Imágenes de páginas
PDF
EPUB

the urethra, a rubber winged catheter was kept in the bladder. A portion of this was broken off and remained there, causing, in a few days, frequent micturition and cloudy urine. Five weeks ago a stone was discovered. Now there is frequent micturition, and abrupt stoppage followed by pain in the glans penis. The bladder was filled and emptied, the fluid measuring half a pint, which quantity was again injected. By the lithotrite the stone measured nearly an inch and a quarter, being doubtless caught lengthwise. A certain elasticity of the closed blades led to their withdrawal with a small fragment of brittle rubber. This withdrawal was twice repeated, with bits of rubber, including the two wings, and also twenty-seven grains of stone. The whole operation had now lasted nine minutes. A straight evacuating tube, No. 31, was next introduced, and the bladder pumped during four minutes, after which it yielded no more foreign material. Almost all the stone thus evacuated, (fifty-five grains,) together with three bits of rubber catheter, measuring respectively three-fourths, seven-eighths, and one-fourth of an inch in length and of a diameter No. 23 Charrière, came through the tube within the first minute. The lithotrite was now again introduced, but nothing more discovered; after which the bladder was again washed out. The entire operation lasted twenty-five minutes, much of which was occupied in determining the fact that the bladder had been evacuated. The next night the patient had no pain, and micturated but twice, instead of six times as habitually before. Two days after, the temperature suddenly rose to 102° Fahr., but as quickly subsided, without other sign or symptom, the patient being entirely relieved.

CASE XI. Patient's age, sixty-two. Date of symptoms, three years, Two stones, lithic; largest diameter, thirty millimetres. One sitting: duration, one hour and twenty minutes: size of tubes, twenty-nine and thirty; quantity removed, three hundred and nineteen grains; urethra somewhat contracted in front of scrotum. In evacuating these stones, the time was found to have been occupied as follows: crushing, twenty-nine minutes; evacuating, twenty-four minutes, the rest of the time being consumed in passing and withdrawing the instruments, renewing the water, etc. As usual most of the fragments passed the tube early in the operation, and readily; much of the time occupied by the evacuation being consumed in making sure that no fragments were left behind. Micturition before the operation was once in one and one-half hours, after the operation about once an hour, and obstructed by purulent mucus. The patient had a large, though yielding prostate. The water was drawn during eight days;

at the end of which he was generally able to relieve himself, the purulent mucus having diminished in quantity. The testicles were somewhat swollen. Though still under treatment, the patient is fairly convalescent.

A discussion of the relative values of lithotrity and lithotomy, at a recent meeting of the Royal Medical and Chirurgical Society (March 16th, 1878, reported in the Lancet of the 12th inst.) has interest in this connection, because it exposes the current English views upon this subject, while it gives prominence, by contrast, to the advantages of the new method of lithotrity over the old one. It is evident that the large tubes offer a ready means for preventing the recurrence of stone by either nuclei or fragments, which are "by no means uncommon" after lithotrity, as Mr. Cadge remarked, and “one of its serious defects"; also, for removing the phosphatic deposits which, in the words of Sir Henry Thompson on that occasion, are "not unfrequently left after lithotrity,"—" being due to the injury done to the mucous membrane by sharp fragments of stone, and by continued instrumentation.' Sir Henry looked upon them as "unavoidable, and as a price paid for the greater security to life which lithotrity affords." Again, Sir James Paget said "he must confess to a general feeling in favor of lithotomy over lithotrity," unless "the calculus can be got rid of in two or three sittings." Sir Henry Thompson on this subject said, "three, or at most, four sittings, at which point he should distinctly prefer to cut."

The obvious question then is, whether, in adult patients, when the stone requires more than three or four sittings of a few minutes each, by the old method, it is safer to cut, or to employ the new and rapid lithotrity with evacuation. The latter must, in cases now rejected by the lithotritist, be preferred to lithotomy, unless it can be shown that its mortality amounts to one in three, this being the death-rate of lithotomy, in such cases, as stated during the discussion. Such a mortality for the new operation is improbable.

There can be no doubt of the importance of the complete evacuation of final fragments, renal nuclei, phosphatic masses and foreign bodies.

