it can be readily seen and obtained, can be without difficulty brought
in contact with the stone, the bladder being partially distended by
urine, or filled to the requisite extent by tepid water injected
through the outer canula of the apparatus. The branches are then so far
expanded, and the drill withdrawn; and by a little cautious management,
turning the instrument, altering the degree of expansion, and sounding
with the drill, the stone is seized, and then fixed by pulling back the
inner canula. By turning the drill with the fingers, and pulling back
forcibly the inner canula so as to close the branches, the concretion
may at once be pulverised; or it may be again seized, and attacked
by the drill on a different side. The operation may, if necessary,
be repeated after the lapse of eight or ten days, or sooner, if the
irritation caused by the former have subsided. Diluents are to be given
so as to facilitate the washing out of the detritus, and strict rest
and abstinence from stimuli must be observed for a few days.
Various forms of drill have been contrived for acting on a large
surface of the stone; others for scooping it out, the shell to be
afterwards broken into fragments and triturated; they are all unsafe
and ineffectual. The instrument is also so constructed that a drill-bow
may be used, and the apparatus may be fixed by what mechanics call a
bench, or it may be attached, by complicated machinery, to the table on
which the patient is laid, and be there secured in a proper position.
But all this implies an intention of attacking large and dense stones,
and a repetition of the attempts. So far as my experience goes—(and
besides having seen Civiale and others operate, I have myself employed
the instruments in many cases, and very successfully,)—I should
dissuade from all endeavours to rid the patient of stone by such means,
unless its size and consistence were such that it would yield to one or
two attacks.
A plan of crushing the stone, by forcing one part of an apparatus
against another by the stroke of a hammer, has been lately promulgated,
and by a person who previously maintained that the grinding and rasping
was quite perfect, though now regarding them as nought. This percuteur
has a short bend at its farther extremity, one-half separates from
and slides on the other, and both are provided with teeth. It is very
possible to entangle a portion of the bladder betwixt its blades; and,
besides, these may bend or break, as they have done in several very bad
and abominable cases, in which incisions were required to disengage the
instrument from the patient’s urethra or bladder A stone may also be
laid hold of by the apparatus, and being so hard as not to yield to the
impulse of the hammer, may become fixed in such a way as it cannot be
freed from the grasp, there being no provision for pushing it out as in
the lithotriteur.
It will be seen from what has been stated, that I am not so
sanguine—and I trust I shall be excused of presumption in giving an
opinion upon the subject—as to suppose that the breaking up of the
stone in the bladder will ever entirely supersede lithotomy. That it
would do so was at one time industriously represented, and perhaps
believed, by some of the advocates and promoters of lithotrity. If,
by some miraculous interposition of Providence, the deposits from the
urine should uniformly be pulverisable, and that bladders be made of
less irritable stuff than they are, and if, above all, the affected
individuals could only be prevailed upon to apply in due time, then
might such pleasant anticipations be entertained, and then might we
with some reason hope to see them realised; but as matters now are,
urinary concretions must, in a great many instances, be cut out of the
bladder. Nor is it a circumstance to be very much deplored, since,
in good hands, the patient neither endures so much suffering, nor
incurs so much risk, as by the proceedings already detailed. The cure,
besides, is far less tedious. The stone-grinders, whilst they conceal
their own unfortunate results, endeavour to depreciate lithotomy by
blazoning abroad the practice of some unlucky surgeon, who, perhaps,
loses four in twelve, or six in twelve, of the patients who come under
his knife.
It has been said that lithotrity is applicable, when, from the advanced
age of the patients and the rigidity of the parts to be cut, lithotomy
is not. This statement is incorrect, at least the latter part of it.
Old people, from 70 to 80, and even beyond that age, recover, when the
operation is conducted quickly, without loss of blood, and so as to
guard against infiltration, as certainly and rapidly as young persons.
Within the last few years the apparatus for breaking up stones has been
very much simplified and improved upon. The screw lithotrite can with
great propriety and safety be employed in cases in which the concretion
has not attained any very large size, and in which also the urinary
apparatus is healthy, and tolerably free from irritability. The cases
for this operation must be well chosen, and the proceedings conducted
throughout with great caution, gentleness, and judgment. Very full
directions are given in the “_Practical Surgery_” for the performance
of this operation.
Perhaps no operative procedure has been more canvassed than that of
lithotomy. The subject has been discussed, and the operation attempted,
by many not very eminently qualified. All sorts of contrivances have
been made and promulgated in connexion with this operation; the greater
number intended to supply the want either of anatomical knowledge or of
operative dexterity. A volume would scarcely contain a catalogue even
of the instruments which are in my possession,—crooked staffs, knives,
spoons, and forceps. I shall content myself with describing what
appears to me the most simple, safe, and certain procedure.
