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CATHETER-EXTRACTION OF A URETERAL STONE PER URETHRAM.
399 state that " although the truth of the original theories which led to the production of casein milk seems repeatedly to have been disproved, the fact remains that the preparation is one of very great value, particularly in many diarrhceal disturbances in infancy." With this we are in complete agreement. The main points to remember when using protein milk are : (1) that it is a medicinal food " and that infants should not be kept on it for more than six weeks; (2) that saccharine should be used for sweetening purposes at the onset in cases of ileocolitis ; (3) that no gain in weight can be expected until sugar in the form of dextrimaltose is added, and this addition should never be delayed for more than a few days ; (4) that although protein milk is a most useful adjunct to infant feeding, it must not be considered as a panacea for every nutritional disturbance occurring "
in
infancy.
BY E. H. R. ALTOUNYAN, M.C., SURGEON
A
CASE
OF
ECLAMPSIA
TREATED
WITH SPINAL ANÆSTHESIA.
CATHETER-EXTRACTION OF A URETERAL STONE PER URETHRAM. ASSISTANT
It is difficult to explain how it was that on two successive occasions the catheters passed up one on each side of the stone. The whole operation was performed without an anaesthetic, local or general, and patient experienced only moderate pain. The cases in which manipulative removal of ureteral stones should be attempted must always remain rare, more particularly in view of the fact that the operation of ureterolithotomy is comparatively safe. Personally I would strongly deprecate the use of all special instruments, however ingenious, as their danger increases in direct ratio to their efficiency. The method described of twisting catheters appears worthy of trial.
TO
ALTOUNYAN SYRIA.
THE
BY R. H.
PARAMORE, F.R.C.S. ENG.,
GYNECOLOGICAL SURGEON TO THE HOSPITAL OF ST. CROSS, RUGBY.
M.D. CAMB., HOSPITAL, ALEPPO,
ALL cases of eclampsia are of interest, and the one here reported is of especial interest because, in spite of spinal anaesthesia, and even after Caesarean section and decapsulation of the right kidney, further fits appeared-due apparently in part to the effect of
UROLOGISTS are always urging surgeons to attempt non-cutting methods in the removal of stone from the pituitrin. urinary tract. That manipulation may occasionally RECORD OF THE CASE. be successful is illustrated by the following case. The patient was a well-developed primigravida aged 24, An Arab male, aged 40, was admitted on Nov. 5th, 1928, seven months pregnant. She was admitted to the Hospital with a vesical fistula following a suprapubic cystotomy for of St. Cross, Rugby, on March 10th, 1930, comatose from His condition was elsewhere. stone, performed general eclampsia. She had noticed swelling of the ankles and poor, and all urine came through the suprapubic cystotomy, hands for three or four weeks. On the advice of a nurse in the scar of which a keloid had developed. On the follow- who found albumin in the urine, she consulted a doctor (March 5th) but disregarded instructions. The day before admission (Sunday, March 9th) she was up and about, and helped in the cooking. At dinner she ate meat, potatoes, peas, and Yorkshire pudding. She rested in the afternoon, but at supper (9 P.M.) had more peas. At 9.30 P.M. she went to bed, complaining of headache. During the night (3.30 A.M.) she awoke her husband, complaining of feeling
He discovered her in a fit on his return from Two further fits occurred at intervals of an hour’s duration. The doctor was called and gave the patient a quarter grain of morphia and sent her to hospital a distance of ten miles. In the ambulance she had another fit. She was admitted at 8 A.M., and had a further fit at 9.25 A.M. Chloroform was given. Eight ounces of highly albuminous urine were obtained by catheter, but did not boil solid. A simple enema was without effect, the injection being retained. I saw her soon after ; she then looked bloated and was semi-comatose and lying on her back. At 10.45 A.M. spinal anaesthesia (tropacocaine 1’5 c.cm.) was induced under chloroform ; she struggled a good deal. She was kept well over in the left lateral position, and the foot of the bed was raised on blocks. At 2 o’clock her condition was rather improved, and there had been no further fit. The next day (March llth) she was much better. A good deal of urine had been passed and the bowels had been opened. The blood pressure was 160/95. Water, solution of glucose, lemon water, or water with sodium bicarbonate only were allowed. The day after (March 12th) she was very much better and seemed to be improving fast. Eighteen ounces of urine had been collected, but it still contained a great deal of albumin. The child was alive. The problem of the renal state-now the central question-was considered ; it was thought that the pregnancy must be terminated if the albumin did not diminish rapidly. Hot baths thrice daily were ordered. On March 13th the had three hot baths, and on the 14th she had one, but they seemed to do more harm than good. On the 13th she appeared still better ; 38 oz. of urine had been collected but it still contained much albumin. The blood pressure was 150/100. But on the 14th she did not look so well-she looked confused. Getting to the bath and back-even with a chair-seemed to have prejudiced her recovery, and that evening the fits recurred. She had one, at 8.40 P.M., for which chloroform was given, and another at 9.14 P.M. Chloroform and spinal anaesthesia were unwell.
