A. F. McGill, F.R.C.S. (_The Lancet_, February 4, 1888). The operation
consists of two parts: (1) The opening and drainage of the bladder; and
(2) The removal of the prostatic valve which prevents the egress of the
urine. A full sized silver catheter, curved according to the nature of
the case, is passed into the bladder, its contained urine withdrawn and
its cavity washed out with a warm saturated solution of boracic acid
till this is returned clean and unchanged. The usual rubber rectal bag
is now introduced and filled with fourteen ounces of water. The bladder
is now rendered prominent by injecting it with a sufficient amount of
warm boracic acid solution. The catheter is retained in the bladder, and
the fluid with which the latter has been distended, prevented from
escaping. The usual median supra-pubic incision is now made, the bladder
exposed and made to project into the abdominal wound by depressing the
catheter. A large curved tenaculum is now passed transversely into the
bladder, touching as it goes the point of the catheter. An incision is
now made longitudinally through the bladder wall, the fluid being
prevented from escaping by plugging the opening with the finger. The
bladder is now seized with nibbed forceps, and applied on each side of
the incision, the catheter is withdrawn from the urethra and the bag
from the rectum, and the first part of the operation is complete. The
interior of the bladder and its neck is now examined, in order to
ascertain the exact nature of the prostate enlargement. A pedunculated
middle lobe can be removed with the curved scissors, but in the case of
a sessile middle lobe, this must be assisted with the finger and
forceps. The “collar” enlargement is removed with greater difficulty. In
order to insure the patency of the urethra, it is advised to pass the
forefinger into the canal as far as the first joint. It is claimed that
the hæmorrhage is not excessive. The operation completed, drainage is
effected by passing a rubber tube out of the abdominal wound, the latter
being partially closed by a point or two of suture. The tube is removed
after forty-eight hours.
The author’s experience is limited to five cases, four of which have
proved successful, while the fifth case is still under treatment. He
claims that, in cases operated upon early, before diseased bladder or
surgical kidney have developed, a radical cure may confidently be
expected.
Two objections to this method occur to us: (1) Whoever has performed or
witnessed supra-pubic cystotomy, either for the purposes of removal of a
calculus or a neoplasm from the interior of the bladder, must have been
struck by the difficulties in the way of a thorough appreciation of the
condition of its posterior wall low down, or of the cystic neck. Unless
specially devised instruments are available for each particular form of
prostatic enlargement, it would seem to be a matter of great uncertainty
as to just how much of the growth is removed. (2) Until satisfactory
granulation of the wound surfaces has been accomplished, drainage, to be
efficient, must be facilitated by placing the patient upon one or the
other side, a position difficult to maintain, particularly in old
people.
RESEARCHES UPON THE VAGINAL PROCESS OF THE PERITONEUM AS A PREDISPOSING
CAUSE OF TENDENCY TO EXTERNAL INGUINAL HERNIA.
H. Sachs (Archiv. f. Klinisch. Chirurgie, Band xxxv., p. 321–372)
advocates quite decidedly the view, basing his opinions upon
preparations of the spermatic cord examined and upon microscopic
examinations of cross sections of the latter, particularly as to the
relations of the vas deferens and the vessels to the vaginal process of
the peritoneum, that the latter is formed before the beginning of the
descent of the testicle rather than as a portion of the abdominal wall
formed or dragged into position by the testicle in its descent. In
proof, he alleges that he has always found, in cases of incomplete
descent of the testicle, that organ upon the posterior wall of the
vaginal process, and not on the floor of the same. In females, the
formation of the canal of Nuck cannot be said to be due to any dragging.
The entrance to the opening of the vaginal process is found covered by a
valve arrangement, and the same is particularly noticeable in the canal
of Nuck. The opening of the vaginal process can be caused to gape
through a spreading out of the mesentery attached to the ilium or that
of the sigmoid flexure. The diameter of the opening is, in general,
greater on the right side than on the left in boys, while in girls this
difference is not observed. Further, the different forms of the
incompletely obliterated opening of the vaginal process agrees with the
most frequently occurring forms of the hernial sac in inguinal hernia.
The relations of the vaginal process to the elementary parts of the
spermatic cord are not constant. On the contrary, the relations which
the smooth muscular structures of the cord bear to the vaginal process,
in so far as their arrangement into bundles, and their positive relation
to the posterior and lateral walls of the same are concerned, are quite
constant, and almost form an integral part of the same. The obliteration
of the vaginal process depends upon a granulating process, which begins
in the middle third of the funnicular portion, and from thence proceeds
more rapidly in a downward than in an upward direction. This granulation
formation takes place essentially during the first ten to twenty days
after birth; after this time it takes place more slowly. The canal of
Nuck, on the contrary, is found to have almost entirely disappeared at
the time of birth. They are both found to be more frequently open upon
the right side.
From these observations it would appear that it is not essential to the
production of inguinal hernia that a broad and short inguinal canal
should be present. The only essential predisposing cause, in children at
least, depends upon the condition of the vaginal process of the
peritoneum itself.
The question of the legal responsibility of employers is an interesting
one, in connection with this question. Hernia cannot be considered as an
accident, in the surgical sense, according to Socin (Korrespondenzblatt
f. Schweizer Aertze, 1887, No. 18), but is really a slowly occurring
disease, to which certain well-defined anatomical peculiarities act as
predisposing causes.