OPERATIONS ON PELVIS.
LITHOTOMY.--However interesting and even instructive it might be, any
history of the various operations for the removal of calculi from the
bladder would be quite out of place in a manual such as this. It will be
sufficient here to describe the operations recommended and practised in
the present day.
There are three different situations in which the bladder may be entered
for the purpose of removing a calculus:--
1. The perineum, where access is gained through the urethra, prostate,
and neck of the bladder.
2. Above the pubes, where the portion of bladder not covered by
peritoneum is opened from above.
3. From the rectum.
1. LITHOTOMY THROUGH THE PERINEUM, by far the most frequent position for
the operation.--Very various methods for its performance have been
devised, differing in the nature and shape of the instruments employed,
the direction and size of the incisions, the nature of the wound; but
all resemble each other in certain very cardinal and important
particulars. Thus all agree that it is absolutely necessary to enter the
bladder at _one_ spot--the neck of the bladder; and that to do this
safely the urethra must be opened, and some instrument previously
introduced by the urethra is to be used as a guide for the knife. But an
instrument in the urethra and bladder is surrounded for at least an inch
of its course by the prostate; and thus the knife, gorget, or finger,
which, guided by the instrument in the urethra, is intended to cut or
dilate the entrance to the bladder for the purpose of allowing the
calculus to be removed, cannot do this without also cutting or dilating
this prostate gland. Experience has proved that much of the success of
the operation depends upon the position and amount of incision made in
this prostate gland. But it might be asked, Why can we not enter the
bladder by one side, avoiding altogether its neck and this prostate
gland? For this, among other reasons, that the bladder normally
contains, and so long as the patient lives must contain, a certain
quantity of a very irritating fluid. It is surrounded by the loose
areolar tissue of the pelvis, into which, if any of this fluid escapes,
abcesses will form and death probably ensue; this result will almost
certainly follow any opening made into the bladder except at one spot.
This spot is the neck of the bladder. Why does urinary infiltration not
occur there? Because the fascia of the pelvis (which when entire can
resist infiltration) is prolonged forwards at the neck of the bladder,
over the prostate (Fig. XXXIV. PF), for which it forms a very strong
funnel-like sheath. So long as this sheath is not cut where it covers
the sides of the prostate, urinary infiltration of the pelvis is
impossible, the urine being carried forwards and fairly out of the
pelvis in this urine-tight funnel.
[Illustration: FIG. XXXIV.[150]]
But it may now be said, If this be the case, we are very much limited in
the size of the incision we may make into the bladder. We cannot remove
a large stone, for the prostate ought not to be larger than a good-sized
chestnut, and any cut we might make through a chestnut without cutting
out of its side must be very small. Very true; but fortunately the
sheath of the prostate, unlike the rind of the chestnut, is very freely
dilatable, and will allow the passage of a very considerable stone.
Again, an inquirer might ask, If it is so dilatable, why should we run
the risk of cutting the prostate at all? Why should we not introduce
instruments gradually increasing in size into the membranous portion of
the urethra, and thus dilate prostate and neck of bladder? For this
reason, that the urethral canal passing through the prostate is itself
lined immediately outside of the mucous membrane by a firm membranous
sheath (Fig. XXXIV. RR), which resists dilatation to the utmost.
Experience tells us that any attempts to dilate or even forcibly to tear
this ring of fibrous texture are both ineffectual and dangerous, while a
clean cut into it and through it into the substance of the prostate is
at once effectual and comparatively safe.
In a word, we can describe the relation of the prostate to the operation
of lithotomy somewhat in this manner:--Its fibrous sheath surrounding
the urethra must be cut freely. The gland substance may be cut and
freely dilated by the finger. Its fibrous envelope must, as far as
possible, be preserved intact, but this interferes the less with the
operation, as it is comparatively freely dilatable.
The firm lining of the urethra, which must be cut, is specially strong
at its base, forming a tough resisting band just at the aperture of the
bladder, which, unfortunately, is often so high up in the pelvis in
tall patients, or in cases in which the prostate is much enlarged, as to
be almost out of reach of the finger, and so far up the staff as perhaps
to escape division. You will be warned of such an occurrence by the
urine in the bladder failing to make its appearance; and if any attempt
be made to dilate the opening and introduce the forceps without further
incision of the base of the prostate, the result will very likely be
fatal, generally from pyæmic symptoms depending on a suppurative
inflammation of the prostatic plexus of veins (Fig. XXXIV.). In fact,
upon a recognition of this fact is founded the aphorism, "that cases in
which the forceps have been introduced before the bladder fairly begins
to empty its contents are generally fatal."
[Illustration: FIG. XXXV.[151]]
We have thus traced the necessary guiding principles as to our incisions
from the bladder outwards through the prostatic portion of the urethra.
We have next to discover what sort of an opening is necessary in the
membranous portion of the urethra consistent with the fulfilment of the
same conditions, namely, freedom of escape for the urine, and room
enough to remove the stone. Both of these are gained at once by a free
incision of the membranous portion, dividing especially those anterior
fibres of the great sphincter muscle of the pelvis, the levator ani,
which embrace the membranous portion, under the special names of
compressor (Fig. XXV.) and levator urethræ (Guthrie's and Wilson's
muscles).
The principles which guide the position and size of the preliminary
incisions which enable the urethra to be opened are very simple:--(1.)
The wound in the perineum should be large enough to give free access to
the urethra, and easy egress to the stone; (2.) It should be conical,
with its base outwards, so as to favour escape of urine and prevent
infiltration; (3.) It should not wound any important organ or vessel;
that is, it must avoid the rectum, the corpus spongiosum, especially the
bulb, if possible, the artery of the bulb, and in every case should
leave the pudic artery intact.
So far for broad general principles, which must guide all methods of
successful lithotomy.
THE LATERAL OPERATION.--_Operation of Cheselden._--(1.) _Instruments
required._--A staff with a broad substantial handle, and a longer curve
than the ordinary catheter requires, furnished with a very deep and wide
groove, which occupies the space midway between its convexity and its
left side. The one used should invariably be large enough to dilate
fully the urethra.
A knife, with its blade three or four inches in length, but sharp only
for an inch and a half from its point, its back straight up to within a
sixth of an inch of its point, and there deflected at an angle to the
point, which again curves to the edge. The angle from the back to the
point permits the knife to run more freely along the groove in the
staff.
A probe-pointed straight knife with a narrow blade may occasionally be
useful in enlarging the incision in the prostate, when this is required
by the size of the stone.
Forceps of various sizes and shapes, some with the blades curved at an
angle to reach stones lying behind an enlarged prostate, all with broad
blades as thin as is consistent with perfect inflexibility, the blades
hollowed and roughened in the inside, but without the projecting teeth
sometimes recommended, which are dangerous from being apt to break the
stone.
A scoop to remove fragments or small stones, sometimes useful with the
aid of the forefinger in lifting out a large one.
A flexible tube of at least half an inch calibre, and about six inches
long, rounded off and fenestrated above, fitted at its outer end with a
ring and two eyelet-holes for the tapes, with which it is tied into the
bladder.
Prior to the operation the patient's health should be attended to, the
stomach and bowels regulated, and any disorder of the kidneys or bladder
as far as possible alleviated. If his health has been good and habits
active, three or four days' confinement to his room on low diet, with a
full purge the evening before the operation, is all the preparatory
treatment that is necessary.
It is of the utmost importance for the safety of the operation and the
patient's comfort after it, that the rectum be completely unloaded
before the operation, and the bowels so far emptied as to permit three
or four days after the operation to elapse without any movement of the
bowels being necessary. If there is any doubt as to the effect of the
laxative, a large stimulant enema should be administered on the morning
of the operation.
