some years ago I operated successful for stone in the bladder on three generations in the same year?son, father, and

grandfather.

The second case, a man, cut. 53, has been patient at St. Peter's Hospital, off and on, for thirteen years, suffering from multiple stricture of the urethra, which has been operated on several times, and symptoms of kidney stone. In 1895 his left kidney was explored for stone by another surgeon, but with a negative result. Temporary relief ensua

May

OPERATION

1899.]

acting, and flakes of pus issuing from them. The patient has continued to improve steadily in health. The pains in the loins have disappeared ; there is no hematuria, and scarcely any ureters were seen to be

returned, and in but the old symptoms again ill, the pain the summer of 1897 he was very at times, severe the left loin being very in accomand testicle and radiating to the groin was very which at times panied by hematuria,also in pain profuse; there was urine occasionally thick was extremely the right loin. The on deposited pus and standing and offensive, I determined bulk. its amounting to half the left to explore circumstances under these on

ed,

kidney again, which

was

were

accomplished

Ipassed my and down to the iliac fossa, the under ribs, lip the peritoneum inwards to the aorta, pushing recovered out of the way. The patient rapidly a very was only there but from the operation, soon set which temporary relief to the symptoms, that Under the impression in as bad as ever. backto due be the symptoms might in laige part stricture, which ward pressure, resultingfrom the a No. 6 bougie, had again contracted, so that with difficulty, I perkidney wasfound, though

was

passed

removed. I will, in conclusion, briefly refer to five other instances of stone impacted or enc\7sted in? the ureter, which have been operated on by mc ?four of these during m}7 experience in India. In three, the stone was impacted at the ureteral orifice, projecting into the bladder and felt by the sound. One occurred in a female, two in males. In each instance an operation was undertaken, under the impression that I had to deal with an case of stone in the blad-

ly

November 18th,

ordinary

formed internal urethrotomy on strictures 189/, cutting three dense cartilaginous was The patientwith scale. up to 16 of the English for two da\rs extremely ill after the operation rising to 106 the temperature severe rigors, he scanty ; but degs. F., and the urine being very the hospital recovered, though slowly, leaving it operation, though early in January. This urine, of his afforded a free flow for the passage other symptoms his diminish did not much dimin1 hough the pain in the left loin graduallyand for increased, loin that in the right

ished, months he continued

to

attend the

der, and in each

admitted

into

tomy

hospital,

pencil-shaped

projecting

cystoscoped.

the stone

was

dislodged'

position by introducing

groin,

out-patient

under an an?e3thetic, ber 9th I cystoscoped him and detected a long, narrow, rough, into the bladder from the right stone of stone projectureteral opening. The portion the cystoscope by ing into the bladder appeared and dark grey in colour. inch long, to be about f Harrison, and othei's My colleague, Mr. Reginald of the stone. I at once had an excellent view four and after three or introduced a lilhotrite, eventually caught the unsuccessful attempts, of the blades, pulled it out stone between the the it and removed ureteral opening, crushed of consisted The debris debris by the aspirator. On Novemurates and weighed twelve grains. The ber 23rd the patient was again both mucus; with bladder walls were coated

case

the forefinger through the dilated urethra in the female and through the ordinary perineal lithotomy wound in the males, scraping the orifice of the ureter by the finger nail, the stone being forced downwards and inwards by the hand placed 011 the the ordinary lithoand then removed

irom its

containing department, his urine aconstantly quantity considerable much pus, and at times loin became the right of blood. Occasionally of the much swollen, and the disappearance in increase an swelling was always followed by In October, the quantity of pus in the urine. of great irritability 1898, he began to complain desire to pass of the bladder; there was constant the of penis. He water with pain at the end and on Novemwas

seen

in better pus in his urine. He states that he is liealth than he has been for years. The history of this case presents many points for speculation which would, however, be foreign to the purpose of this paper; the case being now brought forward onty for the purpose ot illustrating what I believe to be a novel method by which a stone projecting into the bladder from the ureter may possibly sometimes be successful-

lumbar an oblique September 1st, 1897, by but no made, was incision. A most careful search fingers well

English scale,

159

FOR URETER STONE?FREYER.

j

I

forceps.

b}r

In the British Medical Journal, May 9th, 1891, of a boy, cet. page 1005, I have given details two different at I from removed, whom 15, two separate stones, litholapaxy sittings, by grains, aggreweighing respectively 757 and 581 After removing ounces. gating more than the first stone from the bladder, I found that there was a second lying in the lower part of the right ureter close to the bladder. The second stone was felt as a hard tumour in the loin, about three inches long, and could easily be felt in the ureter between a finger in the rectum and1 the hand on the groin. I determined to remove this stone by suprapubic cystotomy as soon as the patient should have recovered from the first operation, but on the fourth day the tumour in the groin suddenly disappeared, and a stone was felt lying free in the bladder, and successfully removed by litholapaxy. Evidently this latter stone, lying in the ureter, rested on the stone located in the bladder; as soon as this support was removed, the ureteral calculus was pushed into the bladder by the force of the accumulated* urine behind it. The fifth case is recorded in the MedicoChirurgical Transaction, vol. 81. It was that of an obscure cystic tumour of the bladder, whichcontained two calculi, weighing 41 grains, removed supra pubicall}7. My explanation of the

C

ifoo

THE INDIAN MEDICAL GAZETTE.

this?-that the stones descending from the kidney were arrested at that portion of the '?'ureter which passes obliquely through the blad

Two Recent Cases of Successful Operation for Impacted Stone in the Ureter.

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