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A CASE OF SUPRAPUBIC LITHOTOMY.
619
I
tion every twenty minutes or half-hour, only a few drops coming away, thus giving but partial relief, while it was withI the catheter was passed previous to the great tion. She suffered from more than ordinary diarrhoea duringi the greater part of the ten months, but since the date of thei operation the improvement has been most marked, as she looks healthier, feels stronger, and is much stouter. [ Nevcstle-on-Tyne.
difficulty
opera-
I
A Mirror OF
HOSPITAL
PRACTICE,
BRITISH AND FOREIGN. Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor. borum et dissectionuin historias, turn aliorum turn proprias collectas habere, et inter se compa.ra.re.—MoRGAGXi De Sed. et Caus. M01b., lib. iv. Prooemium.
A CASE OF SUPRAPUBIC LITHOTOMY. BY A. J. POPERT, M.R.C.S. &C
-
ST. BARTHOLOMEWS HOSPITAL.
FÆCES THROUGH THE URETHRA; consulted by a young COLOTOMY; RECOVERY; REMARKS. man aged twenty-two, who gave the following history. (Under the care of Mr. HARRISON CRIPPS.) For eight or nine years he had suffered from irritability of ’ much may be urged in support of the views of Mr. the bladder and painful micturition, with occasional bloody as to the advisability of performing inguinal in preCripps urine. He could not remember having passed a night withthe nature out having to micturate at least once, and during the last ference to lumbar colotomy in cases such as this, of the of of the disease and the exact communication point three months he had been called upon to relieve the bladder with and bowel the bladder only to be being unknown, four or five times every night. During the day he could as a rule hold the urine for three or four hours. At irregular determined by means of an actual abdominal exploration, intervals he had suffered such severe pain as to incapaci- the opening for which, though small, can be used for the tate him for work and send him to bed. Under the in- further stages of the operation. For the following notes fluence of rest and opiates these paroxysms of pain usually we are indebted to Mr. house surgeon. Gow, subsided, and he would be able to return to his work in W. J-,aged thirty, first noticed pain in the hypogastric three or four days. Although the frequent micturition was about eighteen months ago; this was felt before region constant, he was sometimes so free from other symptoms as a motion, never at any other time. This pain to be able to play football. Lately the attacks of pain had passing become more severe and the intervals of freedom shorter, became worse, sometimes lasting the whole day. For some and he was losing flesh and getting worn out from pain and months prior to admission he had passed blood and slime with his motions. For the last few weeks the urine has want of sleep. When I saw him the urine contained a large quantity of been thick, and passed with much scalding pain; during the same time he has noticed flatus pass by the urethra. albumen, but no casts, and his temperature was 102°. He Present condition.-A fairly healthy-looking man. Comwas obviously suffering from stone and cystitis. His general plains of constant dull aching pain in the pubic region. He condition was feeble and by no means encouraging. Quinine and opium improved matters somewhat, and on the 24th I requires to pass urine nearly every quarter of an hour, and decided to remove the stone by suprapubic incision. It after the urine is passed flatus often escapes with considerable noise. The urine varies in character; it is generally was quite impossible to distend the bladder with water, for the organ would only tolerate from two to three ounces ; so turbid, having an abundant yellowish granular precipitate, I contented myself with washing out its cavity with a solu- with distinct faecal odour. Under the microscope the deposit tion of boro-glyceride ; and having made an incision in the is seen to consist of pus cells, vegetable fibres, and granular skin about three inches long in the middle line immediately debris. The amount of faecal material in the urine is always above the symphysis, I had no trouble in dissecting down greater when the bowels are loose. The motions are semisolid, and urine is not passed by the rectum. The patient upon the bladder, guided by the point of a sound passed down the urethra. Two catgut ligatures were passed through complains greatly of flatulence, and says he feels it descend the bladder in a vertical direction and parallel to each other, into the left iliac fossa, where it seems to stop, and escape Nothing definite can be felt either and by traction on them the bladder wall was steadied and ’, into the bladder. I the abdominal wall or by the rectum. through so into but the entire was conview ; brought fairly organ Forsome weeks the patient was kept at rest in bed on a tracted and small that the incision, which was mademidway between the ligatures, had to be most limited. The stone milk diet, with ten grains of compound soap pill at night, no material improvement following. Mr. Harrison Cripps, was easily found, but considerable difficulty was experienced after consultation, decided to explore the abdomen, and open in removing it owing to the smallness of the vesical aperture. After its removal the edges of the wound were drawn the bowel above the site of communication. Operation.