THE INDIAN MEDICAL GAZETTE.
168 ,,
.
CASES FROM PRACTICE. LITHOTOMY.
By J. Fayrer, M.D., C.S.I. following tabular statement of lithotomy case3 in the Medical College Hospital shows that vesical calculus is neither of very frequent occurrence in Lower Bengal, nor are the results of the operation very successful. Out of 45 cases, 31 only recovered, giving a mortality of 31'H per cent., or about one in three and a quarter?a result which must be regarded as unfavourable, when compared with the success which attends the operation in the Upper Provinces, where the average mortality is only 1 in 8 or 10. The operations here recorded were chiefly lateral, a few were by the median section. It is necessary to analyse the fatal cases to understand the cause of so high a rate of mortality in an operation generally The
The 45 cases here eo successful in other parts of India. recorded have occurred in my wards during the past ten years,
and represent about half of those admitted during that period, the other half having been under the care of my colleague. The total is a small one for a large hospital, and the mortality is high. It is to be remarked that some of the cases came at a time when it was almost too late to hope for success, and when the operation offered, perhaps at the best, but relief from suffering and a faint chance of life. The disease being, comparatively, an uncommon one in this part of Bengal, the subjects of it are less prepared to submit to treatment. They know little of the success of the operation when performed at the proper time, and only make up their minds to seek relief at the hospital, when the mischief has advanced so far that the chance of recovery is reduced to a minimum. On one occasion I remember seeing a poor, emaciated creature carried into my ward; he had, after years of suffering, made up his mind to come to Calcutta for relief. He reached the hospital in a dying state, and sank from exhaustion within ten minute3 after entering the ward. .The post mortem examination revealed a large vesical calculus, extensive disease of the bladder, ureters and kidneys. In the North-West Provinces, where the disease is common, its nature and prospective dangers are thoroughly appreciated by the sufferers, they seek relief early, and numbers find it, in the dispensaries of the civil stations, where, in a dry and healthy climate, they rapidly recover under the care of skilful operators. In the Medical College Hospital there is very little selection of cases. The object is to confer the greatest amount of relief, and in some cases, as I have said, the operation affords, at the best, little hope of more than temporary amelioration of suffering, or of promoting " euthanasia." But as medical knowledge increases, it may be hoped that a more intelligent comprehension of the danger will make them seek more timely relief. The first fatal case recorded is that of a man aged 40. from whose bladder 86 small calculi, two of them of the mulberry form, were removed by the median section. Death, in this case, was caused by blood poisoning and exhaustion, depending on the formation of pus in the prostate, and between the bladder and rectum. On examination after death, which occurred on the 29th day, it was found that there was much induration and a large collection of pus between the bladder and rectum, and that the prostate gland was riddled with abscesses, and its ducts dilated into pouches filled with small calculi (96 in number), varying in size from a grain of rice to that of a pea. The bladder also was thickened, and its rugce of a deep red colour. The kidneys were healthy. The weight of the calculi removed by the operation was 162 grains. The 2nd death occurred in the case of a man aged 24.?A calculus coated with phosphates, and weighing 1,271 grains, was removed by the lateral operation. He was in a wretchedly exhausted and emaciated condition, and suffering so severely, that he gladly accepted whatever hope of relief the operation afforded. The stone was large, heavy, and roughened by the deposit of triple phosphates in the form of lancet-shaped crystals set edgeways. He died of pyccmia, and after death pus wa3 ound in the right pleural cavity; calculi were found in the pelves of both kidneys. The left kidney was shrunken, softened, and infiltrated with pus. The bladder much thickened ulceration having opened into the rectum. Th o i eft iliac fossa contained a large collection, five ouuces c behind the pelvic fascia a3 high as the
fCr^.e^'
diaphra'gm*^^^nS j
was
ya
ery on the 10th
that of
an
old man, who died of acute The disease was
day after the operation,
[August 1,
1870.
neither connected directly with the calculus, nor the operation, from which he was recovering. The 4th death-was that of a man aged 35, who died the day after the operation, which was performed by the median sec-
Right kidney hypertrophied, ureter dilated, left kidney atrophied, bladder thickened, inflamed patches in the vesical mucous membrane, a gangrenous spot near the opening of right nreter into the bladder, cellular tissue around the neck of bladder ecchymosed. The 5th death occurred in the case of a man aged 23. The calculus was encysted in the upper fundus of the bladder, and It was found after death, was extracted with great difficulty. which occurred on the fourth day, tnat there was suppuration about the neck of the bladder and in the sub-peritoneai cellular tissue. The prostate was bruised, and suppuration had taken place in the kidneys, in the iliac fossa and scrotum. Death in this case was due partly to shock, partly to the pytemic condition which so rapidly supervened. In-the 6th case, death occurred on the sixth day, with symptoms of peritonitis, after removal, by the lateral section, of a phosphatic calculus weighing 230 grains.
tion.