_Position._--Much depends on the proper tying up of the patient. He
should be placed with his breech projecting over the edge of a narrow
table, with head slightly raised on a pillow, but the shoulders low. The
hands are then to be secured each to its corresponding foot, by a strong
bandage passing round wrist and instep, or by suitable leather anklets,
the knees should be wide apart, and on exactly the same level, so that
the pelvis may be quite straight. An assistant should be placed to take
charge of each leg.
The staff is next introduced and the stone felt; if there is little
water in the bladder a few ounces may be injected, but this is rarely
necessary, for the patient should be ordered to retain as much water as
possible, and when he cannot retain it, injection of water may do harm,
and will probably not be retained, but at once come away along the
groove in the staff. The staff is then committed to a special assistant,
who must be thoroughly up to his duty, and attend to the staff alone.
Some surgeons direct the assistant to make the convexity of the staff
bulge in the perineum, to enable the groove to be struck more easily. It
will be, however, safer both for the rectum and the bulb, if the staff
be hooked firmly up against the symphysis pubis, as advised by Liston.
The same assistant can also keep the scrotum up out of the way.
If the perineum has not been previously shaved, this is now done.
The operator sits down on a low stool in front of the patient's
breech, his instruments being ready to his hand, and then steadying
the skin of the perineum with the fingers of his left hand, enters
the point of the knife in the raphe of the perineum, midway between
the anus and scrotum (one inch in front of anus--_Cheselden_,
_Crichton_; one and a quarter--_Gross_, _Skey_, and _Brodie_; one
and three-quarters--_Fergusson_; one inch behind the scrotum--_Liston_),
and carries the incision obliquely downwards and outwards, in a line
midway between the anus and tuberosity of the ischium. The length of the
incision must vary with the size of the perineum, and the supposed size
of the stone, but there is less risk in its being too large, so long as
the rectum is safe, than in its being too small. Its depth should be
greatest at its upper angle, where it has to divide the parts to the
depth of the transverse muscle of the perineum, and least at its lower
angle, where a deep incision is not required, and would be almost sure
to wound the rectum.
The forefinger of the left hand is now to be deeply inserted into the
wound, and any remaining fibres of the levator ani in front are to be
divided, the edge of the knife being directed from above downwards. The
left forefinger being still used to push its way through the cellular
tissue, the groove in the staff is now felt in the membranous portion of
the urethra covered by the deep fascia of the perineum. Now comes the
deeper part of the incision. Guided by the finger-nail of the left hand,
the surgeon introduces the point of the knife into the groove of the
staff. He then takes hold of the staff for a moment to feel that it is
held up properly against the pubis, and in the middle line, and also
that the knife is fairly in the groove. Giving the staff back again to
the assistant, and keeping the rectum well out of the way by the left
hand, he now steadily directs the knife along the groove of the staff
till the bladder is fairly entered, and the ring at the base of the
prostate completely divided. When this is the case a gush of urine takes
place, following the withdrawal of the knife.
When making the deep incision, and in the groove of the staff, the blade
of the knife should lie neither vertical nor horizontal, but midway
between the two, so as to make the section of the left lobe of the
prostate in its longest diameter, that is, in a direction downwards and
backwards (Fig. XXXIV. L).
The knife is now withdrawn, and the left forefinger inserted. In most
cases it will be long enough to reach the bladder and touch the stone,
and may then be freely used by gradual pressure to dilate the wound;
this may be done very freely when necessary for a large stone, if only
the ring of fibrous tissue surrounding the urethra be first cut and the
bladder fairly entered. Whenever the stone is felt by the finger, the
assistant may withdraw the staff.
When the operator has thus felt the stone and sufficiently dilated the
wound, the next step is to introduce the forceps; this should be done
under the guidance of the finger, and with the blades closed. When the
stone is felt the blades should be opened very widely, slightly
withdrawn, and then pushed in again, the lower one, if possible, being
insinuated under the stone. The blades must be made fairly to grasp and
contain the stone in their hollow, for if they only nibble at the end of
an oval stone, extraction is impossible. Extraction should then be
performed slowly, with alternate wrigglings of the forceps from side to
side, so as gradually to dilate, not to tear, the prostate, and the
operator must remember to pull in the axis of the pelvis, not against
the os pubis or the promontory of the sacrum.
If there is much resistance, it may possibly be caused by the stone
having been caught in its longer axis, and this may be remedied by
careful manipulation by means of the finger and forceps. If the stone is
still too large to be extracted without greater force than is
warrantable, there are still various expedients (see _infra_, pp. 265,
270).
In most cases, however, the stone is removed rapidly enough by the
single incision. The finger, or a sound, must then be introduced to feel
if any more stones are present. The closed forceps make a very effectual
instrument for this purpose. Much information may be gained from the
appearance of the first stone, the presence or absence of facets. Its
smoothness or roughness enables us to form a pretty certain opinion; yet
the bladder should always be carefully searched; and if the stone has
been friable or broken in extraction, should be washed out by a current
of water. Where the calculi are very numerous, or where many fragments
have separated, the scoop will be found useful, both for detecting and
removing them. All the stones being extracted, there is in most cases
little or no bleeding (see _infra_, Hæmorrhage). The tube already
described may now be inserted and tied into the bladder. It may be
retained for forty-eight or seventy-two hours, according to
circumstances. Care must be taken lest it be closed up by coagula during
the first hour or two after the operation. In children the tube is not
necessary, and from their restlessness might possibly do harm, but in
adults (though neglected by some surgeons) experience shows it is a
valuable adjunct in the after-treatment.
Having thus traced the course of an ordinary uncomplicated case of
lithotomy by the lateral operation, a brief notice is suitable of some
of the obstacles and difficulties, some of the dangers and bad results
which may be met with, and the best methods of overcoming them.
1. _Large size of the stone_, as an obstacle to extraction. When, either
from the enormous size of the stone, generally to be made out before the
operation, or from some congenital or acquired deformity of the pelvis,
it is obvious beforehand that the calculus cannot pass through the bony
pelvis entire, a choice of two courses remains, either--
(1.) The high or supra-pubic operation (_q.v. infra_); or (2.) Crushing
of the calculus in the bladder, and removal piecemeal. Instruments of
great strength have been devised for this latter operation. The risk to
the bladder is very great, and fragments are apt to be left behind;
these are sure to form nuclei of new calculi.
2. _Peculiarities in the position or relations of the stone_ in the
bladder:--
(1.) It may lie in a sort of pouch behind the prostate, and thus be out
of the reach of the forceps. This may be remedied by the use of curved
forceps, or, better still, by the finger in the rectum to tilt up the
stone into the bladder.
(2.) It may lie above the pubis in the anterior wall of the bladder.
Pressure on the hypogastrium, or the use of a strong probe as a hook,
will generally suffice to dislodge it.
(3.) The stone may be encysted. This is extremely rare, and, as
Fergusson says, we hear more of these from bunglers who have operated
only several times, than from those who have had large experience.
3. _An enlarged prostate_ is at once a source of difficulty and of some
danger.
The distance of the bladder from the surface may be so very much
increased by enlargement of the prostate as to render even the longest
forefinger too short to reach the stone or even the bladder. This
renders the introduction of the forceps more difficult and uncertain,
the dilatation more prolonged, and the extraction more dangerous. If
very large, the groove of the staff may not reach the bladder, and thus
the deep incision may fail of cutting the ring at the base of the gland,
and the urine may thus not escape, and all the dangers of laceration of
the ring may result. Such cases may be well managed by the insertion of
a straight deeply grooved staff into the insufficient incision, and
fairly into the bladder, and on this, pushing a cutting gorget through
the uncut portion of the gland. This insures a sufficient yet not
dangerous incision, which we cannot so safely perform with the knife, as
the parts are so far beyond the reach of the guiding forefinger.
Under the head of risks after lithotomy we may class the following:--
1. Sinking, or shock. In the very aged or very young, or after a very
prolonged or painful operation, shock may now and then kill the patient
within a few hours. Since the days of chloroform this result is
extremely rare.
