its extraction, and many instruments have been contrived for the
purpose. I have had no experience of the proceeding, but consider
the following description of instrument as the best adapted for the
purpose—strong, massy forceps, of considerable length; the blades
proportionally narrower, but much thicker, than those of the extracting
forceps, and armed with several strong teeth, thick at their origin,
tapering gradually, and terminating in a sharp ridge; the handles also
thicker than they are broad, that they may not yield to the compressing
force, and approximated by means of a combination of the lever with the
screw. The foreign body is secured firmly between the blades closed
on it; the handles are then fixed by a screw and nut, and compressing
force is exerted by the lever acting both as a lever and a wedge. The
screw, turned by the fingers, will suffice to crush many concretions;
and none can withstand the full power of the instrument. But it is,
perhaps, safer to open the bladder above the pubes, and extract the
stone through a wound in that situation, when it is too large to pass
betwixt the rami of the ischia.
When the stone or stones have been extracted, and the surgeon
has satisfied himself that no more foreign matter remains in the
bladder, the next step in the lateral operation is the insertion of a
gum-elastic tube, from four to six inches in length, according to the
depth of the perineum, in calibre a little larger than a full-sized
catheter, provided with a noose attached to each of two rings at its
neck, and at its farther extremity open at both point and sides. It is
introduced along the forefinger in the wound, and its extremity lodged
fairly within the bladder; a double tape is attached to each of the
nooses at its orifice; one is passed up in front, and secured to the
fore part of a broad band round the loins; the other is brought under
the thighs, and fixed behind. The object of its introduction is to
facilitate the escape of urine externally, and prevent infiltration of
the cellular tissue by this fluid. The wound, when made according to
the directions which have been given, is both conical and dependent—the
external opening is free, the internal small, the intermediate space
gradually contracting as it approaches the bladder, and the inferior
part of the wound of the integument is lower than the corresponding
portion of the prostatic section; thus the draining away of the urine
is favoured, but it conduces very much to the patient’s safety to
ensure still farther its free escape by the insertion of a tube—part
passes through the tube, and drops from its orifice, part flows by its
side according to the laws of capillary attraction. For some hours
after the operation, it is necessary to clear out the instrument
frequently by means of a feather, otherwise its extremity will soon
become obstructed by coagula; in short, this must be persevered in
till colourless flow from the orifice shows that the internal oozing
of blood has ceased, and that nothing is passing but urine. When by
salutary effusion from the vessels the surface of the wound becomes
consolidated and imperviable to the urine, the tube is to be withdrawn,
but not till then; in young persons it may be removed after twenty-four
hours, but in those advanced in life and of relaxed habit it must be
retained for forty-eight or more.
The tube is also of service should bleeding continue from branches of
the superficial pudic, from small arterial twigs in the neighbourhood
of the prostate, or from venous ramifications and the plexus which
surrounds the neck of the bladder; for it admits of the application of
efficient pressure to the bleeding point, without interfering with the
escape of urine, and so increasing the danger of infiltration. Slips
of lint are pushed along it to a sufficient depth, and are retained,
if necessary, by compress and bandage, the orifice of the tube being
left clear. But, as already stated, it is indeed very seldom that this
proceeding will be required, if the operation has been conducted with
proper caution.