In the 7th case, death occurred after the removal of a small 37 grains in weight, from pyaemia and the formation of fibrinous coagula in the right side of the heart. The right side of the heart and the pulmonary arteries contained firm fibrinous clots. The liver was fatty, the spleen and kidneys healthy. The right knee-joint was full of pus. There was a large collection of pus in the left psoas muscle. The right lobe of the prostate contained an abscess, and tlfe calf of the rignt leg was infiltrated with pus under the gastrocnemius. The lungs were congested, but contained no pyaamic patches. In the 8th case, the abdominal cavity was covered with a layer of greenish aplastic lymph. The lower portion of the descending colon was displaced, it lay on the anterior surface of the bladder, and was adherent to it. The perineal wound had a sloughy aspect. The cellular tissue between the bladder and rectum was sloughing. The liver and kidneys were healthy. Both the lungs were studded with patches, of pyosniic origin. Death in this case was due to a low pyajmic form of peritonitis and cellulitis. The 9th case terminated fatally on the 18th day after removal of a uric acid calculus, weighing 360 grains,?from pyaemia. The right pleural cavity was filled witli sero-purulent fluid. The right in its and posterior, lung contained especially lower aspect, numerous gangrenous patches, from the size of a sixpence to that of a shilling. There was nothing morbid about tho
calculus,
prostate, bladder, or kidneys. The cause of death in the 10th case was exhaustion. The patient was a very old, feeble man, much emaciated, with cataract in both eyes and arcus senilis. The urine was albuminous and purulent. The stone was large, and he lost a considerable quantity of blood. Death occurred three hours after the operation, which was performed in tho hope of relieving his great suffering. In the 11th case, death occurred, after removal of a small calculus by lateral section, on tho day following the operation,
from uraemia; no urine was secreted after tho operation, after which there was considerable haemorrhage. The kidneys were found to be extensively diseased, the right one had a cyst at the upper part of the size- of an orange ; the left, contained many small cysts. The kidneys were shrunken and fatty, the bladder was thickened and ulcerated. No infiltration of urine. The other organs were all healthy. In the 12th case, death occurred after removal, by lateral section, of a uric acid calculus, 180 grains in weight, from a man aged 40 years. The perineum in this caso was very narrow, and the operation followed by a good deal of hemorrhage. Death resulted on tho 16th day from erysipelas of the scrotum, which rapidly spread to the neighbouring tissues. The post mortem examination revealed kidneys containing cysts. Bladder thickened, but otherwiso healthy, heart adherent to the pericardium at tho apex of tho left ventricle, the cardiac wall being
thinned at a point corresponding. Thero wero decolorize fibrinous clots in the right ventricle, and atheromatous patches in the aorta. The 13th case was that of an Englishman, W. II., aged 4 > who injured himself, had recto-vesical fistula and subsequent calculus. The stone was removed by tho lateral operation on 7th January, 1869. lie died of pyaemia and cardiac embolisni cn 18th February, 1869. The autopsy revealed extensive pysemio mischief in tho liver, numerous dead patches of tissue, and firm fibrinous coagula in right cavities of heart. Lungs natural. The lithotomy wound had healed.
August 1,
understood in all forms by every surgeon in this But I may just remark that in the case of the lateral operation, I use the simple laterally grooved staff, the common lithotomy scalpel, and the ordinary forceps. I usually commence the incision at au inch and a quarter in front of the anus, and I make an opening sufficiently large both in the perineal tissues and prostate, to permit of extraction of the calculus with as little violence to the tissues through which it passes as possible. In the median operation, (adapted only for small calculi.) I use a staff grooved on the back, a common scalpel, a long probe as a guide, and a pair of ordinary lithotomy forceps. I make the perineal incision either by puncture with the back of the scalpel towards the rectum, half an inch anterior to it, piercing directly into the membraneous portion of the urethra, and then cutting forwards and outwards until an aperture large enough, after dilatation with the finger, is formed for removal of the calculus; or I cut down from without, on the staff, opening the membraneous portion of the urethra. Then introducing a probe, as a guide to the finger, which is insinuated along it into the bladder, I gradually dilate the prostate until the forceps can be introduced, and the calculus withdrawn. I do not, as a general rule, introduce a tube after the operation, unless there be hasmorrhage ; in which case I use a silver tube with a piece of linen tied on at one end, like an umbrella, so that it can be stuffed with lint in the wound, when plugging is needed, otherwise it is unnecessary, as the urine flows through the wound, without danger of infiltration, if it only be made free and in the right direction. In addition to these 45 cases, I would supplement the record with five others which have occurred, out of the hospital, and slightly modify the death figure. A. B., a healthy English gentleman, about 45 years of age? uric acid calculus, size of a marble, removed by median section, on the 2nd January,?recovered rapidly.
