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CASES OF STONE IN THE BLADDER.
131
petechial spotswere seen beneath that membrane;Pacchionian bodies moderately numerous. On slicing the brain-substance,
pale, with rather fewer punctae on the side. Lower down were seen a number of small spots of effused blood, chiefly grouped together in patches about the size of a shilling; these were all in the left hemisphere, also some similar spots at the base of the brain. The ventricles were rather dry, the membrane healthy, and not the seat of haemorrhage. The choroid plexus was found quite sound, and the whole brain tissue normal in consistence
it
was
found firm and
right than on the left
and colour. The exudation of blood, resulting either from its abnormal fluidity or the want of tone in the vessels, was here well marked; and a case of this kind is well calculated to convince of their error those who maintain that such exudation never takes place, but that the rupture of some vessel is indispensable for the escape of blood. The general manner in which the petechise were scattered all over the frame was very remarkable; in fact, spots and vibices were found on the pleura, pericardium, on the investing membrane of a mass of bronchial glands, on the lining membrane of the aorta, beneath the capsules of the kidneys, under the arachnoid membrane, and even in the substance of the left hemisphere of the brain; besides the large spots which were extensively disseminated on the skin. The intercurrent pleuro-pneumonia, which contributed in giving the case a very serious character, was likewise influenced in its pathological manifestations by the haemorrhagic nature of the case, as the fluid effused in the left pleura was strongly tinged with blood. This state of the circulating fluid presents a very striking contrast with the pitchy appearance of the blood in another destructive affection-viz., cholera.
that he had been married eight years; and that she had three children. Her husband had been under medical treatment for several years, and had discontinued work for the last twelvemonth. On examination, however, by the rectum, a very large stone was discovered, the boundaries of which could be but imperfectly traced by the finger. Mr. Lawrence ordered wine, beef-tea, arrow-root, barleywater, &c., and opiates, to allay pain and procure sleep. The patient still continued to suffer greatly, and on Jan. 3, 1853, he was placed under the influence of chloroform, and Mr. Lawrence proceeded to perform lithotomy. The operation was commenced in the ordinary manner, but owing to the very large size of the stone, it was found necessary to divide the right side of the prostate gland also, and to enlarge the external incision. After a protracted and extremely difficult operation-in the course of which the patient lost a considerable quantity of blood-the stone was at length removed. We here give a rough sketch of the stone, of the size of nature.
CASES OF STONE IN THE BLADDER. Mr. 1,AWRENCE. ST. BART11OL03IEw’s HOSPITAL Mr. B. CoopER. GUY’S HOSPITAL Mr. FERGUSSON. KING’S COLLEGE HOSPITAL UNIVERSITY COLLEGE HOSPITAL ...... Mr. ERICHSEN. ......
...............
.........
ST. BARTHOLOMEW’S HOSPITAL. Calculus of unusually large dimensions; Lithotomy; Death;
Autopsy. (Under the
of Mr. LAWRENCE.) THE difficulties encountered by the lithotomist are numerous, and of various kinds: a very deep perinseum, an impacted calculus, a very irritable and small bladder, an enlarged prostate gland, a very friable stone, a very small or a very large one, will throw obstacles in the way of the operation, and endanger the issue of the case. We frequently see the surgeons of our metropolitan hospitals grapple with difficulties of this nature; and the manner in which the latter are generally overcome is certainly very interesting and instructive to behold. Mr. Lawrence lately operated upon a patient, whose case presented the difficulty of a very large stone-indeed, so large, that but very few such have been removed. Additional incisions, and more than ordinary force, management, and time, were of course required for the extraction of this calculus, which extraction was at length effected. It is not a little surprising that the patient continued many years with a stone in his bladder, which for a long period must almost have filled up that viscus; but we are by this case taught to what extent certain organs will accommodate themselves to unfavourable circumstances; and, moreover, that the growth of calculi is almost unlimited, when they form upon patients who will for a long period bear the suffering and inconvenience caused by the presence of the foreign body. We are indebted for the following particulars to Mr. Archer, Mr. Lawrence’s care
house-surgeon :-
Levi B aged thirty-seven years, a labourer, of a pale, sallow countenance, and much emaciated, was admitted Dec. 27,- 1852, into Henry’s ward, under the care of Mr. Lawrence, suffering greatly from the ordinary symptoms of stone, the existence of which was at once discovered on the introduction of a sound. The poor fellow was in such a state of distress and exhaustion as to be wholly unable to afford other than most con-
tradictory statements respecting the origin and progress of his complaint; indeed, nothing definite could be elicited from him of the history of his disorder. But his wife subsequently stated, that the patient had suffered from childhood with frequent micturition, followed by pain, sanguineous urine, &c.
