Clinical Paper: Two cases of lithotomy

The Lancet, 29 August 1868, volume 92, number 2348, pages 280-281

DORSET COUNTY HOSPITAL. 

TWO CASES OF LITHOTOMY. 

(Under the care of Mr. TUDOR.)

THE following cases possess some interest: one, on account of the size and difficulty in extraction of the stone; the other, from its situation in, and attachment to, the bladder.

CASE 1.  –G. S–, aged fourteen, was admitted July 15th, 1867.  The history of this case extended over a period of seven years.  It was, however, sent to the hospital as “chronic urethritis.” Until a short time previous to his admission, the boy had been occupied in the stone quarries of Purbeck.  His general aspect was that of anaemia, with a peculiar expression of the face, indicative of prolonged suffering.  He was otherwise in a sad plight, his linen being saturated with offensive-smelling urine, stained with blood, and the penis swollen, inflamed, and excoriated.  Stone was at once suspected, and, on examining the bladder, a calculus was detected, supposed to be in size equal to a large walnut.  An operation was proposed ; but the mother objecting, the patient was discharged.  Greatly increased suffering ensued.  The boy was consequently brought back again, and readmitted at the end of ten days.  The symptoms were now very severe, and the boy’s life for some time seemed in jeopardy.  The irritation of the bladder was most distressing, accompanied with a continuous dribbling away of the urine, mixed with blood and mucus.  In addition, there was considerable mischief going on in the rectum-frequent paroxysms of tenesmus and prolapse of the bowel, with dejections of muco-purulent matter and blood.  There was at the same time loss of appetite, and little or no sleep.  Soothing applications were applied externally over the region of the bladder and perineum, and opiates were freely given by the mouth and rectum.  The diet was milk, beef-tea, and farinaceous food.

BLADDER STONEAugust 23rd. –The patient’s general condition being now more satisfactory, the usual lateral operation was performed, under the administration of chloroform.  There was some difficulty in the commencement of the operation, owing to the urgent and forcible protrusion of the rectum.  When the bladder was opened, it became apparent that the stone was larger than had been expected, and the attempt to extract it at first failed, in consequence of the forceps slipping, although repeated attempts were made, and with different-sized instruments.  The scoop was tried, with a like result.  The wound in the neck of the bladder was then very carefully enlarged, partly by incision on the right side, but chiefly by dilatation with the finger.  The scoop and the forceps together were then employed.  The former, carefully guided by the finger, was passed well behind the stone, which was held firmly in position against the neck of the bladder whilst Mr. Tudor again introduced the forceps.  By these combined means the extraction was soon effected.  The use of both these instruments required much caution, as the bladder was contracted firmly around the stone, which turned out to be a large-sized “mulberry” calculus, measuring six inches by five in circumference, and weighing three ounces.  In comparing, in this case, the dimensions of the stone (the outline of which is well shown in the accompanying woodcut) with the limited space at the neck of the bladder, in so young a subject, it seems surprising that so large a body could be removed without inflicting irremediable injury; but it is evident that, with due precaution, the parts are susceptible of a considerable amount of stretching, and admit of the employment of what might appear to be rough usage, provided the knife is used sparingly and with judgment, and the scoop and forceps handled carefully.  The use of the scoop was very important in this case, because of the firm contraction of the bladder around the stone.  There was very little haemorrhage; and although the patient was a considerable time under chloroform, he had no bad symptom following the operation.  The wound healed favourably in about the usual time, and the boy made a satisfactory recovery.

CASE 2.  – J. T–, four years of age, a diminutive, sickly-looking child, admitted June 20th, 1867, with symptoms of stone in the bladder.  A few days subsequent to his admission Mr. Tudor passed a small sound, but after a most careful examination failed to detect any calculus.  The symptoms still continued, but, the general health being very unfavourable, a second examination was deferred for several weeks.  On this occasion Mr. Tudor was clearly satisfied as to the presence of a stone, which, however, required the use of an ordinary catheter, or a sound with a large curve, to be reached with facility.  It was also observed that there was a muffled sound given off when the stone was struck, and that the peculiar grating sensation commonly imparted through the instrument was absent.  Unforeseen circumstances prevented an operation until December, and during the interval the child’s health had greatly improved, and there was remarkably little irritation in the bladder.  On Dec. 10th, the child being placed under the influence of chloroform, Mr. Tudor performed the lateral operation, and proceeded to remove the stone in the usual way, but without success, in consequence of its situation in the bladder, apparently resting on and attached to the anterior surface of the fundus behind the pubes, where it could be felt by the finger.  Mr. Tudor withdrew the forceps and employed the scoop, first passing the finger above and behind the stone, and then carefully guiding the instrument upon the finger to the front, making a sort of forceps ; by this means the extraction was easily effected.  The stone (phosphate of ammonia) is in shape and size like a large cobnut, measuring in circumference about two inches and a half ; and on its surface there are three small nodular excrescences, from which springs a thin membranous tissue encysting the stone.  Mr. Tudor remarks that he cannot explain the development of this ; but its existence seems enough to account both for the difficulty in detecting the stone except by the use of a large curved instrument, and also for the failure with the forceps.  It also may explain the subsidence of the severity of the local symptoms which occurred for some time before the operation.  The child made a rapid recovery.

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