VESICAL CALCULUS WITH TWO SMALLER URETHRAL CALCULI?LITHOLAPAXY AND SIMPLIFIED SUPRAPU BIC CYSTOT0MY DEATH THE FOLLOWING DAY.
LARGE ENCYSTED
By Surgeon-Captain G, S.
Thomson, i.m.s., Plague Duty, Satara. The patient was a Hindu Maratha boy, aged 10 years, with a history of stone for the past six years, and the usual symptoms. Latterly, during the past two months, he could get very little sleep owing to frequent calls to micturition, great rectal tenesmus, and prolapsus ani and frequent pulling at the foreskin. Present condition.?Patient is an ill-nourished boy, of nervo-phlegmatic temperament, and rather careworn face with an anxious look. Heart and lungs normal. Abdominal organs Urine cloudy with phosphates. healthy.
v
ENCYSTED VESICAL CALCULUS.
June 1898.]
strains very frequently, with prolapse of the rectum, of the size ot a ducks egg, in repeated spasms. The urine during those o spasms comes dribbling away in quantities about a teaspoonful at a time. The friends state that since about two months ago the flow o
Patient
*e urine has tended to stop quite suddenly. a A small foreskin is red and elongated. lump of the size of a horse-bean is felt, on pa pating externally in the urethra at the junction of the penile and scrotal portions. A Thompson's sound being introduced confirms the presence of the suspected urethral ca cuius at this point. An attempt is made, and frequently repeated, to extract the stone un< ei local cocaine anaesthesia, but fails completely owing to the shape of the stone and its nim -
impaction.
The patient is
now
chloroformed,
and
a
JNo.
o
lithotrite, which had been previously tested with his urethral capacity, is introduced, and the stone readily seized and crushed in situ. The urethra was washed out with warm boric lotion, and a second stone detected in the prostatic urethra. This stone was seized, conveyed back into the partially distended bladder, very gently crushed, and the debris removed with a catheter, No. 8 size, attached to the ordinary evacuator. I had to improvise this evacuator for the occasion, as I found the canulas supplied with the hospital evacuator much too large for a child s urethra. The boy
and no fragmuslin-covthe passed ered bowl upon, and into which he passed urine. Next day a Thompson's sound and digital rectal examination by Dr. Kirtikar distinctly showed the presence of a large encysted stone at the right of the fundus of the bladder and about 2^ inches from the anal aperture. A large fleshy bar, as it seemed, surrounded this calculus at its anterior portion ; and the stone presented a large flat broad surface to the interior of the bladder. Several attempts to grasp the stone with the lithotrite failed, as the stone lay in a pouch with its flat surfaces antero-posteriorly, and all attempts to dislodge it proved fruitless. The lithotrite, however, gave a distinct indication of a stone behind its female blade, and the anterior surface of the stone after extraction showed marks of the lithotrite upon it. Nothing remained but to submit the little patient to supra-pubic cystotomy, which I immediately proceeded to perform under chloroform anaesthesia. By the kindness and with the skilled assistance of Surgeon-Lieutenant-Colonel K. RKirtikar, i.m.s., Civil Surgeon of Satara, this stone was extracted, and weighed one ounce and one and-a-half drachm. It was composed of uric acid with a coating of phosphates, and X 3f x 5 inches in its three measured largest circumferences. It is oval in shape with two
passed
ments of stone were
a
good night, 011
to
217
flat faces and, bears everywhere, except, perhaps in a space sufficient to cover a rupee in the mucous area, marks of adhesion with membrane of the encysted portion of the bladder which had so long been its domicile. It was dislodged with great difficulty by Dr. Kirtikar from its pouch behind the bladder and with proper, by digital manipulation the aid of the lithotomy scoop. The incision in the anterior wall of the bladder was If inches long, and sufficed for its extraction by the lithotomy forceps, in which it was grasped in its longest diameter with the blades applied to its flattened faces. After the extraction of the stone the bladder was carefully explored digitally, and repeatedly washed out with hot concentrated boracic solution, and very little haemorrhage took place. A soft rubber catheter was tied in the bladder, draining by a long rubber tube all the urine away into a suitable receptacle filled in part with boric lotion ; and the abdominal wound sutured, and a drainage tube introduced at its