THE BROOKLYN MEDICAL JOURNAL PUBLISHED MONTHLY BY THE MEDICAL SOCIETY OF THE COUNTY OF KINGS. EDITORIAL COMMITTEE: JOSEPH H. RAYMOND, M. D., ALEX. HUTCHINS, M. D., JOSEPH H. HUNT, M. D., GLENTWORTH R. BUTLER, M. D., FRED. D. BAILEY, M. D. VOL. IV. No. 9. BROOKLYN, N. Y., SEPTEMBER, 1890. Single copies 25 cents. $2 a year, in advance. ORIGINAL ARTICLES. TWO CASES OF OPERATION FOR REMOVAL OF PIECES OF CATHETER FROM THE BLADDER. BY J. S. WIGHT, M.D., Professor of Operative and Clinical Surgery at the Long Island College Hospital. Read before the Brooklyn Surgical Society, June 5, 1890. CASE I.-Mr. S., a business man and farmer, about forty-one years of age, had some urinary difficulty, and called his family physician, who introduced a No. 8 soft catheter in order to draw his water and give him relief. When he came to remove the catheter, it broke and left some six inches of it in the urethra and bladder. The doctor, assisted by a surgeon, worked for about an hour on the evening of the same day to remove the piece of catheter, and did not succeed. Another attempt to remove it was made on the following afternoon it failed. Three attempts were made with urethral instruments, and the result was that the piece of catheter was entirely in the bladder. This case was brought to my attention by Dr. Bartley. I advised him to have his friend come to the College Hospital, where I could make an examination, and determine what could be done. This was in the first week of September, 1887, about fifteen days after the accident. In brief, the examination disclosed the usual symptoms of stone in the bladder. The sound struck a hard substance like a calculus. The patient and his friends were anxious to have the offending body removed through the urethra, without a cutting operation. This I declined to do, for it was impracticable. I advised an operation the same as for stone in the bladder. Assisted by Drs. Bartley, Cochran and Rogers, I operated September 8, 1887. The perinæum was not very deep; the membranous and prostatic urethra was quite short; the bladder was low down, and was easily reached with the knife and fingers; and so there was nothing special about getting into the bladder, except that the tissues were soft and easily torn, and great care was required to keep from pushing the bladder away from its inferior attachments. The operation was that of left lateral lithotomy. With a narrow forceps I removed three pieces of catheter; they were nearly equal in length, and together measured about six inches. They were all completely encrusted with calcareous matter, from one-sixteenth to three-eighths of an inch in thickness, thus making them veritable calculi with large nuclei. This patient did well after the operation. Yet the progress of the case was rather slow. A small fistula kept open for several months; it finally closed. The following remarks are now proper: Two prolonged attempts to remove the piece of catheter by urethral instruments completely failed. The urethral and vesical irritation caused by these instruments was no doubt harmful to the patient. At the time of my operation it would have been impossible to remove the encrusted pieces of catheter through the urethra. And it is reasonably certain that they could not have been satisfactorily crushed, in order to wash them out of the bladder. Truly, we did the very best thing for our patient under the circumstances. CASE II. Mr. E., about forty-five years of age, in January, 1888, introduced a flexible catheter into his bladder to draw the water, and when he removed it there was a piece left. The catheter had broken, and the length of the piece was not accurately known. In June of the same year calcareous matter had concreted about the piece of catheter in his bladder, so that he was in the condition of a man having stone. He suffered very great pain. His emaciation was considerable. He was operated on by a surgeon of skill. The operation was litholapaxy, after the method of Dr. Bigelow. The crushing was thoroughly performed, and the bladder was well washed out. But, unfortunately, the patient did not have complete relief from pain and difficulty. In fact, it was not long when his condition was even worse than before the operation. He got along as well as he could till the following year, when he consulted Dr. A. W. Ford of this city. In June, 1889, Dr. Ford requested me to see his patient. The symptoms of stone were marked. The sound confirmed the diagnosis. The stone was large, or was made up of several irregular masses; it appeared to be soft. The patient was much emaciated, and had lost most of his physical and moral courage. There seemed to be no hope for him without an operation, and an operation did not promise very much. Yet I advised an operation-same as for stone. June 15th I assisted Dr. Ford in performing lithotomy; Drs. Harrigan, Cochran, Welty and others were present at the operation. There was nothing unusual about the cutting part of the operation; it was easy to reach the bladder with the knife and finger. But the contents of the bladder deserve some notice: The calcareous substance was made up of several pieces more or less adherent. Some of the pieces were quite firmly attached to the surface of the bladder. A few of them could be removed by the forceps. It was necessary to use a scoop to detach others. One piece of catheter, one-half inch in length, thickly covered with calcareous matter, was removed, the opening through it was quite pervious. A considerable body was hanging by one end from the roof of the bladder. It was seized by a pair of forceps, and forcibly twisted off and then removed. It proved to be a piece of catheter, a little over an inch in length, and was thickly incrusted with calcareous matter. In all there were some fifteen pieces removed. They were very light, and some of them appeared to have small pieces of catheter for nuclei. The operation-wound was healing kindly, and there was no surgical fever. The patient was improving; but an attack of acute dysentery set in, causing death on the 11th of June. In regard to this case, we are justified in making the following remarks: A scientific attempt, by a skilful surgeon, to remove a piece of catheter from the bladder through the urethra was partly successful; and yet the patient's condition was not improved by the operation. Two considerable pieces of catheter were left, and they were