Page images
PDF
EPUB

Original Articles in Surgery.

CONDUCTED BY

WILLIAM TOD HELMUTH, M.D., LL.D.

GEORGE W. ROBERTS, Ph. B., M.D.

SIDNEY F. WILCOX, M.D.

A UNIQUE

CASE OF CHOLELITHOTOMY, WITH

"UREMIA," CONVULSIONS AND CERTAIN
INEXPLICABLE PHENOMENA.

By T. L. MACDONALD, M.D., SURGEON, AND H. H. HAWXHURST, M.D., URINOLOGIST,

Fa ca

To the National Homoeopathic Hospital, Washington, D.C.

a case is sufficiently interesting or instructive to justify its report, the intelligent reader will discover it without the usual apologetic preface; if it is not, then such a preface is painfully appropriate—we omit it for both reasons.

Mrs.

[ocr errors]

æt. 48, referred to me by Dr. Bliss. History.-Aside from the fact that her father had gout and cataracts the family history was good. She had four healthy children, had suffered some from "rheumatism," backache and vertigo. The latter may have been due to cataracts—one of which was removed by Dr. King, the other is still immature. She had a chronic interstitial nephritis five years ago, but its symptoms and urinary evidence disappeared under appropriate treatment. Six years ago she had an attack of biliary colic. On February 20, 1897, I was asked by Dr. Bliss, her son-in-law, to see her in consultation. For three days she had been suffering indescribably from gallstone colic. Nothing but morphia afforded the slightest relief. She was exquisitely sensitive over the region of the gall-bladder, she loathed food and was constantly nauseated. The fæces had been watched, and she had passed several small biliary calculi. The diagnosis was clear; there was no improvement in her condition, she was still passing calculi the indications were clear for operation. This was advised and she entered the hospital on the following day.

The following contains our hospital records of the case:

Condition on Admission. Still suffering from nausea, pain and soreness in the right hypochondrium. There is no jaundice, but tongue coated badly. She is stout, and abdomen fat and thick. Heart and lungs normal.

A trace of albumin in the urine.

February 22d.-She was prepared for operation. The temperature was 99, the pulse 86, the respirations 18. Anæsthesia was induced by chloroform (two drachms) and maintained by ether (two ounces). Time required to produce anæsthesia, six minutes. A vertical incision was made over the gall-bladder. The incision was longer than usual on account of the depth of the fat. The enlarged gall-bladder was brought up toward the wound, surrounded by gauze pads and incised. As its liquid contents began to well out, numbers of calculi made their appearance. Then with scoop and irrigation, 305 calculi, varying in size from a pea to that of a walnut, were removed. Although no pus was observed, the bladder was regretfully stitched to the abdominal wound on the principle that no viscus containing that number of calculi could be normal and because this method is safer, though not ideal. We had no reason to think the duct was obstructed, although the sound did not pass readily. A tube and gauze pack were introduced, and the usual dressings applied. She rallied well, but vomited repeatedly.

Feb. 23d.--Nauseated, but otherwise doing well; bile flowing through the tube, little or no pain in the wound. Ipecac 3x administered.

Feb. 24th.-Dull and apathetic, indifferent and inclined to sleep; pupil small. The urine contains albumin and casts. Arg. Nit. 3x was employed, with such general treatment as the threatening uremia demanded.

Feb. 25th. Apparently improving. Cantharis, 10 drops in half glass of water; a teaspoonful every two hours.

Feb. 26th. Seems to be improving, bile flowing and wound giving no trouble.

Feb. 27th.--Do. Pushing water; farinaceous food.

Feb. 28th.-Urine scanty; she is drowsy again, sleeps a good deal. No special change till March 3d, when she appears better. March 4th.-Do.

March 5th.--Not so well; dull again and urine more scant. Gave Rhus tox. 3x. Pushing water by stomach and enemata. March 6th.-Passed only five ounces of urine since yesterday. Comments. At 5.30 I was notified of this, by telephone. I instructed the interne to proceed with saline injection (intravenous) and hurried to the hospital. I found the patient unconscious, with a barely perceptible, flickering but uncountable pulse. There was feeble respiration and an occasional movement of the body and

limbs. The skin was cold and she was sinking rapidly. Noting this, I quickly drew off my coat and had scarcely done so when she was seized with a horrible convulsion. It was brief, however—all too brief!—for, after two or three awful muscular contractions and contortions of the body in which life was almost extinct, it became suddenly relaxed and lifeless. There was no heartbeat, no pulse, no respiration; the jaw was dropped, the eye was glazed-she was limp and lifeless. Few of us who are doing constant duty in the surgical department of a hospital (not to speak of private work) are unfamiliar with shock, collapse and fainting, or the temporary cessation of respiration or circulation, on the operating table. know the difference. This woman was one of my dearest friends, and as lifeless as clay. Nurses and internes were gathered about; I pronounced her dead; she was dead! but I would not yield without a fight. I knew that (grossly) animal life may be extinct and still have histological life and function in the tissues; that a muscle removed from an animal, killed suddenly, will give off carbon dioxide for some time, will absorb oxygen and respond to electric stimuli. Even after rigor mortis has occurred tremblings, elongations and contractions have been observed. More than twenty-four hours after removal from an animal, the pancreas continues its fermentation, and the liver also produces sugar after death. It is therefore perfectly legitimate to conclude that if the cellular structures of the grosser muscles and glands thus continue their function, so must the histological elements of the heart muscle or the respiratory or nervous system. But what was more to the point, I knew, from personal laboratory studies, that if the heart of an animal recently killed were pricked or touched, it would begin to beat again, and continue for a short time. Such a stimulus as this might be furnished by the stream of hot salt solution sent through the venous channels to the heart. We tried it again. In the meantime, I had kept up artificial respiration, while one, two-nearly three pints of salt solution were poured into the median basilic vein. I had stopped twice to see if there were any disposition on the part of the respiratory apparatus to take up its work, but there was none, and artificial respiration was continued (it seemed hours) longer, when there was an occasional flutter in the radial artery. Hot black coffee in the rectum at intervals and hypodermic injections of ether, nitroglycerine and strychnine were employed, till slowly and faintly the pulse came back in the wrist, and later, the respiratory aid was gradually dispensed with and life was resumed. Of course, the

