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^iU ti, OLUJ:*^ (^^.c^LMlc^juU-
P<#|^p<>0<>6<>p<>p<
I. A NEW METHOD OF CUTTING URINARY
CALCULI. 2. A CASE OF UNUSUALLY
LARGE CALCULUS REMOVED BY SUPRA-
PUBIC SECTION. j» .* J» .* .* .* .*
...in ...
C.l'.DUC.i: A. riCTI'.kS, M.l! , I'.U.C.S. I'M.
T.iKONTd C.\N.\I)\
ll'-lti ill!' 1 Ifirii Till ( ■ \\ \iii \\ 1*1; \< 1 1 1 ni\i;i- \ M. l:i \ 11 w ,
.l.inil.ir.v . P«..'.
'?^">o?>^%?^/%?%?IIW^>o?%?>T6o< >o<
/^
T
J. A NEW METHOD OF CUTTING URINARY CAL-
CULI. 2. A CASE OF UNUSUALLY LARGE CAL-
CULUS REMOVED BY SUPRA-PUBIC
SECTION.
lU I.KillK.K \ I'KI'Kl:.-. Ml!.. I- I! 1 .S lAi. .
\-,.,..|.„,. r, .1 i-..:^>ir. I, 11. I rl,,ii.-.l s i,^,.rv I '">'i-'l> ..f T..r..Mi.. . -mw- T'lr-iii..
Lviirr^il ll..-|'il..l .
1 \ in, .1-1.1 ll"-|.ii il I"
n.il.lrr... T.'r.iil"
'I'lic lollowiii;;- In il iiirtlKHl ul' ciitiiii-' >lun,'.s cil' all ' 'II.!.--. lianl
ami .sdlt. wliicli tlir iiiuhur liiis fouiiil to !>• of j^ifiit iim' au'l ol
.■.|ii,il siiiililicity. Solar as i-.iii 1p<' msci rtainf(l tlir iiu'IImhI i-
iii\v ami ori^niial.
'I'll.' stiiiif is first of all iliiii>i'il tor a iiioiiifiit into iiirind
l>aratHii was. 'i'liis i;ivfs it a very tliiu foatiiiu' ol' tlu' \v,i\
iKi;^. 1 K) and i.i-.'voiits the stickiii- of plasi.i-of-l'.iris in
uliicli it is to 1 iiibcd.lf'l. As a means of lioldiii;; tli.' stonr
al)>oliitily iiiiinoxalil.' wliih' il is iuMiii; .sawn, the aid of a liors,.-
slio.., as sli.iwn ill till' iKroiiiiiiiiiyin;; illustration (V\<i. \ >. is
liroii-ht into use. 'ni.' Ii.n'scsho. ^ i.lan-d nipoii a hoard witli
its u'l^iddlf fsactly ovn- a liii.- i r'i^'. 1 -V ) juvviously drawn
loiij,'iHliliiially iqioii tlh' lio,inl. 'i'liis linr is t.. s.tvc as a
constant tixt'd indication of thr nntro of the stone. 'I'tie lieels
(,f the lioi-.Msline ni.iy h-' tilted 11]) l>y means of a short 111' ifU
({•'i- 1 i'.liilaced crosswise iiiid<i' the slide, s,, that tln'y will
aholU snhtend tin- centre of tli.' stone. The horseshoe is l|„.ii
n,aile(l tirml.v into iiosilion on the hoard, 'i'he st ( Kiu i «'
i> nnw taken iiilo thr hands of tl i.er.ilor .and can-fully
c.iitrali/i'd opiMPsite ill.- line drawn on tie' ho.-ird IMasli'i-of-
I'aiis cream is then run round il .ind .>\er il in such a way as
lo eiiihed th'' stone COIllpletelv to the .■xt.nl of not 1,-ss lli.ni
|,,.,||- ,,,|| incli of eovcriii-- at any liail, and in such .i in.inner thai
ihr cmhe.ldln- iilast>-r ,al,so cmliracs ih- hr.-l- of the hor>esho.-
, ..-1111.1 .11 ■! Ill
,■1-1 111.-. .1 lli.-'l-.ii-.iiilo 1'h11i.i1..ki.mI s,i,-„-lj, N,iri'iillHM-L'. I'.fil.
4 n TTrNfl OF lUINAIiV lALClLl.