thoroughly
The 14tk case.?A feeble, aged native had a uric acid and phosphatic calculus weighing two ounces and five drachms, ?removed by lateral operation on 25th September, 1869. The wound was nearly healed, when he sank from chronic diarrhoea
country.
the 27th November, 1869. with few It will be observed, that the deaths were, exceptions, an unhealthy condition of due to toxemic causes,?all pointing to conditions. unfavourable hygienic the patients, or to Tendency the unfavourable results to pyaemia exists in the hospital, but local influences. to The nature ?cannot be attributed altogether it evident that tlm combination of the deaths, however, makes It is to be borne was very fatal. of unfavourable circumstances of the operation themselves are in mind, that the subjects Forty-five cases of lithotomy frequently most unfavourable. of which were by the median section. arc here recorded?four most part uric acid or uric acid coated The calculi were for the an occasional example of the oxalate of with phosphates, with varied Irom 21 grains the The weight of the calculi lime the largest. For the most part the smallest, to 1,271 grains for a disease the from considerable period patients had suffered had been proportionately before applying for relief, and damaged on
^
in
constitution.
45 cases was 14 The number of deaths out of these of the lateral operations. two of the median, and twelve causes of death were :?
Pyajmic conditions
Peritonitis Cellulitis
Dysentery,
... ...
...
...
...
diarrhoea
...
Erysipelas
5 2 1 2
being The
1 j
,M
Urcemia
tg
!! ?
C3
.
g
???
s
Cj
?s
1S70.
[August 1,
TITE INDIAN MEDICAL GAZETTE.
270
Tabular Statement of Vesical and Urethral Calculi removed between November, 1859 and April, 1870, in ls? Surgeon's Wards,' Medical College Hospital. Stone. O
Operation. ?
168 ,,
.
CASES FROM PRACTICE. LITHOTOMY.
By J. Fayrer, M.D., C.S.I. following tabular statement of lithotomy case3 in the Medical College Hospital shows that vesical calculus is neither of very frequent occurrence in Lower Bengal, nor are the results of the operation very successful. Out of 45 cases, 31 only recovered, giving a mortality of 31'H per cent., or about one in three and a quarter?a result which must be regarded as unfavourable, when compared with the success which attends the operation in the Upper Provinces, where the average mortality is only 1 in 8 or 10. The operations here recorded were chiefly lateral, a few were by the median section. It is necessary to analyse the fatal cases to understand the cause of so high a rate of mortality in an operation generally The
The 45 cases here eo successful in other parts of India. recorded have occurred in my wards during the past ten years,
and represent about half of those admitted during that period, the other half having been under the care of my colleague. The total is a small one for a large hospital, and the mortality is high. It is to be remarked that some of the cases came at a time when it was almost too late to hope for success, and when the operation offered, perhaps at the best, but relief from suffering and a faint chance of life. The disease being, comparatively, an uncommon one in this part of Bengal, the subjects of it are less prepared to submit to treatment. They know little of the success of the operation when performed at the proper time, and only make up their minds to seek relief at the hospital, when the mischief has advanced so far that the chance of recovery is reduced to a minimum. On one occasion I remember seeing a poor, emaciated creature carried into my ward; he had, after years of suffering, made up his mind to come to Calcutta for relief. He reached the hospital in a dying state, and sank from exhaustion within ten minute3 after entering the ward. .The post mortem examination revealed a large vesical calculus, extensive disease of the bladder, ureters and kidneys. In the North-West Provinces, where the disease is common, its nature and prospective dangers are thoroughly appreciated by the sufferers, they seek relief early, and numbers find it, in the dispensaries of the civil stations, where, in a dry and healthy climate, they rapidly recover under the care of skilful operators. In the Medical College Hospital there is very little selection of cases. The object is to confer the greatest amount of relief, and in some cases, as I have said, the operation affords, at the best, little hope of more than temporary amelioration of suffering, or of promoting " euthanasia." But as medical knowledge increases, it may be hoped that a more intelligent comprehension of the danger will make them seek more timely relief. The first fatal case recorded is that of a man aged 40. from whose bladder 86 small calculi, two of them of the mulberry form, were removed by the median section. Death, in this case, was caused by blood poisoning and exhaustion, depending on the formation of pus in the prostate, and between the bladder and rectum. On examination after death, which occurred on the 29th day, it was found that there was much induration and a large collection of pus between the bladder and rectum, and that the prostate gland was riddled with abscesses, and its ducts dilated into pouches filled with small calculi (96 in number), varying in size from a grain of rice to that of a pea. The bladder also was thickened, and its rugce of a deep red colour. The kidneys were healthy. The weight of the calculi removed by the operation was 162 grains. The 2nd death occurred in the case of a man aged 24.?A calculus coated with phosphates, and weighing 1,271 grains, was removed by the lateral operation. He was in a wretchedly exhausted and emaciated condition, and suffering so severely, that he gladly accepted whatever hope of relief the operation afforded. The stone was large, heavy, and roughened by the deposit of triple phosphates in the form of lancet-shaped crystals set edgeways. He died of pyccmia, and after death pus wa3 ound in the right pleural cavity; calculi were found in the pelves of both kidneys. The left kidney was shrunken, softened, and infiltrated with pus. The bladder much thickened ulceration having opened into the rectum. Th o i eft iliac fossa contained a large collection, five ouuces c behind the pelvic fascia a3 high as the