2. Hæmorrhage seems to be a very infrequent risk. The transverse
perineal artery, which is always cut in the operation, is small, and
rarely bleeds much. If the bulb is wounded, as no doubt frequently
occurs, the flow from it can easily be checked. The pudic is so well
protected from any ordinary incision as to be practically safe; and if
wounded by some frightfully extensive incision, it can be compressed
against the tuberosity of the ischium.
There is an abnormal distribution of the dorsal artery of the penis, in
which, rising higher up than it ought, and coursing along the neck of
the bladder, and the lateral lobe of the prostate, it may be divided.
This may give trouble, and even result in fatal hæmorrhage. Fortunately
it is rare. The author has met with one case in a boy of eleven, in whom
a very severe hæmorrhage was not to be explained. The patient recovered
without another bad symptom.
Again, a general oozing may often appear a few hours after the
operation, when the patient is warm in bed, apparently from the
substance of the prostate. If raising the breech and the application of
cold fail to arrest it, it may be necessary to plug the wound. This is
done by stuffing it with long strips of lint round the tube. Great care
must be then taken lest the tube become occluded.
3. Infiltration of urine may occur as a result of a too free incision of
the vesical fascia (in adults), and still more frequently of a too small
external wound.
Here it should be noticed that in children it is fortunately of very
little consequence to preserve the integrity of the prostatic sheath of
vesical fascia. In them the prostate is so exceedingly small and
undeveloped, that even the forefinger could not be introduced into the
bladder without a complete section of the prostate. Probably from the
blander nature of their urine, and the greater vitality of their
tissues, this is of less consequence, as it is rarely found that any bad
effects result from this section.
Among other risks we find peritonitis, inflammation of neck of bladder,
inflammation of prostatic plexus of veins, resulting in pyæmia,
suppression of urine, and other kidney complications. For the symptoms
and treatment of these there is no place in a mere manual of surgical
operations.
_Wound of rectum and recto-vesical fistula._--Such wounds were not
uncommon, and in many cases unavoidable, before the days of chloroform,
from the struggles of the patient; now they are comparatively rare, and
should be still rarer. They probably occur in more cases than the
surgeon is aware of, and heal up without his knowledge; we may arrive at
this conclusion from the fact that small wounds are found in
_post-mortem_ examinations of cases in which no such complication has
been thought of.
They occasionally heal without giving any trouble, but, at other times,
as the external wound contracts, a communication forms between rectum
and the urethra, in which the contents are apt to be interchanged in a
most disagreeable manner, flatus passing per urethram, and urine per
rectum.
When it is evidently not going to heal spontaneously, the septum between
the external orifice of the wound and the communication with the gut
should be laid open, as in the operation for fistula _in ano_.
There are certain modifications and varieties in the method of
operating for stone through the perineum, which deserve at least a
brief notice:--
1. _The bilateral operation._--Though he was not the inventor,
Dupuytren's name is justly associated with this operation. The
principle of it is to divide both sides of the prostate equally, so
as to give more room for extraction of a large stone, without the
necessity of much laceration, or the risk of cutting through the
prostatic sheath of fascia.
_The operation._--A semilunar incision is made transversely across
the perineum, extending from a point midway between the right tuber
ischii and the anus, upwards, crossing the raphe nearly an inch
above the anus, and then curving downwards to a corresponding point
on the opposite side. The skin, superficial fascia, and a few of
the anterior fibres of the external sphincter, are thus divided,
and the groove of the staff sought by the forefinger. The
membranous portion of the urethra is then laid open in the middle
line, and the beak of a double lithotome caché securely lodged in
the groove. It is then pushed into the bladder with its concavity
upwards, and when fairly in it is turned round, its blades
protruded to the required extent, and withdrawn with its concavity
downwards, thus dividing both lobes of the prostate in a direction
downwards and outwards (Fig. XXIV. D D). The operation is finished
in the usual manner. Though it is a comparatively easy operation,
and theoretically may be proved to have many advantages, experience
has shown that the results are not so favourable as those of the
ordinary lateral operation.
2. _Buchanan's medio-lateral operation_ on a rectangular
staff.--The staff is bent at a right angle three inches from the
end, and deeply grooved on its left side. This is introduced into
the urethra so that the angle projects the membranous portion of
the urethra close to the apex of the prostate and the terminal
straight portion enters the bladder parallel to the rectum. The
angle projects in the perineum, so that the operator with his left
forefinger in the rectum is enabled, by a stab with a long straight
bistoury (held horizontally and with the cutting edge to the left
side), at once to enter the groove, and, by following the groove,
the bladder. Whenever the escape of urine shows that the bladder is
fairly reached, the knife is withdrawn so as to make a lateral
section of the prostate, and then, with the finger still in the
rectum, to make an incision in the ischio-rectal fossa, of
sufficient size to allow the stone to be easily withdrawn.
The inventor claims for this method that it is easier, that there
is less risk of hæmorrhage, wound of the rectum, and infiltration
of urine.
3. _Allarton's operation of median lithotomy_ suits admirably for
stones known to be small, but is quite unsuitable for large ones.
Probably in most cases it should be superseded by lithotrity.
_Operation._--A large curved staff with a central groove is to be
held firmly hooked up against the symphysis pubis, and then
steadied by the left forefinger in the rectum. The operator pierces
the raphe of the perineum with a long straight bistoury about half
an inch above the verge of the anus, enters the groove of the
staff, and cuts inwards, almost, but not quite, into the bladder.
In withdrawing the knife the wound in the urethra is enlarged
upwards towards the scrotum. A ball-pointed probe is then passed on
the staff into the bladder, the staff is withdrawn, and the finger,
guided by the probe, is used to dilate the neck of the bladder, to
an extent sufficient for the removal of the stone by a small pair
of forceps.
In this operation the prostate is hardly incised at all. The
results are not better than those of the lateral operation.
2. LITHOTOMY ABOVE THE PUBES, _or the High Operation_.--In cases where,
from the known size of the stone, or from the deformity of the bones of
the pelvis, it is impossible that the stone can be extracted entire in
the usual manner; in cases where the prostate is very much enlarged, or
where there is any real or supposed likelihood of inflammation of the
neck of the bladder, the supra-pubic operation _may_ be warrantable. Its
performance is easy, it does not involve any wound of the peritoneum if
properly performed, and there is no risk of hæmorrhage. There are
certainly great risks attending it of peritonitis and urinary
infiltration.
In more than one case this operation has been attended by wound of
peritoneum and subsequent escape of intestines through the wound, even
when dressed antiseptically and performed under spray.
_Operation._--The patient lies on his back, with his head and shoulders
slightly raised, so as to relax the abdominal muscles, and his legs
hanging down over the edge of the table. If his bladder can bear it, it
should be fully distended, either by voluntary retention of the urine,
or by injection with tepid water. A vertical incision is then made in
the middle line, separating the recti muscles from below upwards, care
being taken to push the peritoneum well out of the way, which is easily
done by the finger in the loose cellular tissue of the part. The
anterior wall of the bladder is then exposed, uncovered by peritoneum;
it must be opened with great care, also in the middle line, while the
wound in the parietes is held aside by retractors. The wall of the
bladder should be transfixed by a curved needle, and thus held in
position before it is opened. The stone is then removed by a pair of
straight forceps, generally with great ease. Attempts used to be made to
leave a catheter or canula in the bladder wound to prevent infiltration.
Probably the safest method now will be to close the bladder wound at
once by metallic stitches, and stitching the abdominal wound carefully
with deeply entered wires, to leave the patient on his back. When
compared with the lateral operations the statistics of the supra-pubic
operation are discouraging, the mortality being one in three and a half
to one in four. But in cases where the stone is known to be very large
and of firm consistence, the risks are probably less from this method
than from lateral lithotomy, followed by efforts to crush the stone
through the wound prior to its removal.