(Fig. 1 l>». i'he plastti- is then iillowfd to nvi (irmly, ami if it
fiiii be left fur sevenil liayM until it is thoroiijfhiy dried so iiiucli
the lietter, iis it is found tliiit the siiw works more easily in
thorou;;lily ilry plaster. The stone is sawn directly through
the plaster which embeds it in the line previously marked on
the board, and a second cut is made throiigli the plaster between
tlie stone and the heel of the hor.seshoe. If the stone is very
large and hanl, the Iward may U' fastened in a vice, and tlrj
saw cut made through the Ijoard al.so. This .serves very
materially to stea ly the .^aw. This section thus liberated can
then be readily detached from the lx)ard and will be found
to contain one-1-alf of the stone, which '.in I asily lifted
out of the embedding plastei'. part of which may lie cut
away (Fig. 2 Ft. The removal of the stone from the piaster
is facilitated by i)lnnging the wliole into hot water lor a
few moments, when the ])urat!'n wa.x becomes softened iuid
the stone can thu.s be .'asily separ-ited from the plaster. The
last trace of wax is then melted otl' liy holding it under a hf)t
water tap, or putting it into a basin of hot water for a few
moments. The cut surface of the stone may be polished rapidly
and easily by grinding it on a ground-gla.s' surface. In theca.se
ul' ver}- hard stones the |iolishing process is facilitatecl by using
powilered ])umice stone or emi'ry, (hough this is seldom
necessary. In order to get a highly polished surface the
stone should tinally be rubbtij on dry. plain glass, .ind
CirilNIi <iK I KINAIiY CAlAl LI. .".
Intel' on sdiiif \v(M)llcn t'libric wliicli will liriii;; up tlie pDli^li
i)f till' stiiiif. Till' HUtlior liiis founil this nii'tli.-xi of nittiii;,'
til Im' pi-rfcL'tly ii]>|)li('iililr to thf Imri'v I oxiilatf of linii',
as well lis to the sol'tust plinspluiti'- stones, nnil even to
;;iill-stones It is ini|)<)ssilile for the stone to fnicttire The
only case in which iiny ilirticulty was ever experiencol was one
in whicti a very hard oxalate of liiue niicl"ns was surrounded
liy a layer of phosphates of very loose forniution, around
which a;;ain was a more dense ph<is|)liatie layer. l)i!T-iii;j the
^awiiijj of this --tone thr nucleus worked louse iu tin' centre.
The section was. howi'ver, satisfactorily coiii|(l<'tcd.
All ordinary cup >• s su with a fair iiiiiounl of .set
answiis adiiiinihi, . Houlii i\. n^ tliickened hack, as is
found on most suryficjil
.< '\SK n,.- I
Till' ^pl•(•i||len lisrd I
dc-cribi'd iihove is a urinarx
this era and this country
circuiiifeii'iice in the loiii;!
siiiirtcr diaiiii'ier •'> ■ iiidies
idiapi'. Iieiiiij Nli;,ditly lai_
somewhat llattenecl. Its >
ounces and 2:!0 ■riains.
■ \i ■ ' MS.
.t ii.id of ' ittini.'
'lally larj.'!- -i/.-j for
not coninK Its
incht's: ill itir
,1, ^\ iiimeti'i- il • 'val
•id !ll '!" "tleT Hid
t iMir ■ al wn < !•
CI ITIN"; "I lUINAKV CALfl I.I
Till' licwt \\;isa rairiiiT, Mr, . 'tlif .isc stroll;; and Inalthy,
a;;!' ;t!>. Iti- Ii'kI Im'cii iIk' Miihji-ct '>'' yiiiptoiiiH uf ,«.t"iiir in tlir
liliiil'l. r I'liiiii tin.' ii;;'- III' alxmt 9 yi'iirn. At times it proiliici'l
iiiiicii piiiii, 1)111 iiitti'i-ly tlic Nviuptoiii'- liud lurply siiiisiilfd, ami
lir ivally Hiirt'eivil Imt littk'. This wuh explained lit the tirniMil'
Dpeiatiiin liy the I'net timt the stiilie hiid lieconn' p.iiTially
eiicystetl, Hiid thus was iiiiiiiovalile in the hhidder.