-The abdomen was opened by a two-inch together by tying the catgut ligatures to each other. A incision in the left inguinal region. A search was then into the rubber catheter was bladder through large the lower part of the wound, and the superficial wound made with the finger, and a firm mass suggestive of sutured with silk. The stone was composed of oxalate of malignant disease discovered binding the sigmoid flexure to The bowel was traced upwards from this, and lime, weighed an ounce and a quarter, and was a good athe bladder. lower of the loop part of the descending colon drawn out calculus. specimen of the mulberry caiefully united to the parietal peritoneum and skin. During the next four days some peritonitis developed, but and 1 he bowel was opened on the fourth day; the wound liealed was subdued by large doses of opium-six grains in the and the patient left the hospital within the month. rapidly, hours. urine The flowed freely through the twenty-four catheter into a bottle which was secured between the From the time of opening the bowel neither air nor fspces and the urine became clear, the patient’s thighs. Seven days after the operation the catheter passed into the bladder, cystitis disappeared, and the patient expressed himself as was withdrawn from the wound, and one was passed per urethram. The abdominal wound had closed in its entire greatly relieved. When last seen, three months later, he extent, except at the lowest part, which had been kept still continued well, the artificial anus giving very little patent by the catheter; three days later it was perfectly trouble. Remarks by Mr. HARRISON CRIPps.-Cases in which the and on Feb. 10th, seventeen daysafter the operafeature consists in the passage of air and feces was the urethral catheter and the prominent tion, removed, patient had the satisfaction of passing fourteen ounces of urine with the urine are comparatively rare, but yet of extreme The albumen disappeared from the interest as regards their pathology and treatment. In a per vias nat2s.aLes. urine a fortnight later, and the patient is now a fairly recently published paper I succeeded in collecting the notes robust-looking man, enjoying, as he says, better health of over sixty such cases. An analysis ofof these showed that these communicathan he ever did in his life. The bladder has retained cancer or inflammation was the cause its normal capacity, and all symptoms of irritability are tions, the latter being far the more frequent. The bladder may communicate with either the large or small intestine, gone. Dr. Baildon kindly administered chloroform, and assisted me the former greatly predominating; the site of the fistula at the operation; and I am indebted to Mr. J. Todd of Banks being nearly always the upper part of the rectum or the for much useful help in the subsequent treatment of the case. sigmoid flexure. The actual formation of the fistula is often preceded by symptoms from which a dinereutiated Southport.
ON the 20th of
January last
I
PASSAGE OF GAS AND
was
passed
healed,
L
2
I
tion every twenty minutes or half-hour, only a few drops coming away, thus giving but partial relief, while it was withI the catheter was passed previous to the great tion. She suffered from more than ordinary diarrhoea duringi the greater part of the ten months, but since the date of thei operation the improvement has been most marked, as she looks healthier, feels stronger, and is much stouter. [ Nevcstle-on-Tyne.
difficulty
opera-
I
A Mirror OF
HOSPITAL
PRACTICE,
BRITISH AND FOREIGN. Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor. borum et dissectionuin historias, turn aliorum turn proprias collectas habere, et inter se compa.ra.re.—MoRGAGXi De Sed. et Caus. M01b., lib. iv. Prooemium.
A CASE OF SUPRAPUBIC LITHOTOMY. BY A. J. POPERT, M.R.C.S. &C
-
ST. BARTHOLOMEWS HOSPITAL.
FÆCES THROUGH THE URETHRA; consulted by a young COLOTOMY; RECOVERY; REMARKS. man aged twenty-two, who gave the following history. (Under the care of Mr. HARRISON CRIPPS.) For eight or nine years he had suffered from irritability of ’ much may be urged in support of the views of Mr. the bladder and painful micturition, with occasional bloody as to the advisability of performing inguinal in preCripps urine. He could not remember having passed a night withthe nature out having to micturate at least once, and during the last ference to lumbar colotomy in cases such as this, of the of of the disease and the exact communication point three months he had been called upon to relieve the bladder with and bowel the bladder only to be being unknown, four or five times every night. During the day he could as a rule hold the urine for three or four hours. At irregular determined by means of an actual abdominal exploration, intervals he had suffered such severe pain as to incapaci- the opening for which, though small, can be used for the tate him for work and send him to bed. Under the in- further stages of the operation. For the following notes fluence of rest and opiates these paroxysms of pain usually we are indebted to Mr. house surgeon. Gow, subsided, and he would be able to return to his work in W. J-,aged thirty, first noticed pain in the hypogastric three or four days. Although the frequent micturition was about eighteen months ago; this was felt before region constant, he was sometimes so free from other symptoms as a motion, never at any other time. This pain to be able to play football. Lately the attacks of pain had passing become more severe and the intervals of freedom shorter, became worse, sometimes lasting the whole day. For some and he was losing flesh and getting worn out from pain and months prior to admission he had passed blood and slime with his motions. For the last few weeks the urine has want of sleep. When I saw him the urine contained a large quantity of been thick, and passed with much scalding pain; during the same time he has noticed flatus pass by the urethra. albumen, but no casts, and his temperature was 102°. He Present condition.