The late Mr. George Bell, a most successful lithotomist, proposed to
perform this operation in two stages. In a case of greatly enlarged
prostate, where the bladder had been punctured above the pubes by a
country surgeon for retention of urine, he dilated the track of the
canula by means of sponge-tents gradually increased in size, and then
succeeded in extracting through the dilated opening several large
calculi. The case recovered, and may encourage similar attempts.
3. OPERATIONS THROUGH THE RECTUM.--(_a._) _Sanson's Recto-vesical
Operation._--The principle of this operation consisted in laying the two
canals, the rectum and the urethra, into one. A large staff, grooved on
its convexity, being inserted into the urethra, the operator, with the
forefinger of his left hand in the rectum as a guide to the knife,
pierces the anterior wall of the rectum, reaches the groove of the staff
just in front of the prostate, and cutting outwards divides the rectum,
the anterior fibres of levator ani, and the sphincter, as well as the
skin of the perineum in the middle line. Entering the knife again into
the groove of the staff, it is to be pushed right onwards into the
bladder, dividing the prostate, and avoiding if possible the seminal
vesicles and ducts; the stone is then very easily removed.
Though this operation was supposed to lessen the risk of pelvic
infiltration it is _not_ found to do so, and it adds the additional
inconvenience of almost inevitable rectal fistula, through which the
urine escapes. It is certainly a very easy operation, but the mortality
is found to be greater than in the ordinary lateral operation.
(_b._) _Lithotomy through the rectum above the prostate._--The presence
of a small portion of bladder beyond the prostate in close relation to
the rectum renders it possible, in cases where the prostate is not
enlarged, to enter the bladder and remove a stone of moderate size,
without interfering with the peritoneum, prostate, or neck of the
bladder.
This ingenious but difficult operation was performed for the first time
by Drs. Sims and Bauer in 1859.
I quote the brief notice of the operation by Dr. Sims from the _Lancet_
of 1864 (vol. i. p. 111):--
"The patient was placed on the left side, and my speculum was introduced
into the rectum, exposing the anterior wall of the rectum, just as it
would the vagina in the female. A sound was passed into the bladder. The
doctor entered the blade of a bistoury in the triangular space bounded
by the prostate, the vesiculæ seminales, and the peritoneal
reduplication. He passed the finger through this opening, felt the
stone, and removed it with the forceps without the least trouble. The
operation was done as quickly and as easily as it would have been in a
female through the vaginal septum. After the removal of the stone, Dr.
Bauer kindly asked me to close the wound with silver sutures, which I
did, introducing some five or six wires, with the same facility as in
the vagina. There was no leakage of urine. The patient recovered without
the least trouble of any sort. The wires were removed on the eighth day,
and on the ninth day the patient rode in a carriage with Dr. Bauer a
distance of four or five miles, to call on, and report himself to, our
distinguished countryman, Dr. Mott."
The chief risks in this operation seem to be the chance of wounding the
peritoneal _cul-de-sac_, as the amount of free space between it and the
prostate seems to vary much in individuals and in races. Dr. Marion Sims
mentioned to me in conversation that he believed this operation
impossible in the negro race, from the greater projection downwards of
the peritoneal reduplication. An enlarged prostate would be an
insuperable objection. The use of silver wire, to close up the wound at
once, diminishes very much any risk of recto-vesical fistula.
LITHOTRITY OR LITHOTRIPSY.--There exist cases of stone in the bladder,
which, under certain conditions, may be relieved without lithotomy, by
an operation which crushes the stone into fragments small enough to be
discharged through the urethra.
To enter with any fulness into the history, literature, and varieties of
this operation, and the instruments required, would in itself require a
large volume. Suffice it here to describe the case suitable for the
operation, the essentials required in the instrument, and the method of
performance.
1. _For a case to be suitable_ the _stone_ should not be too large, and
especially not too hard, also there should not be too many of them.
The _urethra_ should be capacious enough to let the instrument pass
easily and painlessly.
The _bladder_ should be large enough to contain four ounces of water at
least, should not be much inflamed, and, on the other hand, should not
be paralysed. Paralysis or want of tone in the bladder prevents the
thorough evacuation of its contents, and still more the expulsion of the
fragments of stone.
2. _A good instrument_ should, as far as possible, combine strength with
lightness. The curved portion of the fixed blade should be fenestrated
to allow escape of the fragments and thorough closure of the
instrument.
The movable blade must be so arranged as to combine perfect ease of
movement up and down in seeking for the stone, with a powerful, slow,
and gradual approximation in crushing it. This can be managed by an
ingenious arrangement, which leaves the movable blade under the control
only of the operator's thumb till the stone is found, and yet, by
touching a spring, gives him the advantage either of a fine screw or of
a rack and pinion movement for crushing the stone.
3. _Operation._--The patient being prepared by a free evacuation of the
bowels, and the urethra having been previously fairly dilated, he is
asked to retain his urine as long as possible, or, if he cannot do so, a
few ounces of tepid water may be injected per urethram.
He is then laid on a sofa or table, the breech being well raised by
pillows, the shoulders low, the thighs and knees bent up and separated.
The instrument, well warmed and oiled, is then introduced with the
blades closed. When fairly into the bladder the search for the stone
begins.
There are differences of opinion regarding the best method of fishing
for the stone; great patience and gentleness, with a thorough previous
acquaintance with bladder manipulation, are required, whichever method
be chosen.
The two chief methods may be described as the English and the French,
the latter, Civiale's, being now used by Sir Henry Thompson, and other
English operators. Briefly, the two are:--
(1.) _Heurteloup's and Sir B. C. Brodie's._--In this, after the
instrument is fairly entered, its handle is elevated, thus depressing
the curved extremity, the forceps are then opened, and, by being kept as
low as possible in the bladder, it is hoped that the calculus will fall
into the opened blades by its own weight. In this method the fundus is
the scene of crushing, and there is a risk of injuring the sensitive
neck of the bladder, especially at the moment of opening the blades.
(2.) _Civiale's--Thompson's._--In this the pelvis is to be so elevated
that the centre of the bladder and space beneath it give plenty of room
for seizing the stone, and all contact with the wall of the bladder is
(as far as possible) avoided.
The instrument is introduced closed, and carried fairly away in to the
posterior part of the bladder before it is opened at all. It probably
grazes the stone in passing, and, if so, is directed to the side of the
bladder in which the stone is _not_ lying. Then when nearly touching the
posterior wall, the movable blade is withdrawn, the instrument inclined
towards the stone lying unmoved in the most dependent part, and there
seizes it generally with ease.
If not felt, the blades are again to be opened, turned a little to the
other side of the bladder, and then closed. Sir H. Thompson lays the
greatest stress on the importance of always having the blades fairly
opened before shifting their position, for if moved when closed, the
very opening of the movable blade is certain to drive the stone out of
the way and prevent its seizure.
Certain rules are useful:--Move the axis of the instrument as little as
possible; it should be kept in the centre of the bladder, so far in,
that the movements of the male blade are quite free from the neck of the
bladder and prostate, and the blades only should be moved in the bladder
on the centre of the shaft as an axis. There should be no jerking once
the stone is caught, and the crushing should be done as far as possible
in the very centre of the bladder, the blades not touching any of the
walls.
After the stone is seized, do not crush till, by a turn of the blades
from side to side, you discover that none of the mucous membrane of the
bladder is caught in the instrument.
The lithotrite is not meant to extract stones, but to crush them, hence
never attempt to withdraw it unless the blades are in absolute
apposition.
Never attempt too much at one time. Sir H. Thompson holds that five
minutes is the longest time that should be given, perhaps in most cases
three minutes being long enough.