In the matter of crushing, stress was justly laid upon the difficulty of withdrawing the impacted lithotrite from the blad

der, - both Sir Henry Thompson and Mr. Coulson speaking of fragments actually "preventing the withdrawal of the instrument," and "requiring, in one case, incision in the perinæum." This difficulty is obviated by the new notched lithotrite, which effectually clears itself. It also permits more expeditious work. The larger size, as made by Collin, is much more powerful than the usual lithotrite, while it can readily be introduced into a bladder that will admit a No. 27 tube.

As the female urethra is so easily dilated, this method will doubtless prove to be the easiest way to dispose of calculi in the female, the tubes being made shorter and larger than for the male urethra.

I may again say, in conclusion, that since its first announcement this method of evacuation has by repeated experiment been so modified and reduced to a system, that it has become much more rapid and efficient. The time then consumed by the operation, although it showed a surprising tolerance of the bladder, is no criterion of the time now required for accomplishing the same result. The improvements relate chiefly to the systematic dispersion or collection of fragments in the bladder, to the position of the tube, and to the recognition and immediate removal of obstruction. A considerable part of the time is still consumed in ascertaining whether the stone is wholly evacuated, a large part of it being usually removed at the beginning of the operation.

[From the New York Medical Record, June 8th, 1878.]

RAPID LITHOTRITY WITH EVACUATION.

TO THE EDITOR OF THE MEDICAL RECORD.

AN article by Dr. Keyes, in your last issue (May 18th), gives me occasion to refer to one or two misapprehensions which pervade his allusions to "Modern Lithotrity," as he is kind enough to call the new operation for stone.

In this article, which is devoted mainly to a description of the jaws of a lithotrite, the writer states that my lithotrite "must sometimes clog," because "it is made on the principle of Reliquet's." He is here doubly mistaken. In the first place, with regard to the fancied resemblance between the instruments: lithotrites are of two kinds, one fenestrated, the other with a solid floor. Reliquet's is fenestrated: mine is solid. In the second place, as an ascertained fact, my lithotrite does not impact, the male blade being furnished with alternate notches forming inclined planes by which the detritus is extruded right and left, except where a minute portion at the heel is driven through a slot by a long and effective spur. The latter, which reaches the outside, also serves to brace the heel of the male blade. Reliquet's non-impacting lithotrite is identical with the obsolete fenestrated brisepierre, with the addition of teeth in the opening below to ensure pulverization. Dr. Keyes proposes to remove these added teeth, and return to the brisepierre à mors fenêtré (porte a fàux) of

Charriére. (Nouveau Dict. de Méd. et de Chir., t. 20, Paris, 1875, p. 667.) In fact he goes back to the flattened jaws of the "slightly indented and fenestrated or open female blade" figured by Costello (Cycloped. of Pract. Surgery, Vol. III., pp. 50, 21, London, 1861), with a male blade small as in the usual lithotrite, to avoid pinching the mucous membrane; in short, a common lithotrite with the floor removed.

*

I am gratified to find that the writer of the article endorses my statement, (which is an important corollary of the new system,) that “in future it will be no longer essential to pulverize the fragments, but only to comminute them." This may be accomplished by either a fenestrated or a solid instrument. Any fenestrated lithotrite that reduces to the size of a small opening the fragments driven through it, enables them also to pass the evacuating tubes, the use of which characterizes the new method. But although instruments of this class will doubtless do well enough with small stones, as does indeed the usual lithotrite, my objections to a fenestrated instrument, of which I considered and rejected several (including that proposed in your journal), are these:

1. Sharp fragments, while firmly engaged in the opening, or driven through it, are likely to injure the floor of the bladder. During a long operation, such as I have proposed, it is hardly possible to prevent the frequent contact of the floor of the bladder with the extremity of the instrument, which, instead of protecting the mucous membrane, as usual, by a rounded and polished surface, is then fortified with protruding splinters of calculus, always impinging upon the same region of the floor.

*The mucous membrane would be more secure if care were taken always to blunt, or round a little, the edge of the sole of the male blade.

« AnteriorContinuar »