fCr^.e^'
diaphra'gm*^^^nS j
was
ya
ery on the 10th
that of
an
old man, who died of acute The disease was
day after the operation,
[August 1,
1870.
neither connected directly with the calculus, nor the operation, from which he was recovering. The 4th death-was that of a man aged 35, who died the day after the operation, which was performed by the median sec-
Right kidney hypertrophied, ureter dilated, left kidney atrophied, bladder thickened, inflamed patches in the vesical mucous membrane, a gangrenous spot near the opening of right nreter into the bladder, cellular tissue around the neck of bladder ecchymosed. The 5th death occurred in the case of a man aged 23. The calculus was encysted in the upper fundus of the bladder, and It was found after death, was extracted with great difficulty. which occurred on the fourth day, tnat there was suppuration about the neck of the bladder and in the sub-peritoneai cellular tissue. The prostate was bruised, and suppuration had taken place in the kidneys, in the iliac fossa and scrotum. Death in this case was due partly to shock, partly to the pytemic condition which so rapidly supervened. In-the 6th case, death occurred on the sixth day, with symptoms of peritonitis, after removal, by the lateral section, of a phosphatic calculus weighing 230 grains.
tion.
In the 7th case, death occurred after the removal of a small 37 grains in weight, from pyaemia and the formation of fibrinous coagula in the right side of the heart. The right side of the heart and the pulmonary arteries contained firm fibrinous clots. The liver was fatty, the spleen and kidneys healthy. The right knee-joint was full of pus. There was a large collection of pus in the left psoas muscle. The right lobe of the prostate contained an abscess, and tlfe calf of the rignt leg was infiltrated with pus under the gastrocnemius. The lungs were congested, but contained no pyaamic patches. In the 8th case, the abdominal cavity was covered with a layer of greenish aplastic lymph. The lower portion of the descending colon was displaced, it lay on the anterior surface of the bladder, and was adherent to it. The perineal wound had a sloughy aspect. The cellular tissue between the bladder and rectum was sloughing. The liver and kidneys were healthy. Both the lungs were studded with patches, of pyosniic origin. Death in this case was due to a low pyajmic form of peritonitis and cellulitis. The 9th case terminated fatally on the 18th day after removal of a uric acid calculus, weighing 360 grains,?from pyaemia. The right pleural cavity was filled witli sero-purulent fluid. The right in its and posterior, lung contained especially lower aspect, numerous gangrenous patches, from the size of a sixpence to that of a shilling. There was nothing morbid about tho
calculus,
prostate, bladder, or kidneys. The cause of death in the 10th case was exhaustion. The patient was a very old, feeble man, much emaciated, with cataract in both eyes and arcus senilis. The urine was albuminous and purulent. The stone was large, and he lost a considerable quantity of blood. Death occurred three hours after the operation, which was performed in tho hope of relieving his great suffering. In the 11th case, death occurred, after removal of a small calculus by lateral section, on tho day following the operation,
from uraemia; no urine was secreted after tho operation, after which there was considerable haemorrhage. The kidneys were found to be extensively diseased, the right one had a cyst at the upper part of the size- of an orange ; the left, contained many small cysts. The kidneys were shrunken and fatty, the bladder was thickened and ulcerated. No infiltration of urine. The other organs were all healthy. In the 12th case, death occurred after removal, by lateral section, of a uric acid calculus, 180 grains in weight, from a man aged 40 years. The perineum in this caso was very narrow, and the operation followed by a good deal of hemorrhage. Death resulted on tho 16th day from erysipelas of the scrotum, which rapidly spread to the neighbouring tissues. The post mortem examination revealed kidneys containing cysts. Bladder thickened, but otherwiso healthy, heart adherent to the pericardium at tho apex of tho left ventricle, the cardiac wall being
thinned at a point corresponding. Thero wero decolorize fibrinous clots in the right ventricle, and atheromatous patches in the aorta. The 13th case was that of an Englishman, W. II., aged 4 > who injured himself, had recto-vesical fistula and subsequent calculus. The stone was removed by tho lateral operation on 7th January, 1869. lie died of pyaemia and cardiac embolisni cn 18th February, 1869. The autopsy revealed extensive pysemio mischief in tho liver, numerous dead patches of tissue, and firm fibrinous coagula in right cavities of heart. Lungs natural. The lithotomy wound had healed.