After the tube has been secured by its tapes, or during this process,
the patient is unbound; he is placed in bed with the thighs separated
and bent, and must be kept very quiet. Diluents are administered
copiously, to encourage the secretion of urine; he cannot wet too
much. His nourishment must be very sparing, consisting chiefly of
bland fluids; and all sources of inquietude and irritation must be
carefully avoided. Depletion, whether general or local, will very
seldom be required; danger is not to be apprehended from inflammation
so much as from infiltration of the cellular tissue by urine. In the
fatal cases, unconnected with hemorrhage or exhaustion, the peritoneum
is not found vascular or coated with lymph, nor is there collection
of morbid secretion from this membrane within the abdominal cavity,
but the cellular tissue, along the track of the wound, is black,
disorganised, easily lacerable, putrid; or, if the infiltration has
not been to such an extent or in such a site as to kill speedily
as if by poisoning, unhealthy suppurations are found, extensive,
uncircumscribed, composed of sanies, urine, and dead cellular tissue,
horribly mixed. Should fixed and increasing pain be complained of in
the hypogastrium, the part is to be leeched and fomented; this is the
only indication of inflammatory action which has occurred in any of my
patients, and it has yielded to the simple treatment here mentioned;
so far as I recollect, in only three cases out of more than a hundred,
was the leeching necessary. Some patients require support very soon,
almost from the first; others evince sufficiency of action throughout,
and in them it is very necessary to pay strict attention to the
state of the stomach and bowels, lest the action should exceed; some
proceed favourably for a time, and then become torpid and stationary,
their spirits and constitutional power flagging, in consequence of
confinement and the discharge and irritation of the wound,—such also
require judicious support, and perhaps slight stimulation.
Union of the wound by the first intention is not desirable; attempts to
procure it are dangerous, as conducing to infiltration; the presence
of the tube effectually prevents both. Discharge and granulation take
place, and the cavity contracts gradually and uniformly. By the sixth
or eighth day—sooner in young people, and later in those far advanced
in life—the urine begins to flow in part by the natural passage,
causing considerable pain in consequence of the urethra having been for
a time unaccustomed to its stimulus; and as the opening in the prostate
contracts, the escape of urine by the wound proportionally diminishes.
When the natural course is completely restored, the wound closes more
rapidly than before, granulations soon fill it up, and cicatrisation
takes place. Sometimes, though very rarely, a small fistulous opening
remains for some time, through which a few drops of urine may
occasionally distil; should it prove obstinate in not closing, it may
be touched with a heated wire. And sometimes also, when the urine is
unusually slow of coming by the urethra, this may be expedited by the
occasional introduction of a catheter or bougie.
It is not often that the operation of lithotomy requires to be
repeated. In some few cases, however, the calculous diathesis
continues, a new concretion is formed, and the patient again applies
for relief, perhaps several years afterwards. In such circumstances,
the incisions are to be made in the right side of the perineum; for
the track of the former wound is now consolidated, firm, and hard,
and would be cut with difficulty. But when, from neglect or want of
dexterity, the first operation has been imperfectly performed, one
or more stones being left behind, the wound may not heal, nor even
contract to any considerable extent; and then dilatation of the
existing opening, with fresh section of the prostate, will probably be
sufficient, though at an interval of many months.
It has been proposed to divide the operation into two parts, with
an interval of several days between; first to make the incisions,
leaving the stone undisturbed, and after suppuration has been fairly
established, and the parts become relaxed, then to extract the
foreign body, provided it have not in the mean time been discharged
spontaneously—in short, to perform the operation _à deux temps_.
This method is liable to serious objections. Two operations must in
general be more severe than one. The patient is rendered despondent and
miserable after the first, by knowing that the object of his suffering
has been imperfectly accomplished, or rather not accomplished at all.
Much, and often serious irritation is produced by the wounded bladder
being contracted on the hard and rough foreign body; patients have sunk
under this torture, and the cure is always tedious. From the earliest
times it has been quite well understood, that when the stone cannot be
got out it must be left in; but the proposal of always leaving it in,
on principle and not from necessity, is really absurd. There is room
for suspecting that this mode of operation originated as a virtue from
necessity; the extraction of the stone is always the most difficult
part of lithotomy, requiring much skill and dexterity, and the
operator, finding himself baffled in his attempts to effect it, wisely
desists from his futile efforts at the time, and waits for another
opportunity. This is certainly better practice than the using of much
force, or dilating the wound by incision to a dangerous extent, but it
is very far from being so good as the immediate removal of the foreign
body, smoothly and quickly, skilfully, and without violence; and it has
been already observed, that the cases are very few indeed in which
the stone cannot be removed through the prostatic opening without the
employment of any force, and, without inflicting any injury to the
parts through which it passes—without hazard and without delay. The
sooner the method _à deux temps_ is expunged from the list of surgical
operations, the better will it be for suffering humanity and the credit
of our art.