nuclei for calcareous matter. And one may ask this very reasonable question: Would it not have been better to have performed lithotomy on this patient at the outset? One may feel quite certain that it would have been so. The last operation had no special difficulties, and could have been performed the year before, when the patient was in much better condition, and might have saved his life. There are two points related to these cases that we may briefly consider: In going into the bladder great care must be taken so as not to push the neck of the bladder away from the perineal structures, when the finger of the surgeon is introduced. When the point of the knife reaches the shoulder of the staff, it must be withdrawn. A grooved director must then be passed into the bladder under the staff. Then the finger of the surgeon is gently pushed into the bladder between the beak of the staff and the grooved director. In this way safe dilatation of the neck of the bladder is accomplished without dislocating the bladder upward. I have had occasion more than once to test the great value of this procedure. Also, it seems to me that a sound new catheter will not break while being introduced into the bladder. I saw parts of the one used in Case I., and when they were bent to any extent, small rings would be detached. In Case II, the catheter had been used long enough to make it fragile. An old catheter must not be used. Nor must any catheter be used too long. It is reasonably certain that we cannot have cases of the above kind if we always use good new catheters. Finally, it will be seen that our conclusion is, that it is best not to delay in the removal of pieces of catheter in the bladder. While it might happen that the surgeon would be lucky enough to remove them through the urethra, it would appear that the uncertainty of success is great, and that the operation of lithotomy should be performed at once, even before calcareous incrustation takes place, unless there is some constitutional condition that contraindicates it. DISCUSSION. Dr. WUNDERLICH.-I have listened with great interest to Dr. Wight's paper, and fully agree with him as to the advisability of an early operation for removal of pieces of catheter from the bladder. In some instances it may be preferable to make the suprapubic instead of the median operation, because it renders the bladder more accessible, and the search for the broken piece or pieces can be made under the supervision of the eye. However, due consideration should be given to the greater danger of the suprapubic operation; and the surgeon must be guided in the choice of the operation by the exigencies of each case. Prior to any cutting operation I would make an examination with the cystoscope, to ascertain the position of the broken piece of catheter. Having ascertained the position of the piece of catheter, it becomes more feasible to grasp it with a small lithotrite in such manner as to render the extraction through the urethra possible without undue injury to the parts. In this manner pieces of catheter have been removed from the bladder by Fillenbaum and Antal; a pin by Niccoladoni; and silk ligatures, which had given rise to the formation of calculi, by Nitze and Gross. Dr. RAND.-It seems to me that no one rule can be laid down as the proper one to follow in all cases. The operation indicated will depend upon the character of the foreign body present, as well as upon the length of time it has been in the bladder. In the case of an elastic catheter or of any similar foreign body, recently introduced, which, if once seized at any point can be withdrawn through the urethra without damage to the tissues; a reasonable effort ought to be made to seize and remove it in this way. Where a foreign body of this character has, however, been a sufficient time in the bladder to be well covered with calcareous deposit, the course adopted by the author of the paper would be undoubtedly the proper one. acter. Where the foreign body is hard and cannot be safely extracted unless seized by the extremity, a thing difficult if not impossible to do, the best course to pursue would again be determined by its charIf it can be safely crushed and evacuated as in the operation of litholapaxy, this would certainly be preferable to cystotomy. If, however, it be lead or glass, or a splinter of bone, any substance that cannot be crushed, or, if so treated, would endanger the bladder walls from sharp fragments, then a cystotomy would be indicated. Dr. PILCHER.-It seems to me the suggestion of the use of the cystoscope is one that is well worthy of being taken into consideration by surgeons at all times, for the purpose of getting at an accurate conclusion as to whether in a particular case further attempts to remove through the urethra would be justifiable or would be likely to be attended with success, or whether it were necessary at once to proceed to the cutting operation. I can see in the result of one of the cases which has been related here by the author of the paper this evening, a very valuable comment upon the undesirableness of attempting to use the method of litholapaxy, since by the chewing up of the catheter, which was done, instead of one or two pieces, a multitude of small pieces were left and became nuclei of new accretions; and adhesions to the wall of the bladder formed from the inflammatory reaction which resulted. It seems to me that if an ordinary gum, or a soft flexible catheter, silk or pure rubber, either, has been broken off in the bladder, that there is not very much danger to be apprehended in attempting to seize it with a medium sized lithotrite, and attempting to remove it, and if it breaks again, if it is so brittle that it resists such attempts, then there is nothing further to do but to go on with cystotomy. In those cases where it is covered by phosphate deposits, the use of a lithotrite would commend itself to grind it up as we would any other accretion in the bladder, and endeavor to suck it out by the washing-bottle. When we come, however, to choosing a cutting method for removal of such bodies, it seems to me that except in very extraordinary cases, the ordinary median perineal operation offers the most rapid, most safe and most easy method of gaining access to the bladder and removing the offending material. It has never seemed to me that when the urethra had been opened in its membranous portion |