pulse was uncountable, she was unconscious and life was yet unstable, but she was called back. From time to time during the day, aided by Dr. Bliss, she was stimulated hypodermically, with morphia and atropia, and digitalis. Arsenite of copper was also administered. She passed twelve ounces of urine during the day. In

the afternoon she was conscious, and complaining of the pain inflicted by the hypodermic needles. The pulse could be counted; it was 150 per minute.

March 6th.-Improving slowly. Urine still scant, pupil small, pulse 120. Much nauseated, cannot take medicines or nourishment by stomach. Dr. Gardner, in consultation, advised apomorphia 2x for the nausea, which subsided kindly. He also advised cantharis hypodermically, with satisfactory result.

March 7th.-Improving; passed 20 ounces of urine during the night. Pulse 104, and growing stronger. Gave Blakiston water. March 8th. Still improving, passing more urine and is brighter, taking nourishment by stomach.

March 9th.-Passing more urine and improving generally. Eliminated 350 grains of urea in twenty-four hours. cantharis.

March 10th.-Doing well. Ars. 3x.

March 11th.-Urea diminishing, gave cantharis.

Stopped

March 12th. No bad symptoms, but urea only 140 grains in twenty-four hours-granular casts and albumin. Specific gravity

ΙΟΙΟ.

March 13th.-Do. Some tenesmus vesicæ, probably from catheterism. Merc. corr.

March 14th.-Seems better; passed 54 ounces of urine, with 51 grains of urea to the ounce.

March 15th.-Doing well, wound healing rapidly; passed 30 ounces of urine. There is less albumin, urea 128 grains in twentyfour hours.

She was allowed to go home. She continued to improve slowly, but steadily, the biliary fistula closing in about five weeks.

The Urinary Aspect. The urinary history of this case dates from September 1, 1892, when, in a feebly alkaline specimen, I found several fragments of medium-sized granular casts, no albumin present, density 1013 and urea 5 grains per ounce. The circumstance suggesting an investigation of the renal condition. was a persistent vertigo which had failed to yield to the remedies apparently indicated. At a second examination ten days subse

quent to the initial one made upon the twenty-four hours' quantity of 44 Ounces, the result was, specific gravity 1017, urea 6 grains per ounce, no albumin, and a few perfect granular casts upon each slide, warranting a diagnosis of chronic interstitial nephritis (Delafield's non-exudative nephritis). In the succeeding four years, infrequent examinations were made of the urine. The specific gravity fluctuated between 1016 and 1036-the urea per ounce would swing between 6 and 14 grains--albumin I never found, and oftener than not the small granular casts failed to appear under the lens. Under the treatment and diet indicated by the renal changes, the vertigo disappeared and the patient considered herself in fair health, excepting, of course, at the periods of gallstone colic.

Forty-eight hours after the operation of February 22d, the patient became drowsy, and the urinary analysis showed the following result: Total quantity, 54 ounces; specific gravity, 1027; urea, 12 grains per ounce; albumin, grain per ounce, with abundant granular and epithelial casts, with blood corpuscles under the microscope—an acute renal congestion (Delafield's) was recognized as existing. On the 27th inst. an elimination of over 500 grains of urea (total quantity 44 ounces, specific gravity 1030, urea 141 grains per ounce), in the preceding twenty-four hours, the uræmic symptoms continued and deepened somewhat. Then the renal activity became impaired and for the succeeding six days the total urine secreted was, respectively, 28 ounces, 31 ounces, 21 ounces, 19 ounces, 24 ounces, 15 ounces (150 grains of urea). The record made on the morning of the 6th of March reads, "No urine during the night, and only five ounces since noon yesterday." It was a little before daylight on this date that the two and only convulsions occurred, followed by apparent death, with resuscitation by Dr. Macdonald, as has been detailed. By evening, 14 ounces had been voided, and during the night succeeding the convulsions 20 ounces more, making 34 ounces the total for the twenty-four hours. The storm being over, renal activity again established itself, and for the next ten days or until the patient left the hospital, the average daily quantity was 43 ounces, with urea at 5 grains per ounce the patient being upon a strictly non-nitrogenous diet.

For the acute congestion, cantharides was used as soon as the urinary condition was reported-ten drops of the tincture in half a glass of water (two teaspoonfuls every two hours), by the mouth. During the period of acute uremia when the irritability of the stomach made oral medication impossible, the drug was given hypo

« PreviousContinue »