-A fairly healthy-looking man. Comwas obviously suffering from stone and cystitis. His general plains of constant dull aching pain in the pubic region. He condition was feeble and by no means encouraging. Quinine and opium improved matters somewhat, and on the 24th I requires to pass urine nearly every quarter of an hour, and decided to remove the stone by suprapubic incision. It after the urine is passed flatus often escapes with considerable noise. The urine varies in character; it is generally was quite impossible to distend the bladder with water, for the organ would only tolerate from two to three ounces ; so turbid, having an abundant yellowish granular precipitate, I contented myself with washing out its cavity with a solu- with distinct faecal odour. Under the microscope the deposit tion of boro-glyceride ; and having made an incision in the is seen to consist of pus cells, vegetable fibres, and granular skin about three inches long in the middle line immediately debris. The amount of faecal material in the urine is always above the symphysis, I had no trouble in dissecting down greater when the bowels are loose. The motions are semisolid, and urine is not passed by the rectum. The patient upon the bladder, guided by the point of a sound passed down the urethra. Two catgut ligatures were passed through complains greatly of flatulence, and says he feels it descend the bladder in a vertical direction and parallel to each other, into the left iliac fossa, where it seems to stop, and escape Nothing definite can be felt either and by traction on them the bladder wall was steadied and ’, into the bladder. I the abdominal wall or by the rectum. through so into but the entire was conview ; brought fairly organ Forsome weeks the patient was kept at rest in bed on a tracted and small that the incision, which was mademidway between the ligatures, had to be most limited. The stone milk diet, with ten grains of compound soap pill at night, no material improvement following. Mr. Harrison Cripps, was easily found, but considerable difficulty was experienced after consultation, decided to explore the abdomen, and open in removing it owing to the smallness of the vesical aperture. After its removal the edges of the wound were drawn the bowel above the site of communication. Operation.-The abdomen was opened by a two-inch together by tying the catgut ligatures to each other. A incision in the left inguinal region. A search was then into the rubber catheter was bladder through large the lower part of the wound, and the superficial wound made with the finger, and a firm mass suggestive of sutured with silk. The stone was composed of oxalate of malignant disease discovered binding the sigmoid flexure to The bowel was traced upwards from this, and lime, weighed an ounce and a quarter, and was a good athe bladder. lower of the loop part of the descending colon drawn out calculus. specimen of the mulberry caiefully united to the parietal peritoneum and skin. During the next four days some peritonitis developed, but and 1 he bowel was opened on the fourth day; the wound liealed was subdued by large doses of opium-six grains in the and the patient left the hospital within the month. rapidly, hours. urine The flowed freely through the twenty-four catheter into a bottle which was secured between the From the time of opening the bowel neither air nor fspces and the urine became clear, the patient’s thighs. Seven days after the operation the catheter passed into the bladder, cystitis disappeared, and the patient expressed himself as was withdrawn from the wound, and one was passed per urethram. The abdominal wound had closed in its entire greatly relieved. When last seen, three months later, he extent, except at the lowest part, which had been kept still continued well, the artificial anus giving very little patent by the catheter; three days later it was perfectly trouble. Remarks by Mr. HARRISON CRIPps.-Cases in which the and on Feb. 10th, seventeen daysafter the operafeature consists in the passage of air and feces was the urethral catheter and the prominent tion, removed, patient had the satisfaction of passing fourteen ounces of urine with the urine are comparatively rare, but yet of extreme The albumen disappeared from the interest as regards their pathology and treatment. In a per vias nat2s.aLes. urine a fortnight later, and the patient is now a fairly recently published paper I succeeded in collecting the notes robust-looking man, enjoying, as he says, better health of over sixty such cases. An analysis ofof these showed that these communicathan he ever did in his life. The bladder has retained cancer or inflammation was the cause its normal capacity, and all symptoms of irritability are tions, the latter being far the more frequent. The bladder may communicate with either the large or small intestine, gone. Dr. Baildon kindly administered chloroform, and assisted me the former greatly predominating; the site of the fistula at the operation; and I am indebted to Mr. J. Todd of Banks being nearly always the upper part of the rectum or the for much useful help in the subsequent treatment of the case. sigmoid flexure. The actual formation of the fistula is often preceded by symptoms from which a dinereutiated Southport.
ON the 20th of
January last
I
PASSAGE OF GAS AND
was
passed
healed,
L
2