THE LONDON MEDICAL GAZETTE, OR Journal of Practical Medicine. NEW SERIES. VOL. VIII. ; LONDON: PRINTED FOR LONGMAN, BROWN, GREEN, AND LONGMANS, PATERNOSTER ROW. 1849. STONE IN THE BLADDER-CONTINUED. Choice of means for the removal of a stone from the bladder-Lithontriptics generally inefficient-Lithotrity preferable in some cases to lithotomy-Circumstances under which it may be adopted-Preparation of the patient-The operationNecessary precautions after treatmentA portion of the broken stone sometimes lodges in the urethra-Removal by an instrument, by cutting-Probable effectBest means of healing the wound-Diffi culties that may arise in the operation of lithotrity - Use of scoop lithotrite Seizing the calculus with the lithotriteOperation of lithotrity- Easy of performance-Case-Circumstances in which lithotomy ought to be employed instead of lithotrity-Preparatory treatment of the patient-Varieties of the operationHigh operation-Cases - Lateral operation-Instruments. Mr. Key's straight staff-Ne essity for mature reflection before deciding upon performing this operation. that we are not at present possessed of any medicine capable of dissolving, with safety to the patient, a calculus already formed, either in the kidney or bladder: but although such a remedy has not yet been discovered, we ought not to despair of the accomplishment of this desirable object, remembering the great benefit that has already been derived from the application of the science of chemistry to the treatment of stone. Neither can much be said for the efficacy of injections for the cure of stone: for as yet we have no evidence of their power to remove a calculus when once formed; although, like medicines taken internally, they may sometimes relieve the suffering produced by a stone in the bladder. Dietetic observances, alkaline remedies with opiates, and diluent drinks with injection of the bladder, may all, or each, afford relief; but no hopes can be justly entertained of their producing a cure of the disease. Lithotrity. Our attention must next be devoted to the consideration of the circumstances under which the operation of breaking down the stone, technically termed lithotrity, is to be preferred to the operation of lithotomy. This subject has occupied the attention of many eminent surgeons, and lengthened dissertations have been the result, I think, however, that very few words need be said on the subject. There can be no doubt that there are cases in which lithotrity is infinitely preferable to lithotomy; and it is equally true, that there are many others to which it is wholly in. applicable: nor are the means of judging between these two conditions at all difficult; and the circumstances which should regulate the choice are few, and easily appeeciated. In cases of small stone, and when the bladder is capable of containing about six ounces of water for a considerable time, I believe the operation of lithotrity may always be recommended; and not even a moderately diseased state of the kidneys need prohibit this operation, although in lithotomy the same extent of disease would involve a considerable increase of danger: indeed, the operation of crushing the stone is comparatively so simple, that there is a just hope of the condition of the kidneys becoming improved after the removal of the calculus, unless they have undergone some organic change; and even then improvement may be expected from the removal of so great a source of irritation. AFTER a due consideration of all the peculiarities of a case of stone in the bladder, both with reference to the constitution of the patient and concomitant local circumstances, the surgeon is called upon to decide, firstly, as to the expediency of attempting the removal of the stone by operation; and secondly, whether the operation of lithotrity, or that of lithotomy, ought to be preferred; or whether, instead of the operation, it be advisable to endeavour to effect the solution of the stone within the bladder, by the employment of menstrua technically termed lithoutriptics. In the use of the latter the object must be either the entire solution of the calculus, or its complete disintegration, so that it may be carried off with the urine in the form of detritus; and many different agents have been administered for these purposes, both in the form of in-circumstance to be ascertained is, whether ternal remedies, and as injections into the ❘ bladder. I appeal to experience as to the result of the trials which have been made with lithontriptics, and believe I may venture to say, III-1101. Jan. 5, 1849. A patient requires but little preparation for the operation of lithotrity; the principal the bladder is capable of retaining a sufficient quantity of fluid to keep it in a fit state of distension to allow the lithotrite to act without danger of injury to the coats of the organ. If the bladder be irritable, the operation should not be immediately performed; but remedies should be first administered to alleviate this symptom; and tepid water should be daily injected into the bladder, gradually increasing the quantity and period of its retention until the patient is capable of holding six ounces long enough for the performance of the operation, which may then be considered safe, no further preparatory treatment being required