While many surgeons will still agree with the above advice, Dr. Bigelow
of Boston has lately been highly commending a method which he has called
Litholapaxy, in which, at one sitting under chloroform, the stone is
crushed and aspirated, or sucked out of the bladder at once.[152]
Since the above was written the operation of Litholapaxy has made
great strides in the favour of surgeons, and many stones that would
have been removed by lithotomy are now broken down by powerful
instruments at a single sitting, and removed piecemeal by the
suction apparatus.
S. W. Gross has collected 312 cases, of which 17 died or 5.45 per
cent., but of 180 done by experienced surgeons, Thompson, Bigelow,
Van Buren, Weir, and Stevenson only five died, or 3.33 per cent.,
while of 1470 cases of lithotrity, as formerly practised, 159, or
10.81, per cent. died.[153]
OPERATIONS FOR STRICTURE OF URETHRA.--Under this head many manipulations
and operations might be described; the very instruments devised being
exceedingly numerous and complicated. Enough here to detail a few of the
more simple and practical procedures under the different heads of--1.
_Dilatation_ gradual and forced. 2. _Internal Division._ 3. _External
Division._
1. DILATATION.--Under this head we have--
_a._ _Vital dilatation._--The passing of a succession of bougies,
gradually increasing in diameter, at intervals of three or four days,
for the purpose of exciting an amount of interstitial absorption in the
new material constituting the stricture, sufficient to remove it.
Passing a bougie, though certainly often very difficult, perhaps should
hardly come into the category of surgical operations, yet to preserve a
certain completeness in the account of stricture, a very brief
description may be here inserted.
The recumbent posture is in most cases to be preferred. The patient
should lie flat on his back, with the knees slightly bent and separated,
and the head and shoulders slightly raised on a pillow. The operator
standing on the patient's left side, raises the penis in his left hand,
and with the right introduces the instrument, previously warmed and
oiled, into the meatus. He then pushes it very gently onwards, at the
same time stretching the penis with the left hand, just so far as to
efface any wrinkles in the mucous membrane, till the point reaches the
bulbous portion. The axis of the instrument, which at first for
convenience was over the left groin, has now gradually been approaching
the middle line. When this is reached, the instrument should be raised
from the abdomen, and the handle cautiously carried in the arc of a
circle first upwards and then downwards, till, when the instrument is
fairly into the bladder, the handle is depressed between the patient's
thighs. While this is being done the operator's left hand should be
withdrawn from the penis, and the points of the fingers applied to the
perineum.
In cases of difficulty certain points may be remembered:--
(1.) That the point of the instrument may in the first inch or two be
occasionally entangled in a lacuna in the roof, especially when a small
instrument is used; hence the beak should be at first maintained against
the inferior wall of the canal.[154]
(2.) That the handle should not be depressed too soon; if it is, there
is a risk of a false passage being made through the upper wall.
(3.) The opposite error may force the point out of the urethra between
the membranous portion and the rectum, and onwards into the substance of
the prostate gland.
And certain cautions may be given:--
(1.) In every exploration of an unknown urethra the surgeon should
commence with an instrument of medium size, certainly not less than No.
7 or 8.
(2.) In cases of difficulty occurring in the urethra behind the scrotum,
invariably use the forefinger of the left hand in the rectum as a guide.
(3.) Expression of pain on the part of the patient is no indication that
a false passage is being made, nor its absence that the instrument is in
the passage, for it is a remark of Mr. Syme, that passing an instrument
through a stricture is generally more painful than making a false
passage through the walls of the urethra.
An instrument may be passed, while the patient is erect, with the
following precautions:--The patient should stand with his back
against a wall, his arms supported on the back of a chair on each
side, heels eight or ten inches apart, and four or five inches from
the wall; his clothes thoroughly down, not merely opened. The
bougie should then be held nearly horizontal, with its concavity
over the left groin of the patient, the penis being raised in the
surgeon's left hand. Introduced thus for four or five inches, the
handle is gradually raised into the middle line of the abdomen, and
to the perpendicular; it is then to be lightly depressed, and, as
the point enters the bladder, brought down towards the operator
until it sinks beneath the horizontal line.
_b._ _Mechanical dilatation_ is of two kinds, both very rarely
used:--(1.) When an instrument cannot be passed, it consists of passing
down day after day the point of an instrument (sometimes armed with
caustic, sometimes not), and pressing it against the stricture till it
is overcome.[155] (2.) When an instrument is introduced through an
intractable stricture, and is left there either for some hours, or for
some days, to excite what is called "suppuration" of the stricture.[156]
_c._ _Forced dilatation._--Under this head we might describe at great
length mechanical contrivances to force or rupture a stricture. A word
or two on a few of the most important:--
(1.) Conical bougies of steel or silver.
(2.) Mr. Wakley's method, on which many others have been founded. He
passed a small bougie or wire into the bladder, over which were slipped
straight tubes of varying size, with perfect certainty that they could
not leave the urethra.
(3.) Mr. Holt's method.[157]--The principle of it is to rupture the
stricture at once, so that a No. 12 catheter can immediately be passed
into the bladder.
He attains this object by means of an instrument composed of two grooved
blades, united about one inch from their apex, into a conical sound,
which at its apex is about the size of a No. 2 bougie. This is passed
into the bladder, and the grooved blades are separated to any extent
that is desired by passing down between them a straight rod equal in
size of a No. 8, 10, or 12, bougie. To guide this properly it is made
hollow, and it is passed down over a central wire which lies between the
grooved blades of the instrument and is welded to the apex. A great
improvement is effected on Mr. Holt's later instruments by this wire
being made hollow, and fitted with a stilette, for by this means we can
with certainty ascertain whether or not the instrument has been passed
into the bladder. This instrument, which is an improvement upon one
invented by Perrève nearly forty years ago, has been used on very many
occasions by Mr. Holt and others with success. The risk to life, if the
case be properly managed, is trifling, but, like every other means of
treating stricture, it has the objection that the stricture is liable to
recur, unless bougies be passed at intervals for months and years.
Sir Henry Thompson has introduced and described another very ingenious
instrument for the same purpose, constructed on somewhat similar
principles. His account of it, to which I must refer, will be found in
Holmes's _System of Surgery_, 1st ed. vol. iv. p. 399.
2. INTERNAL DIVISION OF STRICTURE is a mode of treatment which by many
surgeons is highly disapproved, yet of late years it has been more used
than formerly, especially in resilient strictures. It may be done in two
ways:--
(1.) _From before backwards._--This method, to be at all admissible,
requires a guide to be previously passed; a lancet-shaped blade may then
be slipped down a groove in this guide till the stricture is divided.
This is least objectionable in cases of stricture close to the meatus.
(2.) _From behind forwards._--To make the incision thus, it is of course
necessary that the stricture should be so far dilatable as to admit an
instrument the point of which is large enough to contain the blade by
which the stricture is to be divided. This will be found to be at least
equal in size to a No. 3 or No. 4 catheter. In many instruments it is
much larger.
_Civiale's_ instrument for internal incision of the urethra from behind
forwards has the very high recommendation of Sir H. Thompson.[158] It
consists of a sound with a bulbous extremity (as large as a No. 5
bougie) which contains a small blade, which can be made to project for
such a distance as the operator wishes. It is passed through the
stricture with the blade concealed, till the bulb is carried about
one-third of an inch or more beyond the stricture; the blade is then
projected, and the incision made by drawing it slowly but firmly
outwards towards the meatus, with the blade towards the floor of the
urethra, till the stricture is divided in its whole extent. Sir H.
Thompson recommends this to be used in cases _where it is not that the
stricture is of very small calibre, but that it is undilatable_, that
prevents the cure. Many modifications of above have been devised by
Lund, Teevan, and other surgeons, on similar principles.