The calculus, size of nature; it weighed twelve ounces and a quarter. Crust of lithate of ammonia, with probably a uric-acid nucleus.
As the
pulse was very feeble and frequent after the operathere was slight vomiting and constant nausea, diffu. sible stimulants were given, followed, as night came on, by a full dose of opium. tion, and
The patient slept several hours, expressinghimself very greatly relieved next morning, and stating that he had not passed so comfortable a night for years. The urine was discharged freely by the wound; there was no haemorrhage; no tenderness of the abdomen; the vomiting and nausea had subsided; and the man’s condition was altogether satisfactory, except that the pulse remained extremely feeble and frequent, and that he complained greatly of thirst. No material change in his condition occurred; and,notwithstanding the frequent exhibition of brandy, no reaction followed ; the man gradually sank, and died at nine- o’clock ill the morning of the second day after the operation, retaining his consciousness to shortly before death. Exa??tinatio2z of the body.-The whole urinary apparatus exhibited in a striking manner the ordinary consequences of long-continued stone:-The bladder was as contracted as the enormously thickened condition of its walls would seem to permit. The mucous membrane was raised into numerous elevations, more or less rounded, but varying in size and out-
petechial spotswere seen beneath that membrane;Pacchionian bodies moderately numerous. On slicing the brain-substance,
pale, with rather fewer punctae on the side. Lower down were seen a number of small spots of effused blood, chiefly grouped together in patches about the size of a shilling; these were all in the left hemisphere, also some similar spots at the base of the brain. The ventricles were rather dry, the membrane healthy, and not the seat of haemorrhage. The choroid plexus was found quite sound, and the whole brain tissue normal in consistence
it
was
found firm and
right than on the left
and colour. The exudation of blood, resulting either from its abnormal fluidity or the want of tone in the vessels, was here well marked; and a case of this kind is well calculated to convince of their error those who maintain that such exudation never takes place, but that the rupture of some vessel is indispensable for the escape of blood. The general manner in which the petechise were scattered all over the frame was very remarkable; in fact, spots and vibices were found on the pleura, pericardium, on the investing membrane of a mass of bronchial glands, on the lining membrane of the aorta, beneath the capsules of the kidneys, under the arachnoid membrane, and even in the substance of the left hemisphere of the brain; besides the large spots which were extensively disseminated on the skin. The intercurrent pleuro-pneumonia, which contributed in giving the case a very serious character, was likewise influenced in its pathological manifestations by the haemorrhagic nature of the case, as the fluid effused in the left pleura was strongly tinged with blood. This state of the circulating fluid presents a very striking contrast with the pitchy appearance of the blood in another destructive affection-viz., cholera.
that he had been married eight years; and that she had three children. Her husband had been under medical treatment for several years, and had discontinued work for the last twelvemonth. On examination, however, by the rectum, a very large stone was discovered, the boundaries of which could be but imperfectly traced by the finger. Mr. Lawrence ordered wine, beef-tea, arrow-root, barleywater, &c., and opiates, to allay pain and procure sleep. The patient still continued to suffer greatly, and on Jan. 3, 1853, he was placed under the influence of chloroform, and Mr. Lawrence proceeded to perform lithotomy. The operation was commenced in the ordinary manner, but owing to the very large size of the stone, it was found necessary to divide the right side of the prostate gland also, and to enlarge the external incision. After a protracted and extremely difficult operation-in the course of which the patient lost a considerable quantity of blood-the stone was at length removed. We here give a rough sketch of the stone, of the size of nature.
