Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson.

  • Thompson, Henry, Sir, 1820-1904.
Date:
1882
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Licence: Public Domain Mark

Credit: Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson. Source: Wellcome Collection.

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    safely infer that all belong to the same variety. In such a case also it is probable that the patient empties his bladder per- fectly by his own efforts. On the other hand, if the urine is alkaline, and deposits phosphatic matter; also, if the patient is unable to empty his bladder by his own efforts, and requires a catheter, you may conclude that it is a phosphatic stone, or, at all events, that it is covered with phosphates. I have spoken of uric-acid and of phosphatic calculi. But we may have to deal with an oxalate-of-lime stone—a fact which it is very important to ascertain. You will examine the urine, and observe if it contains much oxalate of lime deposit. The patient may have passed a small mass of oxalate of lime before, and it may be thence inferred that an oxalate-of-lime calculus exists now; but it may have an external coating of phosphates, and thus its real nature may be hidden. The fol- loAving is a case in point. I had some time ago to operate on a large stone in the bladder of a private patient. I crushed the stone four times, bringing away a good deal of phosphatic material. I soon noticed that my lithotrite never went through the stone : it always went a certain way, and then there w^as a hard mass. After four sittings I could not crush any more. It was clear that there was a very hard centre stone, on which my strongest litho- trite made no impression, the crust only having been removed. I know, from ex- perience, the recoil of the lithotrite from an oxalate-of-lime stone so well, that I had no hesitation in saying such an one was present. Accordingly I performed litho- tomy, and removed a large and well- marked specimen of that kind. In such a case, there would not be oxalate of lime in the urine, but a large deposit of phos- phates. It is worth remarking here, that in dealing with the hardest uric-.icid stone in a lithotrite, an impression will be made by a turn of the screw, the jaws of the lithotrite will make some impression on the stone even if they do not crush it; but an oxalate-of-lime stone communicates a sensation when grasped by the instru- ment as if you were laying hold of a piece of iron—you make little or no impression upon it until considerable force be ap- plied. The number of calculi present is the next thing to be ascertained. Usually there is only one, but occasionally there are more. There is a patient here on whom I shall perform lithotrity to-morrow, who has two rather large uric-acid stones in the bladder. You may determine that point thus: Having seized one in the lithotrite, move it gently in every direc- tion as a sound for others. If then you encounter one on one side and one on the other, you know that there must be at least three stones. There is a source of deception here which it is necessary to guard you against. While retaining the stone between the blades of the lithotrite, and moving the instrument from side to side in search for another, a rattling sound is easily produced which resembles very closely that of contact with another stone. This arises because the stone seized is not closely fixed between the blades of the lithotrite, and it rattles between them. I have seen the error conmitted of inferring a second stone from this cause. Sometimes a great number of small calculi are present, varying between the size of a small nut and that of a pea, so that the rattle of several is heard, and, I may add, felt. These are favourable cases for operation, when compared with those in which a single calculus is present, taking equal weights. The large stone on being crushed results in large hard and sharp fragments. The small stones may be regarded as fragments already made, and also possessing a much less irritating form. Of course much less mechanical work is necessary to crush and remove the calculous matter in the last-named condition. In the patient's interest I would rather remove six drachms of such small calculi, than four drachms in the form of a single stone. Having obtained all these data, the important question is, What operation is to be performed? Are you to perform Lithotomy or Lithotrity ? You know there are only two modes of removing the stone. You must make an opening sufficiently large to admit of its withdrawal at once, o]- you must crush the stone into small fragments, so that they may be removed by the natural pas- sage. It was far less important to make a diagnosis of all the points named, when there was but one operation—namely, that of cutting. Formerly, whether the stone was large or small, the patient was always cut. There was no other way of removing it. Now that we have two operations, it is very necessary that we