August 1,
understood in all forms by every surgeon in this But I may just remark that in the case of the lateral operation, I use the simple laterally grooved staff, the common lithotomy scalpel, and the ordinary forceps. I usually commence the incision at au inch and a quarter in front of the anus, and I make an opening sufficiently large both in the perineal tissues and prostate, to permit of extraction of the calculus with as little violence to the tissues through which it passes as possible. In the median operation, (adapted only for small calculi.) I use a staff grooved on the back, a common scalpel, a long probe as a guide, and a pair of ordinary lithotomy forceps. I make the perineal incision either by puncture with the back of the scalpel towards the rectum, half an inch anterior to it, piercing directly into the membraneous portion of the urethra, and then cutting forwards and outwards until an aperture large enough, after dilatation with the finger, is formed for removal of the calculus; or I cut down from without, on the staff, opening the membraneous portion of the urethra. Then introducing a probe, as a guide to the finger, which is insinuated along it into the bladder, I gradually dilate the prostate until the forceps can be introduced, and the calculus withdrawn. I do not, as a general rule, introduce a tube after the operation, unless there be hasmorrhage ; in which case I use a silver tube with a piece of linen tied on at one end, like an umbrella, so that it can be stuffed with lint in the wound, when plugging is needed, otherwise it is unnecessary, as the urine flows through the wound, without danger of infiltration, if it only be made free and in the right direction. In addition to these 45 cases, I would supplement the record with five others which have occurred, out of the hospital, and slightly modify the death figure. A. B., a healthy English gentleman, about 45 years of age? uric acid calculus, size of a marble, removed by median section, on the 2nd January,?recovered rapidly.
thoroughly
The 14tk case.?A feeble, aged native had a uric acid and phosphatic calculus weighing two ounces and five drachms, ?removed by lateral operation on 25th September, 1869. The wound was nearly healed, when he sank from chronic diarrhoea
country.
the 27th November, 1869. with few It will be observed, that the deaths were, exceptions, an unhealthy condition of due to toxemic causes,?all pointing to conditions. unfavourable hygienic the patients, or to Tendency the unfavourable results to pyaemia exists in the hospital, but local influences. to The nature ?cannot be attributed altogether it evident that tlm combination of the deaths, however, makes It is to be borne was very fatal. of unfavourable circumstances of the operation themselves are in mind, that the subjects Forty-five cases of lithotomy frequently most unfavourable. of which were by the median section. arc here recorded?four most part uric acid or uric acid coated The calculi were for the an occasional example of the oxalate of with phosphates, with varied Irom 21 grains the The weight of the calculi lime the largest. For the most part the smallest, to 1,271 grains for a disease the from considerable period patients had suffered had been proportionately before applying for relief, and damaged on
^
in
constitution.
45 cases was 14 The number of deaths out of these of the lateral operations. two of the median, and twelve causes of death were :?
Pyajmic conditions
Peritonitis Cellulitis
Dysentery,
... ...
...
...
...
diarrhoea
...
Erysipelas
5 2 1 2
being The
1 j
,M
Urcemia
tg
!! ?
C3
.
g
???
s
Cj
?s
1S70.
[August 1,
TITE INDIAN MEDICAL GAZETTE.
270
Tabular Statement of Vesical and Urethral Calculi removed between November, 1859 and April, 1870, in ls? Surgeon's Wards,' Medical College Hospital. Stone. O
Operation. ?