The bladder may be opened, for the removal of stone, in various
situations; at its forepart, by incisions above the pubes; in the
posterior fundus, by division of the sphincter ani and a portion of
the bowel; at its neck, by cutting upon it through the perineum. The
first mode is termed the high operation, the second the recto-vesical,
the last the lateral. The lateral shall be first considered: it is the
safest, the most advisable, and the most frequently resorted to.
Keeping the patient in suspense for days after operation has been
agreed on, with the view of preparing him as it is called, is
prejudicial. Unless his digestive apparatus be in disorder, or
he be labouring under some other affection incompatible with his
safety should an operation be performed, the sooner he is cut the
better. Delay often inflicts much mental suffering, is apt to induce
despondency, and to weaken the defensive and reparative powers of the
system. On the night before the operation, a dose of castor-oil, or
other mild purgative, is to be administered, so as to obtain an empty
state of the lower bowels; should this fail, an enema must be given.
The existence of a stone should be ascertained immediately before
proceeding to the operation; it is not enough that the sounding was
satisfactory the day before, or at any former period; and the operator
will also, for his own sake, satisfy those who are met as his advisers
and assistants of the fact that there is a stone in the bladder. All
apparatus that may be required should be at hand. A grooved staff,
a knife, forceps, a scoop, and an elastic-gum tube, are in general
sufficient. A Read’s syringe should also be provided, lest the stone
should prove brittle, and crumble under the forceps. When the operator
has, by previous examination, ascertained that the stone is of an
unusually large size, then he must be provided with a narrow, straight,
and probe-pointed knife, with forceps of considerable length and grasp,
and also with forceps so constructed as to effect crushing of the
stone, should this prove necessary.
The staff should be curved, of a size sufficient to fill the urethra,
or nearly so, and with the groove placed betwixt the convex surface and
the side presented to the left of the patient. This form of instrument
will prove the most convenient guide into the bladder. It is introduced
fairly into the viscus, and made to touch the stone audibly. Its
concave surface is raised towards the arch of the pubes, and retained
thus, firmly hooked under the bones—as if with the intent of lifting
the patient from the table—perpendicularly straight, without any
inclination of the handle, or any bulging of the convexity towards the
perineum. After being properly placed, the instrument is intrusted to
an experienced assistant, who keeps it exactly in the same position
from the beginning to the conclusion of the incisions. He at the same
time elevates the scrotum, and standing behind the patient, leaves the
surgeon with both his hands at liberty, and with the patient’s perineum
all clear. The operator is thus enabled to guide the knife by the left
hand; whereas, if he use a straight staff, his left hand must be solely
devoted to the management of this instrument during the most delicate
part of the incisions.
The staff is introduced either before or after the patient has been
secured. The fixing of the patient is in this operation very necessary
and important; on the proper management of that depends much the
facility of completing the operation quickly and satisfactorily.
Children are easily and conveniently held on the lap of an assistant,
who, grasping the knees, places and secures the limbs so as to expose
the perineum. In adults ligatures are indispensable; the hands and
ankles are to be fixed together by means of strong and broad worsted
tapes; and, in addition, the pelvis requires to be secured, and the
limbs must be retained well separated, by two steady and powerful
assistants, pressing obliquely down towards each other. A band may also
with advantage be passed under the hams, and tied round the patient’s
neck: the proper position is thus still further secured. The patient is
placed on a firm table, of a height convenient to the operator, who is
seated on a low stool. A table from two feet and a half to three feet
in height, with a stool about a foot lower, will be found to suit very
well. The instruments likely to be required are disposed in the folds
of a towel placed on the floor, on the right side of the operator, and
at a convenient distance.
Before proceeding to incise, the finger is introduced into the rectum
to ascertain that it is in an empty state, and also to promote its
contraction. A knife is used, with blade and handle somewhat longer
than those of a common dissecting knife, and without any edge till
within an inch and a half from the point,—held lightly in the fingers,
the end of the handle resting on the palm. It is introduced close to
the raphe, on the left side, and nearly opposite to where the erector
penis and accelerator urinæ approach each other. Its point is made
to penetrate through the skin, fat, and superficial fascia of the
perineum, and is carried downwards with a slight sawing motion, by
the side of the anus—about midway betwixt the anus and the point of
the tuberosity of the ischium—and is continued till nearly past the
lower part of the orifice of the bowel. The forefinger of the left
hand is then introduced into the wound, and the resisting fibres of
the transverse muscle of the perineum, and of the levator ani, are
touched with the edge of the knife directed downwards. Wound of the
rectum is avoided by pressing it downwards and to the opposite side by
the finger; indeed the finger should be constantly in the wound as a
guide to the knife. In this stage of the proceedings, incision upwards
would be likely to interfere with the artery of the bulb, whatever
its distribution may be,—whether the vessel come from the pudic,
or from the posterior iliac. It occupies nearly the same relative
situation in either case, and by care can always be avoided during
the second incision. Division of it occasions most profuse, alarming,
and dangerous hemorrhage. I have seen the patient lose much blood in
consequence during the incisions; and after the occurrence of reaction,
have seen the blood soaking through the mattrass, dropping from the
foot of the bed, and collecting in pools on the floor. The bleeding is
difficult to arrest; the application of ligature is very troublesome,
if not impracticable, and efficient pressure cannot be made with safety.