'I'h(( eiilciiiuM was removed hy supra-puliic cystotomy on the
1st of .flllle, IMOI. (Ill opeiiini; tlie liiiidder the stone was
I'oiind with its lar;;e end upwards, and its siimller end
eiiiheddeii to a siijjht extent in the fundus of tiie ''ladder behind
the proMtjili'. 'I'lie wound in tin lijadih-r wall wa. iiade lar;;e
enoui.di to mIIuw the stone to 1(0 removeil without undue lacera-
tion. .\rter reiiiova! the bladder was llushed out and stiti!i"d ep
with two rows of chroniicized catijul sutures. The etli.id
I'liipliiyed for disteiidiii;^ the bladder before deration v -- iiiat
.idviK'ated by Urei;; Smith, viz. by attaci ■ tin- tab. if a
resei\i)ii' at an ele\a* i of aUait '1 ft to a cutrieter intro luci d
into the liladder, and after stitt'hin;; up the ineision, the bladder
was tested for the accuracy of the suturing; by allowing,' it to
bi come distended tlirouj^li the catheter. .V tube surrounded by
a layer of ;;aii/e was used for drainaj;e down t<,>. but not into, the
bj.icldi'r. The patient had no bad syinptoiiis whate\er, and the
bl,ii|i|er wound hea'ed by tii'st intention, so that at the end often
days then- was no leaka;,'e whatever. I5ut shortly after this a
\cry small leaka^^e oceiirred uiid persisted for some time, ulti-
iii.itely hialiiiLf however, and leaving; a ;,'oo<l, healtliy letentixe
bladder.
I hi section the stoni' proves to lia.f been in the first instance
an oxalate of lime calculus. Thei-e is ;i nucleus of very tirin,
l.iiiiinated dark brown o.xalate about ; of an inch in diameter
and bounded by a ver_\' "lark creiiateil line (jf the same salt.
Outside of this is anothir layer ^ of an inch thick, showing:
oxalates .iiipareiitly of very much looser formation with stri.e
r.idi.itiiif; towards the centre. (Mi the (jutside of this central
oxalate portion is ;i lamin.ited crust Naryiii;; fiuni half an inch to
an iiieli in thickness exlendiiii; lo the circumleixnce .iiel
consisting,' proliably of ,i ndxture of urate of aiiiinoniui and
jiliosphates. The .\-ray photoLrriiph of the stone shows these
'•••rriM: OK luiv
\i:v
'■"":""■ "'••'*< lUMrk.. Ilv, will,
• ■Ai.ni.i
■"■'•ti'-M <ir th.- ,r
Mir
"""<"'''I"'<'l»ll,|yJurt„t|
l'"l>- wliicl. ,iiv |„,,„|
l;'""'i- sul..,.....,.,. „ |,i,,, i, ,. ,,^^^_,
til.' I
noiv ,||.|i.si. [)||
IHIIIIIIII
'm-ul»rly.|iHtnl,„t,..||
^<'lw.
••'ills till
plilllHil,!
in tl
•••" t"att,.,„,,ti,,,v,„|„l,
'"'"■•' «" t-n ill .tun,
"t Me. .I,,„atlmii Mutcl
y --uiMiis.- (Ill
HII
witli
i"*< i-ase til., aetiial oi,
iHers lial.itiiHllv I
|'ll<<\vin;r |,j„,
'I tl
llllsiiii
'"•y. Hiiici)
"" I'HN.V ,,||,. ,„i^,l|,
A 111. I, from 4
'.f
course
iiiiptTleot assiii
ri Ills ur'
'■'"" '''•'•"iij;fiii,.|,| or th- .|.-,r
■■■''"';;;" Ut.wtious .i,.,K,,siN
\l-hil.. .* . '
"> ( vi'iuN i,r
H-'f.
:'': """*:• "■""- "'—"-r lie s„h;
"'"' ''I'l-'iin;,' ,,,iin Hit
'Xilllltt
|.;»*s«s |-..,- invtli
n
|)lSsit,;r i,,.;,,^. ; „,
•FM I'
ij'ustiv.. ..r<,'uii.s.
an- CDiiiiiiuii
I'DIII
■H HI ..XC-SS, Uy ,,,„, ,,^. ,^^, ,
iciitiii'
i.is r
'•lll.litij;
deletion of
"■ l'"'"*"^'- "»■ tiles., calcl
-;."^r..u-M.uiija....,,„„,, ,';
"111 colic iiti!l j),:.|.|
'"■ ""••'■'weopic .|ii;,ntit
1 r-
IfS,
■■"•f..iii|,a.,i,.,| 1,^. i,|,„„,
'nips
""'• '•alciili.