3. MR. SYME'S OPERATION OF EXTERNAL DIVISION.--Mr. Syme held that no
stricture through which the water can escape should be called
_impermeable_, for by patience and care the surgeon should always be
able to pass a slender director through the stricture on which it may be
divided with ease and certainty. The old operation of "perineal section"
for so-called impermeable stricture is very different, being difficult,
dangerous, and uncertain in its results.
_Operation._--A director is passed into the stricture. Mr. Syme's
directors are of different sizes, the smallest being in diameter less
than an ordinary surgical probe. They are made of steel, are grooved on
the convexity, and have this peculiarity, that while the lower half is
small, the upper is of full size (No. 8 or 10), the difference in
calibre occurring quite abruptly. The presence of this "shoulder" on the
staff enables the operator to ascertain exactly the position of the
stricture, and also to tell when it is fully divided without the
necessity of withdrawing the instrument.
This being fairly in the stricture, the patient is put in the position
for lithotomy, an assistant holds the staff in his right hand, drawing
up the scrotum with his left.
The surgeon then makes an incision in the middle line over the
stricture for the necessary distance, from above downwards, till he
exposes the urethra, and feels exactly the shoulder of the staff. Care
must be taken not to go past the urethra at either side. When he
distinctly feels the outline of the staff, he takes it in his left hand,
and a short sharp-pointed bistoury in his right. It should be held
firmly in the palm of the hand, with the back of the blade resting on
the forefinger, the pulp of which guides the point to the groove, and
guards it when making the incision; the knife is to be placed on the
groove beyond (_on the bladder side_) of the stricture, and brought
forwards, slowly cutting through _the whole_ stricture; till the
shoulder of the staff is reached. It requires strength and precision to
divide thoroughly the indurated stricture, which is apt to elude the
knife.
The shoulder of the staff can now be passed through the stricture if the
operation is complete; if not, the incision must be extended, always in
the middle line, and guided by the groove. When thoroughly divided, the
staff is now to be withdrawn, and a full-sized catheter with a double
curve passed into the bladder. This should _not_ be furnished with a
stop-cock or plug, lest the bladder should by inadvertence be allowed to
be too full, and extravasation into the cellular tissue of the urethra
take place along the side of the instrument.
The catheter should be tied in, and left for two, sometimes for three
days, when it can generally be removed with safety, and a bougie should
be passed at intervals of three or four, till the wound is healed. To
prevent recurrence of the stricture, it is a wise precaution to pass an
instrument at intervals for many months after the cure is apparently
complete.
In certain cases, where the stricture is far back and the urinary
symptoms severe, Mr. Syme found advantage from the introduction of a
shorter double-curved catheter (only about nine inches long) through
the wound into the bladder, where it should be left for three days.
This seems to diminish the risk of rigors, and other symptoms of fever,
which are apt to occur when the urine is allowed for the first time to
pass over the wound.
_Perineal Section_ is an operation both dangerous and difficult; as Sir
Astley Cooper used to say, "the surgeon who performs it requires to have
a long summer's day before him."
No director or guide can be passed. A full-sized catheter must be passed
as far as possible _up_ to the stricture, and held firmly in the middle
line. The patient must be tied up in lithotomy position on a table in
the very best light that can be obtained. The perineum being shaved, an
incision must be made in the middle line from over the point of the
catheter to the verge of the anus, if the stricture extends far back.
The urethra should then be opened over the catheter, the edges of the
mucous membrane held to each side by silk threads passed through them;
and the surgeon must endeavour to pass a fine probe into the opening of
the stricture; if this can be done, it is comparatively easy to slit the
stricture up. If not, the surgeon must simply seek for the remains of
the urethra by slow, cautious dissection in the middle line. If
successful, a catheter must be secured in the bladder in the usual way.
A stricture near the orifice, or, as it is not uncommon, involving
merely the meatus, can be treated with great ease in the above manner by
division on a grooved probe. When quite close to the orifice, with a
well-defined hardness, as of a ring round the urethra, it may be divided
subcutaneously by a tenotomy knife or other narrow-bladed instrument. It
is not necessary to keep a catheter in the bladder in cases where the
stricture has been in front of the scrotum.
PUNCTURE OF THE BLADDER.--A patient and dexterous use of the catheter
prevents this operation from being often required; still, circumstances
may arise in which it is found impossible to enter the bladder _per vias
naturales_. In such a case the bladder may be punctured from the outside
by a curved trocar and canula, in either of two situations.
1. _From above the pubis._--This operation is a very simple one, and
when the bladder is distended need not imply a wound of the peritoneum.
_Operation._--A preliminary incision, varying in length according to the
amount of fat, should be made above the pubis exactly in the middle
line; the edges of the recti should be separated, the peritoneum pushed
out of the way and upwards by the finger, and a curved trocar plunged
into the distended bladder obliquely backwards. The canula should be
retained for a day or two, and then a flexible catheter with a shield
inserted instead. Such instruments have been worn for years. The
aspirateur pneumatique of Dr. Dieulafoy will be found an exceedingly
useful instrument for puncture of bladder and removal of urine. The
author has now used it very frequently with the best results. Its
advantage is that the urine is removed through an aperture so small as
to allow of the withdrawal and reintroduction of the canula as often as
is necessary.
[Illustration: FIG. XXXVI.[159]]
2. _From the Rectum._--Except in cases of enlargement of the prostate,
it is at once easier and safer to puncture the bladder from the rectum.
The well-known triangular space uncovered by peritoneum, with its apex
in front close to the prostate, and bounded on either side by the vasa
deferentia and vesiculæ seminales, can be easily reached by a curved
trocar. This should be guided by one, or, still better, by two fingers,
into the rectum, with its concavity upwards, and the point should be
pushed upwards by depression of the handle, whenever it is fairly behind
the prostate. The trocar may then be withdrawn, and the canula retained
for at least forty-eight hours by a suitable bandage. Mr. Cock, of Guy's
Hospital, had a special canula for the purpose, which expands at its
extremity after its introduction, and thus is not apt to slip.[160] Some
surgeons insist that the surgeon should be able to ascertain the
existence of fluctuation between the finger in the rectum, and the other
hand above the pubes. This is exceedingly difficult to elicit when the
bladder is very much distended, and from the constrained position of the
finger in the bowel.
PHYMOSIS.--Elongation of the prepuce, with contraction of its orifice,
in most cases congenital, sometimes so extreme as to cause difficulty in
micturition, and frequently preventing the uncovering of the glans.
_Operation._--In all well-marked cases, the following is required:--The
elongated prepuce should be pulled forwards by a pair of catch-forceps,
and a circle of skin and mucous membrane removed by a single stroke of a
bistoury, or by sharp scissors. Care should be taken lest the glans be
included in the incision, as has happened in _at least_ one instance.
The skin will then be found to retract very freely beyond the glans, but
the mucous membrane is found still to cover the glans, and its orifice
is still constricted. It must then be slit up (Fig. XXXVII. _b b_) on
the dorsum of the glans, with probe-pointed scissors, as far as the
corona, and the glans will then be thoroughly exposed. The edges of
mucous membrane and skin should then be stitched to each other by at
least five or six fine silk sutures, any bleeding points having been
first carefully secured. The angles will in time round off, and a
wonderfully seemly prepuce be obtained. This operation may be done as a
method of cure for obstinate enuresis in cases in which the prepuce is
very long and redundant, even when it is not too tight. The author has
done this in more than twenty cases with excellent results.
[Illustration: FIG. XXXVII.[161]]
_Varieties._--When the prepuce is narrowed at its orifice without
being redundant in length, a milder operation will prove
sufficient. The principle is the same as in the former, but the
amount of incision is less, and nothing is removed. Two methods are
possible:--
1. _By scissors._--The blunt point of a pair of scissors is
introduced through the preputial orifice, the other blade being
outside, and the skin and mucous membrane are divided for about
half an inch; the skin being then retracted, the mucous membrane is
still further divided by one or two additional snips, and then the
edges of skin and mucous membrane are stitched together by one or
two points of suture.