In those rare cases in which the stone is so large that it cannot be
brought through the outlet of the pelvis, it must either be broken
into fragments, or removed entire through incision above the pubes;
as already stated, it is probable that the _high operation_ is the
safer proceeding. It is, however, an operation attended with much
danger. The wound is necessarily extensive, and important parts are
liable to be interfered with; and, from not being dependent, the
escape of the urine by it is almost certain to cause infiltration
of the cellular tissue surrounding the bladder—an occurrence almost
always proving fatal and that rapidly. The first part of the procedure
is to insure distention of the bladder, so that it may rise in the
pelvis, and afford sufficient space between its lower part and the
anterior reflection of the peritoneum; but this may prove either very
difficult or altogether impossible, even with the aid of injection by
the urethra, in consequence of the unyielding contracted state of the
viscus, and the great thickening of its coats. An incision is made
through the integument and fatty matter, from three to four inches in
length in the mesial line, and terminating over the symphysis pubis;
the recti and pyramidal muscles are then separated, the cellular tissue
cautiously divided, and the fore and lower part of the distended
bladder exposed. The coats are pierced at the most inferior part, and
an opening made sufficient for the introduction of the finger. By the
finger the dimensions of the stone are ascertained, and then the wound
is enlarged upwards to such an extent as will by dilatation admit of
the extraction. Forceps are introduced, of sufficient length and grasp,
and the foreign body removed without laceration or bruising of the
parts. The patient is then laid on his side, a piece of dressing being
interposed between the edges of the wound to favour the discharge of
the urine externally. The escape of this fluid maybe free and copious,
and the wound may close favourably; but the majority of the patients
on whom this operation has been performed, have perished either from
urinary infiltration, from peritoneal inflammation, or from exhaustion.
Fortunately, I have never had occasion to resort to it.
It has been proposed to combine this mode of operation with wound of
the posterior part of the urethra from the perineum, in order that a
free and depending outlet may be afforded to the urine, and also, that
by introducing instruments into the bladder from the lower opening,
the organ may be elevated and stretched so that its fore part may
afford sufficient space for the high incision without danger to the
peritoneum. With this view the perineum is incised, similarly but to a
less extent than in the lateral operation, and the membranous part of
the urethra opened. Through this aperture the sound with a stilet for
elevating the bladder is passed, and intrusted to an assistant; the
incision above the pubes is then made, the stone extracted, and a tube
is left in the perineal wound for discharge of the urine. The plan,
though complicated, appears feasible, and likely to diminish hazard by
preventing infiltration.
The _recto-vesical_ method should never be resorted to in preference
to the lateral; in other words, it is unwarrantable, in my opinion, in
those cases to which lateral operation is applicable. It consists in
exposing the neck of the bladder by division upwards of the sphincter
ani and lower part of the rectum, and then either making a section
of the prostate in the usual way, or dividing also the coats of the
bladder in the posterior fundus, when the concretion is large. The
cure is tedious and harassing: the urine and feces are discharged
together, and hardened feculent matter may accumulate within the
bladder; the wound is long in contracting, and often cannot be made
to close completely without much trouble, and after a long time;
often a fistulous opening remains, communicating with the bladder and
rectum, and through this the urine continues to be in part discharged.