lower part; iodoform and mercuric lint, and pad and bandages completed the technique of the operation. The patient came to half an hour after the commencement of the operation, and recognized his brother and sister, but two hours afterwards he shivered and became collapsed. He rallied, however, during the day and again about sunset collapsed, with temperature sub-normal, down to 97F., and died at 9-45 a.m. on the 16th April, exactly 23 hours after the operation, in spite of rigorous stimulation. Remarks.?This is the first supra-pubic cystotomy case I have lost out of 105 such operations during the past nine years, and considering the size of the stone, the patient's age, and the peculiarity of such a large stone being encysted, the mischance can hardly be put down to want of skill in the performance of the operation. Under an ideal state of universal knowledge the growth of a vesical calculus for so long and to such a size ought to be impossible; but the fatalistic tendency of the ignorant native, who often, as in this case, seeks surgical aid as a last resort, ought to be borne in mind, and is to a great extent chargeable with such a disaster. This operation has been described b}r me previously elsewhere, and must be well-known to I. M. S. men and Indian Surgeons generally. I think supra-pubic cystotomy may be still further simplified for children at any rate, and can be successfully performed with a scalpel, a suitable catheter, a syringe of ordinary nickel ear pattern, a lithotomy forceps and scoop, and suitable retractors for the abdominal wall to keep the bladder well in view. It was with such simple instruments that the bladder was readily opened and explored in this instance. The cumbrous and doubtfully useful rectal bag (a suitable rectal plug to tilt the bladder up
INDIAN MEDICAL GAZETTE.
218
will serve to prevent that viseus from being torn up from its peritoneal connections posteriorly), the irrigator for distending the bladder under hydrostatic pressure, and the artificial nail (introduced by Sir H. Thompson) are, in my opinion, unnecessary, and may be dispensed with entirely in this operation. It is sufficient to inject 4 to 8 ounces of boracic lotion through a suitable (preferably large) silver catheter, and keep the bladder distended by the assistant who looks after this catheter keeping his thumb on the canula hole. It serves the very important purpose of indicating where the initial cut in the uppermost part of the anterior surface of the bladder should be made. After division of the parietes the tissues can be torn or scraped through by the finger or a director, and the end of the catheter felt in this wound, as indicated above, readily guides the operator to the anterior wall of the bladder into which an incision is made from the projection of the catheter forwards to the pubes. With ordinary care and attention a mistake is impossible. Sutures in the bladder are,in my opinion, a work of' supererogation, extremelj7 difficult to adjust and needlessly prolonging the operation, and therefore not necessar}7, as the free drainage of the bladder can be maintained, and its function as a reservoir for urine temporarily abrogated. One can easil}7 test the sealing capacity of the collapsed viscus by injecting about 2 ounces of water which it will be found the non-sutured bladder can retain without leaking even immediately after the operation, or before suturing the abdominal wounds. A few superficial skin sutures are required, and a drainage tube reaching down to, but not into the bladder. The usual vesical sedatives lows :? Tinctura
R.
Hyoscyami
Tircturte Belladonnas
Liquoris Opii Sedativi Aquam Camphoraa ad
were
given
as
...
m
xx
...
m
x
...
m.
v
...
"i,
i
fol-
M.
Misce et
fiat linustus. Signe.?This draught to be given twice dail}\ This case properly belongs to Dr. Kirtikar, but knowing that I was to be his locum tenens during the next two days after lie saw it, and having recognised the horse-bean shaped urethral calculus the previous day and displaced it by
of urethral forceps to make a temporary passage for the flow of urine, and to prevent distention of the bladder by the entire stoppage of urine, Dr. Kirtikar made over the
means
of
a
pair
case to me.
post-mortem was not possible, as the body claimed by his brother and sister. The bladder showed signs of chronic inflammation, A
was
especially
appears to
about the sac. The cause of death me to be the result of shock following
[June
1898.
the operation, in a subject already exhausted by long-continued sufferings from chronic cystitis.