2. _By knife._--A director being introduced within the prepuce, a
narrow-bladed knife is guided along it, and pushed through the
prepuce from within, and then made to divide skin and mucous
membrane from within outwards. Stitches as before.
_N.B._--Be careful lest the director pass into the meatus
urinarius, and the glans be split up.
Again, some surgeons prefer two lateral incisions instead of one
dorsal one. In this case skin and mucous membrane should be divided
by scissors for about a quarter of an inch, and then a single
stitch inserted in the angle of junction. This has been further
modified by Cullerier, who proposed the division of the tight
mucous membrane only, in three or four points. He used a pair of
scissors with one sharp and one probe-pointed blade, the sharp one
thrust in between skin and mucous membrane, the blunt one between
the mucous membrane and the glans.
AMPUTATION OF THE PENIS.--This exceedingly simple operation is performed
by a single stroke of an amputating knife, drawn along from heel to
point, while the penis is stretched in the operator's left hand. As
there is more risk of redundancy than of deficiency of the skin, no
attempt is made to save it. Numerous vessels in the corpora cavernosa
require ligature. Amputation of the penis may be done bloodlessly by the
thermo-cautery even close to its root. Transfix the root of corpora
cavernosa by a needle; above this pass two or three turns of an elastic
ligature; then slowly divide at a low red heat the skin and corpora
cavernosa below the needles; split the urethra after dividing its mucous
membrane with a knife. The author has done this several times with ease
and rapid healing.
[Illustration: FIG. XXXVIII.[162]]
The chief risk is stricture of the orifice of the urethra. To prevent
this, several modifications of the operation have been introduced.
1. _Ricord's method._[163]--After the amputation the surgeon seizes with
forceps the mucous membrane of the urethra, and with a pair of scissors
makes four slits in it, so as to form four equal flaps, and with a silk
ligature stitches each of these to the skin. Contraction of the
cicatrix will thus tend to open rather than close the urethral orifice.
2. _Teale's method._[164]--He slits up, by a bistoury on a director, the
urethra and skin over it for about two-thirds of an inch, and then
stitches the one to the other, thus making it a long oval dependent
orifice (Fig. XXXVIII.).
3. _Miller's proposed method._[165]--"A narrow-bladed knife is first
used to transfix the penis between the spongy and cavernous bodies close
to the root; the knife having been carried forwards for an inch and a
half, its edge is turned perpendicularly downwards, and the urethra and
skin flap are divided, the cavernous bodies and dorsal integument being
then cut perpendicularly upwards where the knife was originally entered
for transfixion. A button-hole is afterwards made in the lower flap,
though which the corpus spongiosum and urethra protrude, while the flap
itself is turned upwards, and attached dorsally and laterally, so as to
cover in the exposed cavernous structure."
HYDROCELE.--The very simple operation necessary for hydrocele is thus
performed:--The surgeon supports the tumour in his left hand so as to
project it forwards, and make the scrotum as tense as possible in front.
Having carefully ascertained the exact position of the testicle, which
can generally be easily enough done by a finger accustomed to
discriminate the difference between a soft solid, and a bag tensely
filled with fluid, aided by the peculiar sensation of the testicle when
squeezed, the surgeon enters a trocar and canula about an eighth of an
inch in diameter into the distended cavity of the tunica vaginalis, near
the fundus of the swelling. When it is evident the instrument is fairly
entered, and not till then, the trocar is withdrawn, and the fluid
allowed completely to drain off. When it ceases to flow the surgeon
places his forefinger over the end of the canula to prevent the entrance
of air, till he fits into its orifice a suitable syringe containing two
drachms of the tincture of iodine, made according to the Edinburgh
Pharmacopoeia: the tincture of the British Pharmacopoeia is not
sufficiently strong. Having injected this cautiously into the cavity,
the canula is withdrawn, and the surgeon, seizing the now flaccid
scrotum in his right hand, gives it a thorough shake, so as to spread
the iodine over as much as possible of the inner wall. When properly
performed this very simple procedure very rarely fails to produce a
radical cure; though less thorough operations, such as mere evacuation
of the fluid, less stimulating injections, unguents introduced on
probes, and the like, often fail of success, and thus give encouragement
to absurdities, such as wire-setons, or to more severe operations, such
as laying open the sac.
HÆMATOCELE.--When the contents of the sac of the tunica vaginalis are
found to be grumous instead of simply serous, or when, as often happens,
only pure blood escapes when the fluid is nearly evacuated, it is found
that simple evacuation and injection are very rarely sufficient to
effect a cure.
After they have been fairly tried, the sac of the hæmatocele should be
laid open in its full extent; any large vessels which bleed should be
tied, and the cavity then stuffed with lint. When the lint can be
removed, which will be after two or three days, the edges of the wound
should be brought closely together, and the cavity will then rapidly
heal up from the bottom, and be obliterated by secondary union of
granulations.
In cases where the walls of the cavity are enormously thickened, or
even, as sometimes happens, almost bony in consistence, an elliptical
portion may be removed with advantage.
EXCISION OF TESTICLE.--This operation is rarely required except for
tumours of the testicle. Hence the size of the incision necessary must
vary much with the size of the tumour; and the amount of skin to be
removed (if any) on the amount of adhesions it has formed to the tumour.
One or two points must be attended to in every case of extirpation of a
testicle:--
1. The incision should commence over the cord just outside of the
external ring, and be continued fairly over the tumour to its base.
2. As to removal of skin, some surgeons advise that none should be taken
away, others that a considerable quantity can be spared. There is
certainly less risk of secondary hæmorrhage if a portion be removed,
than when a flaccid empty bag is left. The author invariably removes a
very large quantity of skin if the tumour is large, as there is much
more rapid healing, and the resulting scrotum is much more comfortable
for the patient.
3. The cord should be exposed at the beginning of the operation, raised
from its bed and given to an assistant, who should compress it gently,
not from any fear of its escape into the abdomen, but to prevent
hæmorrhage. If the tumour has been very large and heavy, the cord will
have been much stretched, and if divided too high up, may really give
trouble by its elasticity, unless the above precaution is taken. The
cord then having been divided close to the tumour, the latter is
removed, care being taken not to include the sound testicle in the
removal. All the vessels are then to be tied or twisted, and the
spermatic artery is to be secured alone, not, as used to be the case,
included in a common ligature with the other constituents of the cord.
Secondary hæmorrhage is very apt to occur from small scrotal branches
which may have escaped notice during the operation.
OPERATIONS ON THE ANUS AND ITS NEIGHBOURHOOD.--FISTULA IN ANO.--While
much might be written on the pathology of fistula, and a good deal even
on its diagnosis, a very few words will suffice to describe the simple
and effectual operation for its relief.
Dismissing at once all so-called palliatives, drugs, unguents, pressure,
and injections, as mere waste of time, and holding that the only method
of cure consists in laying the fistula fairly open, the question narrows
itself into this: What is the best method of laying it open? Prior to
the discovery by Ribes of the great principle that the internal orifice
of the sinus is always within an inch or an inch and a half of the
orifice of the anus, the operations for fistula were most unnecessarily
severe; the gut used to be divided as far up as the sinuses extended;
and large portions of the anus used to be excised bodily along with the
sinuses. It is now a much simpler and more satisfactory operation.
_Operation._--A common silver probe bent to the required shape is passed
into the external opening, or, if there are more than one, into the
largest and oldest one. The forefinger of the left hand being introduced
into the rectum, the probe is passed through the internal orifice, and
its point brought out by the anus. The portion of tissue raised by the
probe can then be easily divided with the certainty that the fistula is
laid fully open. Anal fistulæ have been divided by the elastic ligature,
but it seems slower in action and more painful, with no counterbalancing
advantages.