In my own practice I have had little or no trouble from
hemorrhage—chiefly, I believe, from never cutting upwards after the
first incision. One instance of secondary bleeding occurred. The
patient was sixty-one years of age, and had laboured under symptoms of
stone for eight years. He had been dyspeptic for some weeks before the
operation, but otherwise appeared a favourable subject. Very little
blood was lost during the operation, but on the fifth day hemorrhage
occurred to the extent of seven ounces; on the eighth day, the same
amount was lost; on the twelfth, a pound; on the sixteenth, five
ounces; on the seventeenth, about a pound. The bleeding was uniformly
preceded by a feverish attack; and the blood had a florid, arterial
appearance, and flowed rapidly. It proceeded from the interior of the
wound, and a suppurating cavity in the neighbourhood of the prostate
was felt by the finger. From the prostatic side of this abscess the
blood appeared to spring; probably a considerable branch of the pudie
ramifying in this situation had been opened by unhealthy ulceration.
Pressure proved always effectual at the time, the hemorrhage recurring
on the loosening and separation of the lint. After the last bleeding
the dressing was retained for some days, and on its removal no
recurrence took place. The patient had been much exhausted by this
severe loss of blood, but, notwithstanding, made a good, and by no
means tedious, recovery. In one case, also, troublesome hemorrhage
occurred within twelve hours from the operation on a patient advanced
in life. The bleeding was arrested with some difficulty by ligature and
pressure. The patient died on the third day. The cause of the bleeding
was found to be ossification, as it is called, or earthy degeneration
of the coats of the vessels. The bleeding was from the external
hemorrhoidals. The artery of the bulb was untouched.
Many patients have perished within the first day or two from bleeding,
owing to the using of the knife too freely, and in an improper
direction. By very slight application of the edge to the resisting
fibres, and by gentle dilatation with the finger, the membranous
portion of the urethra is reached. The knife is passed over the back of
the forefinger in the wound, and lodged in the groove of the staff; it
is then carried forwards through the prostate, with the edge directed
downwards and outwards, cutting the gland obliquely. In this incision
the knife is raised very little from the groove, the object being to
divide the gland to the extent of no more than barely three-quarters
of an inch. By so doing, the reflection of the pelvic fascia remains
uninjured, and the boundary is left entire betwixt the external
cellular tissue, and that loose and very fine texture immediately
exterior to the bladder—betwixt it and the fascia lining the pelvis;
thus the risk of urinary infiltration is done away with, at least much
diminished. There is great danger in dividing the base of the prostate
completely, and much more in cutting any part of the coats of the
bladder. When the knife enters the groove of the staff, this latter
instrument must be held very steady; if it be at all withdrawn, its
point may escape through the wound, and mislead the knife.
There is no great risk of wounding the trunk of the pudic artery,
unless by using either a broad instrument called the gorget, or a
concealed knife. The former is now almost wholly abandoned. Besides
endangering the pudic, it is apt to lacerate the neck of the bladder,
pushing the prostate before it, and so tearing its cellular connexions.
The latter, the lithotome caché, makes the internal wound larger than
the external; the coats of the bladder are slit up to an unnecessary
extent, being cut much more easily than the prostate, and the
instrument not affording sufficient resistance to the gland.
Through the prostatic opening the finger is easily passed into the
bladder, and the stone felt. The staff is then withdrawn. Sometimes
it is a troublesome matter to reach the bladder with the finger, in
consequence of the straining and struggling of the patient, causing the
organ to ascend in the pelvis; the difficulty is overcome by patiently
waiting till these exertions cease. By steady and gradual movements of
the finger in the wound of the prostate, the opening is much dilated,
so as to admit of the ready introduction of instruments for laying hold
of and removing the stone. Indeed, the neck of the bladder is capable
of dilatation without any incision. In a case of perineal abscess
containing a portion of exfoliated bone, on account of which incision
was made, it was found that the cavity communicated with the urethra;
lest other foreign matter should remain, I introduced my finger into
this aperture in the membranous portion, and found that by the most
gentle movement I could not only easily reach the bladder, but dilate
the opening in it to a very considerable extent.