fetching her mother.
Stone removed per urethram.
It measured 1’8
x
0’8
cm.
the scar was excised and the bladder drained. On Dec. 4th a stone impacted in the urethra was removed by external urethrotomy. On Jan. 10th, 1929, he underwent a second operation to close the suprapubic fistula, and yet a third on Feb. 5th. The last was successful. On March 4th the urine was still dirty, and a complete X ray examination was repeated, and revealed:c (1) a stone in the right ureter, (2) a stone in the pelvis of the left
ing day
kidney.
In view of the poor general condition of the patient it decided to attempt to dislodge the ureteral calculus by catheterisation. Two ureteral catheters were passed well up the right ureter, and X rays showed them lying one on each side of the stone. On removing the catheters with considerable effort, something, presumably the stone, was felt to give, though at the moment it seemed probable that the catheters had broken off in the ureter. Next day the procedure was repeated ; only after passing the catheters well up towards the kidney it was decided slowly to twist them round and round before pulling them down. This manoeuvre apparently freed the stone from the ureteral wall and at the same time secured a firm grip for the catheters, for on slowly withdrawing them, while keeping up a twisting movement, the calculus was safely delivered at the meatus. The most I had hoped for was a dislodgment into the bladder, but apparently the mouth of the ureter had been drawn down to the orifice of the prostatic urethra, and the transit of the bladder was thus safely accomplished. It seems important to pass the catheters as high as possible towards the kidney. The passage of three or four very fine catheters or sounds might make the result more certain. was
patient
in
infancy.
BY E. H. R. ALTOUNYAN, M.C., SURGEON
A
CASE
OF
ECLAMPSIA
TREATED
WITH SPINAL ANÆSTHESIA.
CATHETER-EXTRACTION OF A URETERAL STONE PER URETHRAM. ASSISTANT
It is difficult to explain how it was that on two successive occasions the catheters passed up one on each side of the stone. The whole operation was performed without an anaesthetic, local or general, and patient experienced only moderate pain. The cases in which manipulative removal of ureteral stones should be attempted must always remain rare, more particularly in view of the fact that the operation of ureterolithotomy is comparatively safe. Personally I would strongly deprecate the use of all special instruments, however ingenious, as their danger increases in direct ratio to their efficiency. The method described of twisting catheters appears worthy of trial.
TO
ALTOUNYAN SYRIA.
THE
BY R. H.
PARAMORE, F.R.C.S. ENG.,
GYNECOLOGICAL SURGEON TO THE HOSPITAL OF ST. CROSS, RUGBY.