The author has for last few years operated almost exclusively by a
long knife which is continued into a steel probe. The probe is
passed up the fistula, then into the bowel, and is hooked out at
the anus, and in being simply pushed on the knife cuts the
fistula--tuto, cito, et jucunde, the patient rarely knowing that
more has been done than an exploration.
In cases where, from the hardness and density of the parts it is
impossible to pass the probe and bring it out at the anus, a strong
probe-pointed bistoury may be passed in by the external orifice
till its probe-point can be felt by the finger in the bowel at the
internal opening. Supported by the finger it can then be made to
cut outwards till the whole septum is divided.
FISSURE OF THE ANUS, ULCER OF THE ANUS, resemble each other alike in the
exceeding annoyance which they give to the sufferer, and in the
simplicity of the treatment needed.
_Operation._--Once the presence of either is determined by the finger in
the anus, a sharp-pointed curved bistoury should be introduced,
transfixing the base of the fissure or ulcer, and then guided on the
finger, completely dividing it, so as to change the ragged ulceration
into a simple wound which will rapidly heal.
PROLAPSUS ANI, _Operation for_.--Complete prolapsus in which the whole
gut is involved, as seen in the very young and the very aged, is suited
for palliative rather than radical treatment.
Cases of prolapsus of the mucous membrane only, as is not uncommon in
connection with or as a result of hæmorrhoids in adults, give
opportunity for operative interference.
We may act on either the skin or mucous membrane, or both at once.
1. _The skin_ is often found loose, and arranged in radiating folds
round the anus. In such cases, as recommended first by Dupuytren, some
of these projecting folds may be removed. Again it may be prolapsed in a
great loose ring or circular fold round the margin, forming an
exaggerated external pile; in such a case the loose fold may be fairly
excised with curved scissors, as recommended by Hey of Leeds.
The first of these methods is apt to be insufficient, the second again
has the risk of removing too much.
2. If the protrusion is chiefly mucous membrane exposed in folds, or a
ring, which is generally outside, one of two methods of treatment may be
tried:--
_a._ By ligature, as recommended by Mr. Copeland. Raising a longitudinal
fold of the mucous membrane, he passed a ligature round it as if it were
a pile. There is less chance of the ligature slipping if a double thread
be used and its base thus transfixed. Three, four, or even more folds
may be thus treated.
_b._ When the mucous membrane has been so long exposed as to have lost
many of its characters, and to resemble leather in its toughness,
excision will be found less painful and much more rapid than ligature.
A longitudinal fold at each side of the anus should be pinched up and
excised by a pair of probe-pointed curved scissors. There is always a
certain amount of risk of hæmorrhage following such an operation. The
risk is lessened and the result improved by stitching up the wound in
the mucous membrane before the protruded portion of bowel is returned.
POLYPI OF THE RECTUM.--Pedunculated growths varying in consistence,
shape, and size, but resembling each other in having a distinct stalk,
and in frequently being protruded at stool.
_Operation._--Invariably by ligature, which may be single round the
stalk, if the tumour be globular and with a distinct narrow stalk, or by
transfixion, if (as sometimes happens) the tumour be of uniform
thickness throughout, like a worm.
HÆMORRHOIDS OR PILES.--In the treatment of piles it is the differential
diagnosis that is troublesome and occasionally difficult; the operative
interference required is generally very simple, if the nature of the
case be rightly determined.
_External piles._--_Operation._--The apex of the soft flabby excrescence
should be seized by a pair of catch-forceps, and it should be cut off
close to its base with a knife, or, what is better, a pair of curved
scissors. Any little vessel which jets may then be secured. If, instead
of numerous individual tumours, a ring of skin round the anus be
involved, the whole of it should be shaved off, but not very close to
its base, lest too great contraction of the anal orifice should ensue.
If the surgeon, after excising a pile or piles, will take the
trouble to stitch up the wound with catgut, he will find the cure
much more rapid and less painful than when this is omitted.
_Internal piles._--Incision is extremely dangerous, from the vascularity
of the parts, and their being so inaccessible from their position within
the sphincter ani. Hence ligature is safer and equally effectual. The
patient should be directed to sit over hot water, and strain till the
whole of his piles are fairly protruded. The surgeon should then
transfix the base of each separately with a curved needle bearing a
strong double thread. The needle being cut off, the threads should be
very firmly tied, each isolating its own half of the pile. The tying
should be exceedingly tight, so as to cause instant and complete
strangulation and death of the tumours. All the piles should be tied at
the same sitting. If the piles are very small they may be secured
without transfixion in a single noose after being seized by a hook or
forceps. There is greater risk of the noose slipping than when the base
has been transfixed.
The strangulated masses must then be returned into the bowel, and the
patient kept in bed or on a sofa till the ligatures separate, which is
generally not till the fourth or fifth day. A certain amount of urinary
irritation, showing itself sometimes in strangury, sometimes in complete
retention, occasionally follows this operation.
Mr. Smith of King's College, and many other surgeons, treat internal
piles by means of an ivory clamp to hold them tight, while they are
burned off by the actual cautery or the thermo-cautery at a low red
heat. They claim that pyæmia more rarely follows this mode.
There are certain cases in which the lower inch or two of the
rectum are found red and congested, and in which every stool is
followed by the loss of a certain quantity of florid arterial
blood, and yet no distinct hæmorrhoidal tumour is to be seen. In
such cases the ligature is not applicable, and relief is obtained
by the application of pure nitric acid, or other potential caustics
to the bleeding surface, as recommended by Houston, Lee, Smith,
Ashton, and others. These cases are comparatively rare, and
whenever they can be applied, the ligature is much simpler, safer,
and more certain.
_Venous piles._--When a sudden effusion of blood has occurred into one
of the varicose veins or sinuses of a congested anus, an oval or rounded
tumour is felt, very tense, shining, and painful. To slit it freely up
with an abscess lancet, and evert the clot inside, at once relieves all
the symptoms.
FOOTNOTES:
[150] Diagram of section of prostate seen from the inside:--PF, pelvic
fascia or prostatic sheath; RR, ring which must be cut; L, position of
incision in the lateral operation; DD, position of incisions in the
bilateral operation.
[151] Diagram of muscles of membranous portion of urethra seen from the
inside:--SS, section of os pubis; U, urethra; G, Guthrie's muscle,
compressor urethræ; W, Wilson's muscle, levator urethræ.
[152] _Boston Medical and Surgical Journal_, May 29, 1879.
[153] Gross, _Surgery_, 6th ed. vol. ii. p. 736.
[154] Holmes's _Surgery_, vol. iv. p. 392.
[155] See Miller's _Practice of Surgery_, p. 212.
[156] Solly's _Surgical Experiences_, pp. 537, 538, etc.
[157] _The Immediate Treatment of Stricture._ By Bernard Holt, F.R.C.S.
London. Third Edition, 1868.
[158] Holmes's _System of Surgery_, 1st ed. vol. iv. p. 403.
[159] Diagram of puncture of the bladder:--B, bladder; SP, symphysis
pubis; SC, scrotum; _b_, bulb; _pr_, peritoneum; P, prostate; R, rectum;
S, sacrum and coccyx.
[160] _Med. Chir. Trans._, vol. XXXV.
[161] Diagram of operation for phymosis:--_a_, glans penis; _b b_,
mucous membrane exposed by retraction of the skin, and slit up; _c d_,
sutures introduced and ready to be tied, uniting the skin and mucous
membrane.
[162] To illustrate Teale's operation:--_c_, section of penis _b_,
thread inserted uniting mucous membrane and skin; _a_, thread tied.
[163] _Med. Times and Gazette_, vol. xix. p. 354.
[164] Miller's _System of Surgery_, p. 1255.
[165] Miller's _System of Surgery_, p. 1256.