LARGE ENCYSTED
By Surgeon-Captain G, S.
Thomson, i.m.s., Plague Duty, Satara. The patient was a Hindu Maratha boy, aged 10 years, with a history of stone for the past six years, and the usual symptoms. Latterly, during the past two months, he could get very little sleep owing to frequent calls to micturition, great rectal tenesmus, and prolapsus ani and frequent pulling at the foreskin. Present condition.?Patient is an ill-nourished boy, of nervo-phlegmatic temperament, and rather careworn face with an anxious look. Heart and lungs normal. Abdominal organs Urine cloudy with phosphates. healthy.
v
ENCYSTED VESICAL CALCULUS.
June 1898.]
strains very frequently, with prolapse of the rectum, of the size ot a ducks egg, in repeated spasms. The urine during those o spasms comes dribbling away in quantities about a teaspoonful at a time. The friends state that since about two months ago the flow o
Patient
*e urine has tended to stop quite suddenly. a A small foreskin is red and elongated. lump of the size of a horse-bean is felt, on pa pating externally in the urethra at the junction of the penile and scrotal portions. A Thompson's sound being introduced confirms the presence of the suspected urethral ca cuius at this point. An attempt is made, and frequently repeated, to extract the stone un< ei local cocaine anaesthesia, but fails completely owing to the shape of the stone and its nim -
impaction.
The patient is
now
chloroformed,
and
a
JNo.
o
lithotrite, which had been previously tested with his urethral capacity, is introduced, and the stone readily seized and crushed in situ. The urethra was washed out with warm boric lotion, and a second stone detected in the prostatic urethra. This stone was seized, conveyed back into the partially distended bladder, very gently crushed, and the debris removed with a catheter, No. 8 size, attached to the ordinary evacuator. I had to improvise this evacuator for the occasion, as I found the canulas supplied with the hospital evacuator much too large for a child s urethra. The boy
and no fragmuslin-covthe passed ered bowl upon, and into which he passed urine. Next day a Thompson's sound and digital rectal examination by Dr. Kirtikar distinctly showed the presence of a large encysted stone at the right of the fundus of the bladder and about 2^ inches from the anal aperture. A large fleshy bar, as it seemed, surrounded this calculus at its anterior portion ; and the stone presented a large flat broad surface to the interior of the bladder. Several attempts to grasp the stone with the lithotrite failed, as the stone lay in a pouch with its flat surfaces antero-posteriorly, and all attempts to dislodge it proved fruitless. The lithotrite, however, gave a distinct indication of a stone behind its female blade, and the anterior surface of the stone after extraction showed marks of the lithotrite upon it. Nothing remained but to submit the little patient to supra-pubic cystotomy, which I immediately proceeded to perform under chloroform anaesthesia. By the kindness and with the skilled assistance of Surgeon-Lieutenant-Colonel K. RKirtikar, i.m.s., Civil Surgeon of Satara, this stone was extracted, and weighed one ounce and one and-a-half drachm. It was composed of uric acid with a coating of phosphates, and X 3f x 5 inches in its three measured largest circumferences. It is oval in shape with two
passed
ments of stone were
a
good night, 011
to
217
flat faces and, bears everywhere, except, perhaps in a space sufficient to cover a rupee in the mucous area, marks of adhesion with membrane of the encysted portion of the bladder which had so long been its domicile. It was dislodged with great difficulty by Dr. Kirtikar from its pouch behind the bladder and with proper, by digital manipulation the aid of the lithotomy scoop. The incision in the anterior wall of the bladder was If inches long, and sufficed for its extraction by the lithotomy forceps, in which it was grasped in its longest diameter with the blades applied to its flattened faces. After the extraction of the stone the bladder was carefully explored digitally, and repeatedly washed out with hot concentrated boracic solution, and very little haemorrhage took place. A soft rubber catheter was tied in the bladder, draining by a long rubber tube all the urine away into a suitable receptacle filled in part with boric lotion ; and the abdominal wound sutured, and a drainage tube introduced at its lower part; iodoform and mercuric lint, and pad and bandages