beyond merely opening the bowels freely. The operation being decided on, the most convenient position in which the patient can be placed is sitting in a semi-recumbent posture upon the foot of a low bed, with his feet resting upon two chairs, sufficiently separated to allow the operator to sit conveniently between them. The bladder should next be injected with about six ounces of tepid water, and the lithotrite then carefully and gently passed into the bladder, -not with the same motion of the hand as that by which the sound or catheter is introduced, but being rather pushed or pressed onwards, the penis being drawn forwards upon the instrument. As soon as the instrument has entered the bladder, the screw should be turned to release the blades from its influence, and they should then be separated, so as to be ready to grasp the stone: if at this time any water makes its escape by the sides of the lithotrite, an assistant should press the urethra against it, to prevent the flow. The operator now standing up before the patient, as it can be made to flow; in this effort a considerable quantity of detritus is generally brought away: but this is not invariably the case, for it some. times happens that but few fragments come away directly, although the stone may have been effectually crushed. The patient should not be allowed to walk or move about after the operation, but should be immediately put to bed, and a large dose of opium administered, to check the liability to rigor, as well as to overcome the irritability of the bladder necessarily excited by the irritation to which it had been subjected. The prevention of the rigor is a matter of the greatest importance; for if it be not checked at first, by the opium, there is not only the ill effect of the one attack to overcome, but it seems as if the patient became subject to its recurrence; while, on the contrary, if it be stopped at first, he seems to be but little liable to it subsequently. This fact was first mentioned to me by my friend Sir Benjamin Brodie; and I am from experience thoroughly convinced of the accuracy of his judgment on this as on every other surgical subject. For the first two or three days after the operation, the patient should be kept in bed, and should pass his water in the recumbent posture, not attempting to force the fragments away with his urine until the irritability of the bladder has ceased; he should then micturate in the erect posture, or even lean forwards, so as to direct presses the convexity at the end of the litho-the broken portions of stone towards the trite with considerable firmness upon the in- urethra. If a fragment becomes lodged in ferior region of the bladder, and, giving the passage, its extrication should not be the lithotrite a gentle tap, the stone natu- immediately attempted, but a dose of opium rally falls into the cavity, so as to render be given, and the patient kept in bed to that part most depending: and being imme- await the chance of the stone passing with diately felt by the instrument, is easily the next flow of urine. Should this not grasped by closing the blades: by the action happen, and the patient still retain the of the screw, it is now to be broken down, power to pass the urine, the surgeon should and piece after piece seized until the whole not yet interfere; but if the urine cannot is crushed into fragments sufficiently small | escape, the fragment of stone must be reto pass as detritus through the urethra. As moved by mechanical means. For this purto the number of times the stone may be pose, various instruments have been inseized, no definite directions can be given; vented, such as forceps of different forms; this must depend upon the temperament of but the best contrivance I have seen, and the patient, and the degree of suffering pro- which I have found upon one or two occaduced by the operation; but the surgeon sions perfectly efficient, is a French instrushould remember that the more he can safely ment, made in the form of a straight staff, do at the first operation, or "sitting," the with a joint at the extreme end and a screw better. Every time the lithotrite is passed, at the top. This instrument is of small the approximation of the blades should be size, as it is intended to pass beyond the secured by turning the screw to its fullest foreign body in the urethra; when thus extent; a precaution which is not always placed, the screw is turned, and, acting upon taken, but which is important, as it prevents the little joint at the extremity, brings it to the possibility of the blades separating during a right angle with the shaft of the staff; then their passage through the urethra, and the upon gently withdrawing the instrument, consequent liability of injury to its memthe stone is necessarily brought up with it. brane. After the operation the bladder Sometimes, however, these means may fail; should be washed out by injecting it with and then it will be requisite to cut the porconsiderable force, and the water should be ❘tion of the calculus out of the part in which drawn off through the catheter as rapidly it is fixed. Fortunately this necessity oc. curs most frequently at the orifice of the urethra, which is the narrowest part of the canal, and the operation is a matter of no danger as to result. Not