""<■ <Jay,i.stone .Injps ,1
Ml .'fuss
'■scape fro,,, the bla.|,|
M'H 'linvi. (vom tl... |,i,|,
•sp.'c.|iii,.n in <|Hestion. It
itT, ami bee,
•y I'Ut fails t.
\hitt
oxalate crystals a Usorl.tl
now <,'i-o\vs sloivl
""-•^ the nucleus .,r th..
'"'""■" ■■'■'"ost to hlaek-,„.s.s
part of the speciii
that tin
It
iK'n consunii..! i;
"' pi;;iiients
I'V iccretion. Th
'irii a,„
'oriiieil in aiioti
looser, more chaot
"' or 20 se
"'. i-,i,|iat
'oiii..
>I.U.|<|.st
''!•« in its -rowth ■
prohahl, ^„.^ ,^^, ,
lei-
or (; v.
an. I ph.)sphat..s f,
la_\-er of urate:
'•'•ii.ain.le, of th.. :'jo ,.,j,'|
''"'"' ^l"- -lin-s of ,.|,os,;|
ni^' layer outside of
••""I that th.. .1
this
possibly in.li
"•.■siiltinif i
'i-ate atta..|v-s of mil,!
orrninjr th,. crust
y.irs of t|„. lij.,. ^^^.
'pl'at.-s throii;rhout th
'••I'<»*its of th,.
oeeupii.(l the
tl
n ciir...
.liatl
If
one shouM pre.lic;
■yxtitis. calliier f,
lis caleuhis
St, in.
nia\'
r it.st
of o.\alut..of I
inark-i.,1 , liatl
" COIKjit
to tl
"■-■"^ ."'tl'is,n.Iivi,lual,th,.,.|
une t.) the ,|
laii''..
•ite a
'>ni tl
I.I
lit. tie re\e
l'-I>osit of ,„.,it,,^ ,j
"a'k(.ti oxalat..
'<'I)i-eeipit,rion
lor
>< as re.'nr. Is ,1
■''■<"'• for Hutel,
ofs not iii.li
iiisoii
leai
'O'^'' Hhieh pro,lur.. i
hf't, pfo.lue,. th
''■'■an;rei„em
"icaei.l, i
points ,,„t flat
'^'ostive p.Mver siniil
It
eoxalat,.s"an,l
■ay uii,!,.!- sli.riit
lar
i"'f''ration of
'^ an i'xtraor.linar\- f
thoufjh th.. oxalat.. eal
hemorrhai:.. ar.. not,
iU't, as
Iculiis is r
''>;''mplirie(J in tl
I I
ia\e
as a rule,
■oil;rh an.l v,.,-v 1
11^ ease, t|,,i,
eaiis,. it is
/*pol«'ii of this stori
pi"omin..nt
-ynipt
i..av\-
OIIIS.
pam and
>f the larffi.st
e as one of (11
if
not tl
"Usual size I,,..
''"■,i;''st, that
C'l'TTINC; <»K lUINAUY ('AIA'11,1.
Iiiis cDiiii' iiikIci- my nliMTvatioii in tliin coiliilry iis Imv-
iiii' l)fiii n-iiuivfil l)y i)|w'r:itioii. Stoiii' is r.iri' in <"inmilii
lis compareil with Kurojicaii iiiul Asiatic countries, and it is
hut dill' t() tlie medical iirofession in Canada to say that when
presint it is usually iliseovered and icmoved ln-rorc it ri-achcs
any such dimensions as this specimen exhihits. Ihit tiiis is a
small stone compared to some recordeil eases. Hutchinson
>,'ives the following iw .some of the largest removed during life :
A stone measuring in girth l(i^, x 12^, inches, Ctterhavens ;
Hunter, (Madras) weight 2'i ounces: Morri.son, (Northumber-
land) weight 1 pound ii'l oniici-s: Sir Henry Thompson, weight
14 ounces, (avoir).
lif.' I'oi.i.KiiH St.. ToiiovTo.