completed the technique of the operation. The patient came to half an hour after the commencement of the operation, and recognized his brother and sister, but two hours afterwards he shivered and became collapsed. He rallied, however, during the day and again about sunset collapsed, with temperature sub-normal, down to 97F., and died at 9-45 a.m. on the 16th April, exactly 23 hours after the operation, in spite of rigorous stimulation. Remarks.?This is the first supra-pubic cystotomy case I have lost out of 105 such operations during the past nine years, and considering the size of the stone, the patient's age, and the peculiarity of such a large stone being encysted, the mischance can hardly be put down to want of skill in the performance of the operation. Under an ideal state of universal knowledge the growth of a vesical calculus for so long and to such a size ought to be impossible; but the fatalistic tendency of the ignorant native, who often, as in this case, seeks surgical aid as a last resort, ought to be borne in mind, and is to a great extent chargeable with such a disaster. This operation has been described b}r me previously elsewhere, and must be well-known to I. M. S. men and Indian Surgeons generally. I think supra-pubic cystotomy may be still further simplified for children at any rate, and can be successfully performed with a scalpel, a suitable catheter, a syringe of ordinary nickel ear pattern, a lithotomy forceps and scoop, and suitable retractors for the abdominal wall to keep the bladder well in view. It was with such simple instruments that the bladder was readily opened and explored in this instance. The cumbrous and doubtfully useful rectal bag (a suitable rectal plug to tilt the bladder up
INDIAN MEDICAL GAZETTE.
218
will serve to prevent that viseus from being torn up from its peritoneal connections posteriorly), the irrigator for distending the bladder under hydrostatic pressure, and the artificial nail (introduced by Sir H. Thompson) are, in my opinion, unnecessary, and may be dispensed with entirely in this operation. It is sufficient to inject 4 to 8 ounces of boracic lotion through a suitable (preferably large) silver catheter, and keep the bladder distended by the assistant who looks after this catheter keeping his thumb on the canula hole. It serves the very important purpose of indicating where the initial cut in the uppermost part of the anterior surface of the bladder should be made. After division of the parietes the tissues can be torn or scraped through by the finger or a director, and the end of the catheter felt in this wound, as indicated above, readily guides the operator to the anterior wall of the bladder into which an incision is made from the projection of the catheter forwards to the pubes. With ordinary care and attention a mistake is impossible. Sutures in the bladder are,in my opinion, a work of' supererogation, extremelj7 difficult to adjust and needlessly prolonging the operation, and therefore not necessar}7, as the free drainage of the bladder can be maintained, and its function as a reservoir for urine temporarily abrogated. One can easil}7 test the sealing capacity of the collapsed viscus by injecting about 2 ounces of water which it will be found the non-sutured bladder can retain without leaking even immediately after the operation, or before suturing the abdominal wounds. A few superficial skin sutures are required, and a drainage tube reaching down to, but not into the bladder. The usual vesical sedatives lows :? Tinctura
R.
Hyoscyami
Tircturte Belladonnas
Liquoris Opii Sedativi Aquam Camphoraa ad
were
given
as
...
m
xx
...
m
x
...
m.
v
...
"i,
i
fol-
M.
Misce et
fiat linustus. Signe.?This draught to be given twice dail}\ This case properly belongs to Dr. Kirtikar, but knowing that I was to be his locum tenens during the next two days after lie saw it, and having recognised the horse-bean shaped urethral calculus the previous day and displaced it by
of urethral forceps to make a temporary passage for the flow of urine, and to prevent distention of the bladder by the entire stoppage of urine, Dr. Kirtikar made over the
means
of
a
pair
case to me.
post-mortem was not possible, as the body claimed by his brother and sister. The bladder showed signs of chronic inflammation, A
was
especially
appears to
about the sac. The cause of death me to be the result of shock following
[June
1898.
the operation, in a subject already exhausted by long-continued sufferings from chronic cystitis.