CASES OF STONE IN THE BLADDER. Mr. 1,AWRENCE. ST. BART11OL03IEw’s HOSPITAL Mr. B. CoopER. GUY’S HOSPITAL Mr. FERGUSSON. KING’S COLLEGE HOSPITAL UNIVERSITY COLLEGE HOSPITAL ...... Mr. ERICHSEN. ......
...............
.........
ST. BARTHOLOMEW’S HOSPITAL. Calculus of unusually large dimensions; Lithotomy; Death;
Autopsy. (Under the
of Mr. LAWRENCE.) THE difficulties encountered by the lithotomist are numerous, and of various kinds: a very deep perinseum, an impacted calculus, a very irritable and small bladder, an enlarged prostate gland, a very friable stone, a very small or a very large one, will throw obstacles in the way of the operation, and endanger the issue of the case. We frequently see the surgeons of our metropolitan hospitals grapple with difficulties of this nature; and the manner in which the latter are generally overcome is certainly very interesting and instructive to behold. Mr. Lawrence lately operated upon a patient, whose case presented the difficulty of a very large stone-indeed, so large, that but very few such have been removed. Additional incisions, and more than ordinary force, management, and time, were of course required for the extraction of this calculus, which extraction was at length effected. It is not a little surprising that the patient continued many years with a stone in his bladder, which for a long period must almost have filled up that viscus; but we are by this case taught to what extent certain organs will accommodate themselves to unfavourable circumstances; and, moreover, that the growth of calculi is almost unlimited, when they form upon patients who will for a long period bear the suffering and inconvenience caused by the presence of the foreign body. We are indebted for the following particulars to Mr. Archer, Mr. Lawrence’s care
house-surgeon :-
Levi B aged thirty-seven years, a labourer, of a pale, sallow countenance, and much emaciated, was admitted Dec. 27,- 1852, into Henry’s ward, under the care of Mr. Lawrence, suffering greatly from the ordinary symptoms of stone, the existence of which was at once discovered on the introduction of a sound. The poor fellow was in such a state of distress and exhaustion as to be wholly unable to afford other than most con-
tradictory statements respecting the origin and progress of his complaint; indeed, nothing definite could be elicited from him of the history of his disorder. But his wife subsequently stated, that the patient had suffered from childhood with frequent micturition, followed by pain, sanguineous urine, &c.
The calculus, size of nature; it weighed twelve ounces and a quarter. Crust of lithate of ammonia, with probably a uric-acid nucleus.
As the
pulse was very feeble and frequent after the operathere was slight vomiting and constant nausea, diffu. sible stimulants were given, followed, as night came on, by a full dose of opium. tion, and
The patient slept several hours, expressinghimself very greatly relieved next morning, and stating that he had not passed so comfortable a night for years. The urine was discharged freely by the wound; there was no haemorrhage; no tenderness of the abdomen; the vomiting and nausea had subsided; and the man’s condition was altogether satisfactory, except that the pulse remained extremely feeble and frequent, and that he complained greatly of thirst. No material change in his condition occurred; and,notwithstanding the frequent exhibition of brandy, no reaction followed ; the man gradually sank, and died at nine- o’clock ill the morning of the second day after the operation, retaining his consciousness to shortly before death. Exa??tinatio2z of the body.-The whole urinary apparatus exhibited in a striking manner the ordinary consequences of long-continued stone:-The bladder was as contracted as the enormously thickened condition of its walls would seem to permit. The mucous membrane was raised into numerous elevations, more or less rounded, but varying in size and out-