It has been argued, that the recto-vesical method is advisable, with
the view of obtaining more room for extraction of the stone; but
to me it appears that the divided rectum will occupy just as much
space in the outlet as when entire and empty. Circumstances may,
however, occur, rendering this operation, or a modification of it,
absolutely necessary, as in the following case—the only instance in
which I have encountered an encysted stone. The patient, aged 64,
of a spare habit of body, was seized with symptoms of stone in the
bladder about twenty-four years previously to my seeing him; at that
time he was sounded, but no stone could be discovered. The symptoms
gradually subsided, and ultimately disappeared, and he remained for
considerably more than twelve years totally free from any affection of
the urinary organs. But, about three years previous to the operation,
the symptoms returned, and again attentive examination of the bladder
was made, without detecting any stone; on introducing the finger into
the rectum, however, as high as possible, a firm substance was felt,
globular, of considerable size, and very slightly moveable. From this
time the symptoms gradually increased in severity, ultimately becoming
almost intolerable. At length the presence of a stone was distinctly
ascertained by sounding, and the instrument was passed beneath as well
as over the calculus; from simultaneous examination by the rectum, it
was evident that the hard bulging body was connected with the foreign
matter struck by the sound. The lateral operation was performed, and,
expecting to meet with a large stone, both sides of the prostate were
divided. The forceps were introduced, but the stone, though easily
laid hold of, could not be moved. Attempts with the instrument were
accordingly abandoned, and further examination made by the finger,
when it was found that the stone lay fixed in the lower and anterior
part of the viscus, that it was firmly enveloped by a cyst situated
between the rectum and posterior part of the prostate, and that only
a part, small in proportion to its body, projected into the cavity of
the bladder. Of this unusual and untoward circumstance, the medical
gentlemen present were also satisfied by manual examination. It
was quite apparent that it would be impossible to divide the cyst
sufficiently without wounding the rectum, and I therefore determined
to lay the bowel, the cyst, and the track of the wound into one cavity.
This was effected by cutting the upper and anterior part of the cyst,
passing a blunt-pointed and curved bistoury behind the remainder of
the cyst, insinuating it through the coats of the gut at that part,
meeting the point with the forefinger of the left hand passed per
anum, and then carrying the instrument forwards to the surface. A
strong scoop, much curved, was passed behind the stone, and without
much difficulty extraction was thereby completed. Not above a few
tablespoonfuls of blood were lost during the operation, in which not
much time was occupied, and no bleeding took place after reaction was
established. The cure proceeded favourably, though necessarily slow
and tedious, the more so since the patient had been very much reduced
by the previous suffering. Some superficial sloughing took place in
the wound, but the sloughs soon separated, and healthy discharge and
granulation followed. By keeping the bowels gently open, the annoyance
from feculent evacuation by the wound was in some measure diminished.
The patient was daily out of bed, and took food in good quantity and
with relish. At the end of the fifth week, however, he was seized with
a severe bowel attack—vomiting, purging, cold extremities, &c.—and the
effects of this were never surmounted. The real Asiatic cholera was at
that time prevalent, and the patient was under great apprehension of an
attack. The weak state in which it left him continued and increased:
he was soon confined entirely to bed, the wound made no progress in
closing, sloughing of the back took place, and he sank about the end of
the eighth week from the operation.
Calculi sometimes lodge in the urethra, obstructing the flow of urine,
becoming firmly impacted, and increasing in size. If in the perineal
portion of the canal, they are to be fixed and made prominent by being
grasped with the fingers, and then exposed by an incision made in the
raphe: they are turned out, either with the finger, or by means of
a small scoop. If situated in the part covered by the scrotum, the
opening should be made, if possible, behind, not anterior to it, for a
wound in the latter site will be closed with difficulty. When in the
posterior part of the canal, they are reached by incision on the left
side of the perineum and opening of the membranous portion. After such
operations, the wound, if not anterior to the scrotum, usually closes
in a few days.
_Calculus of the female_ is exceedingly rare. Concretions are not
so apt to be retained in the bladder as in males; they are passed
by the urethra. The symptoms are similar to those which have been
described as indicating stone in the other sex. Sounding is easy; it is
performed with an instrument slightly bent at the farther extremity,
and considerably shorter than those employed in the male. Even when
the calculi are of considerable size, they can be removed, as well as
other foreign matter, by dilatation of the urethra, effected gradually.
Portions of gentian root, and sponge tents, were formerly used for
this purpose; but of late years various dilators have been contrived.
