Jalai, years,



Din, Mahoinmedan male, aged 55 admitted into Sialkote Civil Hosthe 26th September 1891, sufFeriuoD

was on

DAVIDSON, Surgeon, Sialkote,



from symptoms of vesical calculus which had existed for four years. Ou the sound being passed, a large calculus was at once observed. On the 27tli September be was placed under chloroform and litholapaxy attempted. With some difficulty the stone was seized and a part of it was crushed. While attempts were being made to catch the calculus between the blades of the forceps, a projection was noticed about three inches above the pubes, a link to the right When the of the median line of the abdomen. lithotrite was withdrawn, this projection disappeared. After about 2 oz. of debris had been crushed and removed, it was found impossible to seize the remaining portion of the calculus. After many futile attempts I decided to perform suprapubic lithotomy, as the remaining portion of the stone appeared very large. The bladder was injected with boracic solution, but did not dilate satisfactorily, nor was there a Peterson's Rectal bougie in store. An incision about two inches long was made in the median abdominal line reaching well down to the pubes. The different structures were divided upon a director till the point of a Thompson's sound which had been previously



clearly felt, especial




The surface which had been in the bladder was studded with fine


apposition to mammillary

projections. It is evident from the nature of the case that neither litholapaxy nor lateral lithotomy would have been successful. The question arises as so whether the calculus was encysted or The larger a calculus is, the adherent. nearer as a rule is it located to the neck of the

bladder. In the cases of encysted calculus mentioned by Thompson in Holmes' System of Surgery, all with the exception of one (which is doubt-

the neck of the bladder. of an encysted calculus projects iuto the bladder, it is usual to find that a neck exists demarcating the free and

ful) were situated Moreover where

near a


encysted portions. In this case the stone was firmly fixed to the summit of the bladder, which too appeared fixed to the tissues behind it. The total weight of the stone was 4 oz. 6 drachms. Of this the projecting portion (if the stone was merely encysted), weighed only 2 oz., nor could any line of demarcation be discovered. It was with extreme difficulty that the calculus could be separated from the vesical walls. Taking everything into consideration, I am inclined to the opinion that this was a case ot adherent calculus, although Sir ELenry Thompson almost seems to doubt the existence of this condition. Unfortunately a post-mortem examination was not allowed.

taken to keep the peritoneum out of the way. The bladder was found to have been very slightly distended and was about 2| inches below the level of the skin. A small incision was made upon the point of the sound, which at once appeared in the wound. This incision was then enlarged with the finger. On passing the hand into the bladder, the stone was easily found situated at the upper part of the bladder, but only one face of it could be felt, the remainAntiseptics in iihyme.?Dr. Deney, of ing surfaces being closely grasped by the bladder. With the finger the stone was with Keytesville, describes in rhyme the way in much difficulty partially exposed, and on appli- which a surgeon should prepare for an operation. cation ot the lithotomy forceps it was still found The following is an extract: " Although in details we may vary, firmly fixed. The bladder too gave the impresSome plan is necessary, sion of being adherent to the neighbouring To heal a wound by first intention. Structures, as even with a reasonable amount Some needful rules I here will mention. The surgeon first his clothes should doff, of traction it could not be made to advance His coat and vest and shirt pull off. towards the wound, the traction being applied In rubber apron should be drest. through the calculus. After frequent attempts Extending from the feet to chestScrub well his hands with soap and water, with the finger and forceps the stone was finally If he don't he ort'r. released and removed. The patient sponged 'till all is sweet, The bladder was carefully examined and Is laid upon a rubber sheet. The towels all on chairs are hung, It was washed out with boracic found intact. And water by the waiter brung. lotion, a drainage tube was inserted, and the As vicious germs will always breed, of the closed abdominal wound was Some antiseptic he will need. upper part As bichloride is dangerous stuff, with buried and superficial sutures. Absorptive One in two-thousand is enough, dressings were then applied and a morphia Carbolic acid one in thirty, in the rectum. Will keep the knives from getting dirty." suppository placed " When once a wound is dressed, The patient slowly sank, dying from exhausIt must be left at rest." tion at. 8 p.m. ou the 27th (the day of the " ?

operation). The



drachms. It


found to weigh 4 oz. uric acid one and extremely


was a

Success alone inures to he Who never yearns the wound to see. The cortege of a med'ling ape Are hearses, obsequies, and crape."

A7. 1", Medical Record,

May 2,1891.

A Case of Vesical Calculus with Peculiar Complications.

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