M.D. CAMB., HOSPITAL, ALEPPO,
ALL cases of eclampsia are of interest, and the one here reported is of especial interest because, in spite of spinal anaesthesia, and even after Caesarean section and decapsulation of the right kidney, further fits appeared-due apparently in part to the effect of
UROLOGISTS are always urging surgeons to attempt non-cutting methods in the removal of stone from the pituitrin. urinary tract. That manipulation may occasionally RECORD OF THE CASE. be successful is illustrated by the following case. The patient was a well-developed primigravida aged 24, An Arab male, aged 40, was admitted on Nov. 5th, 1928, seven months pregnant. She was admitted to the Hospital with a vesical fistula following a suprapubic cystotomy for of St. Cross, Rugby, on March 10th, 1930, comatose from His condition was elsewhere. stone, performed general eclampsia. She had noticed swelling of the ankles and poor, and all urine came through the suprapubic cystotomy, hands for three or four weeks. On the advice of a nurse in the scar of which a keloid had developed. On the follow- who found albumin in the urine, she consulted a doctor (March 5th) but disregarded instructions. The day before admission (Sunday, March 9th) she was up and about, and helped in the cooking. At dinner she ate meat, potatoes, peas, and Yorkshire pudding. She rested in the afternoon, but at supper (9 P.M.) had more peas. At 9.30 P.M. she went to bed, complaining of headache. During the night (3.30 A.M.) she awoke her husband, complaining of feeling
He discovered her in a fit on his return from Two further fits occurred at intervals of an hour’s duration. The doctor was called and gave the patient a quarter grain of morphia and sent her to hospital a distance of ten miles. In the ambulance she had another fit. She was admitted at 8 A.M., and had a further fit at 9.25 A.M. Chloroform was given. Eight ounces of highly albuminous urine were obtained by catheter, but did not boil solid. A simple enema was without effect, the injection being retained. I saw her soon after ; she then looked bloated and was semi-comatose and lying on her back. At 10.45 A.M. spinal anaesthesia (tropacocaine 1’5 c.cm.) was induced under chloroform ; she struggled a good deal. She was kept well over in the left lateral position, and the foot of the bed was raised on blocks. At 2 o’clock her condition was rather improved, and there had been no further fit. The next day (March llth) she was much better. A good deal of urine had been passed and the bowels had been opened. The blood pressure was 160/95. Water, solution of glucose, lemon water, or water with sodium bicarbonate only were allowed. The day after (March 12th) she was very much better and seemed to be improving fast. Eighteen ounces of urine had been collected, but it still contained a great deal of albumin. The child was alive. The problem of the renal state-now the central question-was considered ; it was thought that the pregnancy must be terminated if the albumin did not diminish rapidly. Hot baths thrice daily were ordered. On March 13th the had three hot baths, and on the 14th she had one, but they seemed to do more harm than good. On the 13th she appeared still better ; 38 oz. of urine had been collected but it still contained much albumin. The blood pressure was 150/100. But on the 14th she did not look so well-she looked confused. Getting to the bath and back-even with a chair-seemed to have prejudiced her recovery, and that evening the fits recurred. She had one, at 8.40 P.M., for which chloroform was given, and another at 9.14 P.M. Chloroform and spinal anaesthesia were unwell.
fetching her mother.
Stone removed per urethram.
It measured 1’8
x
0’8
cm.
the scar was excised and the bladder drained. On Dec. 4th a stone impacted in the urethra was removed by external urethrotomy. On Jan. 10th, 1929, he underwent a second operation to close the suprapubic fistula, and yet a third on Feb. 5th. The last was successful. On March 4th the urine was still dirty, and a complete X ray examination was repeated, and revealed:c (1) a stone in the right ureter, (2) a stone in the pelvis of the left
ing day
kidney.
In view of the poor general condition of the patient it decided to attempt to dislodge the ureteral calculus by catheterisation. Two ureteral catheters were passed well up the right ureter, and X rays showed them lying one on each side of the stone. On removing the catheters with considerable effort, something, presumably the stone, was felt to give, though at the moment it seemed probable that the catheters had broken off in the ureter. Next day the procedure was repeated ; only after passing the catheters well up towards the kidney it was decided slowly to twist them round and round before pulling them down. This manoeuvre apparently freed the stone from the ureteral wall and at the same time secured a firm grip for the catheters, for on slowly withdrawing them, while keeping up a twisting movement, the calculus was safely delivered at the meatus. The most I had hoped for was a dislodgment into the bladder, but apparently the mouth of the ureter had been drawn down to the orifice of the prostatic urethra, and the transit of the bladder was thus safely accomplished. It seems important to pass the catheters as high as possible towards the kidney. The passage of three or four very fine catheters or sounds might make the result more certain. was
patient