Part 50

But still the operation of breaking up a stone in the bladder is very advisable in certain cases, and may be resorted to with every prospect of a safe, speedy, and successful conclusion. But it can be recommended and employed only within certain limits; the case must be well chosen, and every circumstance must be perfectly favourable as regards the condition of the urinary passage and of the bladder, and the size and nature of the stone. Every operating surgeon should make himself well acquainted with the instruments and their mode of application, so that he may resort to them as occasion requires.

A great deal of ingenuity has been expended of late years in inventing and improving upon the apparatus. Many useless, inapplicable, and highly dangerous machines have been produced, a few efficient and perfectly safe.

The knowledge of the fact that the curvature of the urethra can be effaced, and a perfectly straight instrument, or one with a short curve can be passed into the bladder with equal ease and freedom from uneasiness as a largely curved one, has facilitated very much the application of means for seizing and acting upon a stone in the bladder.

The three-branched instrument, which it is unnecessary to describe, as 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 The branches are then so far expanded, and the drill withdrawn; and by a little cautious management, turning the instrument, altering the degree of expansion, and sounding with the drill, the stone is seized, and then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.

It has been proposed to break the stone when very large, to facilitate 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.