By the finger in the bladder, the size and position of the stone is
ascertained; and no extracting instrument should be employed till after
the finger is in contact with the stone. When it is of moderate size,
and after having been turned, if necessary, into the most favourable
position for extraction, the forceps are introduced. This instrument
should be tolerably long, so as to afford power in its use; and the
extremities of its blades should be covered with coarse linen, for
thus it is not so likely to slip or to chip the stone as those with
raised and projecting teeth. For flat stones, the forceps should
be flat-mouthed; for round, more open, hollowed, and bent at the
points; or for the latter description of stone, forceps with a sliding
joint may be used. The object is to lay hold of the concretion by
as many points as possible—to bring a large surface in contact with
the instrument. Those with the sliding joint are of no service when
the stone is flat, as it either cannot be caught by them at all, or
merely by their points, or near the joint; they are applicable only
to round stones of considerable size, but they are very troublesome
to manage. The instrument is introduced shut, along the finger, and
on reaching the prostate is gently insinuated, whilst the finger is
at the same time withdrawn. It is brought in contact with the stone,
and carefully opened, the handles being raised. One blade is passed
under the stone, the other remaining above, and then the instrument is
closed, firmly but not forcibly. By the finger, again introduced, along
the side of the forceps, it is ascertained whether or not the stone is
held securely, and in the proper direction; if not all right, it may
then be turned by using the point of the finger and slightly relaxing
the grasp. Now the handles of the instrument are depressed, so as to
avoid resistance from the bones in the front of the pelvis, and the
extraction is commenced, in a steady and gradual manner; if difficulty
is experienced, dilatation is effected, and the process facilitated, by
moving the forceps gently backwards and forwards; no force or violence
is required, either in pulling or dilating; all should proceed smoothly
and with deliberation.
The forceps must be proportioned in length to the size of the stone;
a large concretion requires long forceps, both that it may be grasped
securely, and that sufficient power may be afforded for the extraction.
Some stones are of such a size as will not admit of passage through the
section of one side of the gland. By using the blunt-pointed knife,
directed by the finger, without any additional external incision, a
wound is made on the right side of the prostate, in the same direction
and to the same extent as that on the left. Thus a triangular flap is
formed, the apex towards the membranous portion of the urethra, and
through the opening thereby afforded any stone, which will pass through
the bones of the pelvis, can be extracted without much difficulty. But
no benefit can result from cutting both sides of the prostate, either
by the double lithotome or in the manner just detailed, in all cases.
It is time enough to incise the opposite side when, by introduction
of the finger through the usual wound, it has been ascertained that
the stone is too large to pass through it. Then it is safer to cut the
other side, than to enlarge the original opening, either by the knife,
or by laceration in cruel attempts to extract the stone through an
insufficient opening.
When the stones are small, the scoop is the preferable instrument.
By it the bladder may be soon cleared, even when the concretions are
numerous. It is introduced along with the finger, is brought in contact
with the foreign body, and passed beyond it or beneath it. Then the
point of the finger is placed on the lower part of the stone, so as to
steady and secure it, and the scoop and finger retaining this relation
are gradually withdrawn along with the stone. More than one, perhaps,
may be removed at each withdrawal of the instrument. The flat and
slightly bent lever, usually forming the handle of the scoop, is useful
should the forceps unfortunately slip during extraction, leaving the
calculus impacted in the wound; by insinuating this instrument behind
the stone, and employing it partly as a lever, partly as an extractor,
removal is completed.
If the stone break, which should not often happen if the forceps be
used properly, the fragments must be carefully brought away, the larger
by the forceps, the others by the scoop. The sand and detritus which
may remain are washed away by injecting tepid water into the bladder,
afterwards promoting copious secretion of urine by diluents.
After almost every operation for stone, particularly when the
concretions are numerous, or when they have broken into fragments,
a searcher is useful to ascertain whether or not all have been
removed. It is a slightly curved sound, with a bulbous point. Having
been introduced by the wound, it is passed into every part of the
bladder with great care, with the view of detecting small calculi, or
fragments, which may have escaped the search of the finger, forceps,
and scoop. Besides this precaution, the extracted fragments should
be carefully examined, and the stones built up, that the surgeon may
better judge if they be all there. The surface of the stone affords
considerable information; if it be uniformly rough, the likelihood is
that it is solitary; if one or more points are smooth, it is probable
that these have been occasioned by the attrition of other calculi.
If suspicion still exist of part remaining, examination may be made
through the wound, during the suppurative stage, six or eight days
after the operation, before it has closed much.