so, however, when the stone becomes impacted lower down; for although there may exist little obstacle to its removal, it may prove afterwards very difficult to heal the opening, in which case a fistulous passage, termed a traumatic hypospadius, may permanently remain. Before, therefore, the surgeon proceeds to cut out a fragment which is impacted low down in the urethra, every means should be attempted to effect its passage with the urine. Opiates, warm-bath, and tartarized antimony, should be exhibited; and if these remedies fail, it should, if possible, be pushed back into the bladder, in order that it may be further broken down by the lithotrite. If, however, it be found impossible to push the fragment back into the bladder, then, and not till then, should it be cut down upon, and removed from the urethra; and when it becomes actually necessary to cut into the perineum to remove the calculus, I believe the best method of healing the opening, or rather to facilitate its healing, is to use the catheter for the first week or ten days, whenever the patient requires to pass his water, so that no urine may pass through the wound; and this plan I think preferable to that of leaving an instrument constantly in the bladder, as the urine has a tendency to escape between the urethra and the catheter, and to produce great irritation. It must not be supposed, from this description of the operation of lithotrity, that it is without its difficulties. This is not the case; and these difficulties may arise from many different sources: one of the most frequent of these is perhaps a congenital narrowness of the meatus of the urethra, which is sometimes so contracted at its orifice as not to admit of the entrance of the lithotrite. This may generally be remedied by enlarging the opening by means of a probe-pointed bistoury; for the contraction does not often extend far into the canal, which, through the remainder of its length, is usually of the normal size. Where stricture of the urethra is present, a great obstacle is also opposed to the introduction of the lithotrite; and before it can be employed, the obstruction must be overcome by the use of instruments: indeed, if the stricture cannot be removed so that the urethra is restored to its natural capacity, the operation of lithotomy must be substituted for that of lithotrity. The dread with which a patient naturally anticipates a surgical operation, be it even of a comparatively slight character, generally produces a degree of excitement, in consequence of which the bladder is often rendered too irritable to retain sufficient water for its proper distension during the operation, although on the occasion of former trials it was found perfectly competent to do so. Thirty drops of laudanum should therefore be given to the patient about an hour before the operation; and a suppository inserted into the rectum will also be found to produce a very favourable effect. Should, however, the irritability of the bladder be so great as not to be controlled by these means, it is better to postpone the operation until, by the employment of constitutional remedies, the patient can be bronght into a more suitable condition. Another difficulty, but of a mechanical character, sometimes arises in the use of the instrument termed the "scoop lithotrite," which is intended to bring away portions of detritus after the stone has been crushed. This instrument can sometimes only be withdrawn with considerable difficulty, in consequence of the accumulation of calcareous matter between its blades; and I have in one instance known it to be broken within the bladder in attempting to screw it up sufficiently close to admit of its passage through the urethra. I see, however, but little advantage in this forcible removal of the broken-down matter of the stone; for the detritus, when the portions are small enough to be brought away by the scoop, will also generally pass off with the urine; and, moreover, the most urgent symptoms which I have ever witnessed as the result of the operation of lithotrity have been in those cases in which the "scoop lithotrite" was employed to withdraw the detritus; for the danger seems to be in proportion to the stretching and laceration of the prostate gland and urethra, and not to the injury sustained by the bladder itself. Sometimes, however, it is impossible to avoid the use of this instrument, as in the following case :i A few weeks ago I performed the operation of lithotomy on a patient, and found no difficulty in repeatedly seizing and completely crushing the stone. A very small quantity of detritus passed away, however, after the operation, so little, indeed, as not by any means to correspond with the size of the stone; and I was therefore compelled to employ the scoop. This was followed by a profuse secretion of ropy mucus, which passed off readily with the urine. Observing one day, in the glass vessel in which the mucus was kept, a very considerable sediment, it occurred to me that a large portion of the detritus was held in suspension, and possibly partly in a state of solution. Upon this supposition, I desired the mucus to be preserved, and, having collected a sufficient quantity, I requested my friend Mr. Nicholson, of the Royal Chemical College, to make an analysis of it. |