Some are really new, others have been published as such, though
correctly represented in works some hundred years old. Their blades are
made to separate in a parallel direction by peculiar adaption of the
screw; and, by gradually and very slowly increasing their separation,
uniform dilatation is effected. Very soon the opening is sufficient
to admit the finger; then the size of the stone is ascertained, and,
if necessary, the dilatation is continued to a sufficient extent.
When thus the canal has been widened so as to admit of the passage
of the stone, forceps are introduced, and extraction accomplished in
a direction downwards, that is, towards the vagina. Incontinence of
urine is apt to continue for some time after this operation, if the
dilatation have been considerable, as well as after the removal of
larger stones by incision.
Incision has been proposed in various directions—into the vagina, or by
the side of it, upwards and outwards; and it has also been recommended
to cut the bladder, on the fore and lateral part of its neck, without
interfering with the urethra.
By the latter method the chance of incontinence remaining is
diminished, but there is a risk of urinary infiltration, and this will
require to be provided against by the use of a tube, as after the
lateral operation in the male. A staff is introduced, and by it the
urethra is depressed towards the vagina. An incision is then made by
the side of the crus clitoridis, and through this the finger reaches
the neck of the bladder, more by dilatation than by additional use of
the knife.
In one case I removed a very large stone by incision. By a straight
grooved staff the urethra was depressed; a straight blunt-pointed
bistoury, being slid along the groove» was carried upwards and
outwards, first on the left side, and then on the right—dividing
the urethra and parts exterior, so as to form a track of wound,
which, after dilatation, would admit of the ready passage of the
stone. Extraction was easy. Incontinence continued for many months,
but ultimately was in a great measure removed by promoting farther
contraction of the opening by the cautery. The preferable plan, and
one I have since then followed in a few instances, is dilatation to
some extent, and by a proper instrument; then slight incision on each
side upwards and outwards; then further dilatation; in a few minutes,
without much pain, the finger is admitted, then the forceps. The
stone is then extracted quickly, with but little pain, and no bad
consequences follow.
_Gonorrhœa in females_ is often confounded with _Leucorrhœa_, which
is a very common complaint both in married and unmarried women.
Leucorrhœa sometimes occurs at a very early period of life, at the
age of ten or sooner; and in such circumstances affections of the
glandular and osseous systems often supervene. Frequently it precedes
the accession of the coloured menstrual discharge, and in many
instances is substituted for it; it is always most profuse after the
menstrual period. In leucorrhœa there is generally neither heat nor
pain during the passing of urine, and the colour of the discharge
differs from that of gonorrhœa, though sometimes very slightly; the
stain of gonorrhœal matter is yellow with a black border; leucorrhœal
is white or yellowish, but does not possess the latter characteristic.
The application of leucorrhœal matter will induce discharge from the
urethra or from the external parts of some males, but the affection
thus caused is, perhaps, not so violent, nor of so long duration, as
that which arises from specific contagion. The effects of leucorrhœa
on the system are very troublesome. There is general debility,
disorder of the stomach, pains of the back, sides, and limbs, a sallow
bloodless complexion, paleness of the lips. It is often a cause, at
other times a consequence, of miscarriage. Sometimes it is accompanied
with a prolapsus uteri, sometimes with thickening of the os uteri. The
discharge which attends ulceration of the parts, from whatever cause,
is generally bloody, sometimes it is thick, and of a laudable aspect,
sometimes thin and fetid. More or less discharge attends polypus, and
is often profuse and coloured.
In gonorrhœa the inflammation is usually limited to the external
parts, but sometimes extends along the vagina. In neglected cases
great tumefaction of the labia takes place, along with excoriation of
the neighbouring parts, patchy ulceration around, and swelling of the
absorbents and of the inguinal glands. Heat, pain, and scalding, are
experienced in making water, but in comparison with the other sex,
females suffer little or nothing from this disease. The parts are much
less complicated; and bad effects seldom follow either the affection or
the remedies employed, however strong.