Part 67

The patient is placed recumbent. An incision is commenced a little above the inguinal aperture, and carried downwards; on reaching the tumour it is inclined to one side, so that with a similar one on the opposite side an elliptical portion of integument may be included. This is always necessary when the tumour is adherent to its coverings, or when a fungus has been protruded. One straight incision may be sufficient for removal of the tumour; it is sometimes necessary to take away more or less skin, so that a large, loose, and flabby bag may not remain after the extirpation. This preliminary wound penetrates only through the skin and cellular tissue, and should be made rapidly. At its upper part the chord is then to be cut down upon, exposed, and divided; but the division should not be made until the chord has been isolated for some distance, so as to afford a firm hold to an assistant, and not before the assistant has secured it firmly in his fingers, otherwise it may retract within the inguinal canal, rendering the bleeding from the spermatic artery troublesome. The dissection is now to be continued downwards, rapidly, and yet cautiously; the tumour is detached on all sides, and removed along with a sufficient quantity of integument. In dissecting off its posterior surface, care must be taken not to wound the septum of the scrotum. All adherent skin must be taken away, and in the case of fungus, the incision of the integument must be wide of the projecting part. But, at the same time, unnecessarily extensive removal of skin is always to be avoided, otherwise there will sometimes be a difficulty in covering the root of the penis and the remaining testicle. The assistant has, during the extirpation, retained his firm grasp of the chord, so restraining hemorrhage from that quarter; now the branches, generally two, of the spermatic artery are pulled out by the forceps, and a ligature applied to their extremities, inclosure of any of the surrounding parts being studiously avoided. To tie veins, artery, nerves, vas deferens, and cellular tissue, in one mass, would lead to most serious mischief, not to mention the immediate and excruciating pain occasioned. It has been recommended either to pass a temporary ligature round the chord, before its division, to prevent retraction, or to tie the artery before it is cut across. I have never found either practice necessary; the latter retards the operation; the fingers of an assistant are generally as effectual as a ligature, and inflict less injury to the parts, and less pain to the patient. Should the chord slip, there can be but little difficulty in pulling it down again by means of a hook; at the worst, slight extension of the incision upwards may be necessary. The scrotum is to be sponged clean of coagula, and its bleeding vessels secured: they are often numerous. The incision is brought together by several points of suture, and cold cloths applied. In no operation is secondary bleeding more frequent, occurring within an hour or two after reaction has been established, and the patient begun to get warm in bed. The flow is always from the scrotal vessels in the lower part of the wound, and often profuse. The dressing must be partially undone, so as to expose the vessels, and permit of the application of ligature. On this account, it is well not to approximate the lower part of the wound in the first instance, but to fill the cavity with charpie or dry lint, retaining this until risk of hemorrhage has passed over, or better still to have the wound quite open for five or six hours, and then to bring the edges together. The upper part of the incision often heals by the first intention, but this is seldom effected in the lower; suppuration takes place, and the cavity fills up slowly by granulation. Indeed, attempts to procure primary union of the scrotal wound are scarcely to be recommended; they are very seldom effectual; and should bleeding take place, the patient is either put to much pain, by removal of the stitches, and separation of the edges, or the blood is confined, accumulates in the cavity, and is infiltrated into the cellular tissue, producing much tumour, which terminates in extensive and unhealthy suppuration. Such retardation of the cure is avoided by open dressing of the lower part of the wound from the first.

Not unfrequently infiltration of the cellular tissue over the chord takes place within a few days after the operation, extending upwards under the superficial fascia of the abdomen, with discoloration of the integument, diffused doughy swelling, and much irritation of the system. Matter soon collects at one or more points. Early incision will check the advancement of this affection, followed by fomentation, and poultice, and attention to the constitution. Collection of the matter should never be waited for; and when depôts have formed, a free and dependent opening should be made early. Sometimes the patient may perish, exhausted by the profuse discharge and the disturbance of the system, in cases that have been neglected, or in which infiltration is rapid and extensive and the powers of life weak.

_Calculus Vesicæ._ Morbid action of the kidneys, producing altered secretion of the urine and deposition from it, takes place in consequence of derangement of the digestive organs—often occasioned by the free use of acids, or of acescent diet, such as fruit tarts, or drink containing a great quantity of saccharine matter. Many causes, which have not as yet been well ascertained or understood, seem to influence and predispose to calculous disorders. The prevalence of these affections in particular districts has been attributed to the quality of the water, or to the use of peculiar food or beverages; but such opinions, in all probability, have been adopted neither on very good grounds, nor after due inquiry and consideration. The county of Norfolk, and the eastern part of Scotland from the Frith of Forth northwards, are districts very similarly situated, exposed to cold and piercing winds, and appear to furnish a greater number of cases of stone than the rest of Great Britain, with Ireland to boot. The reason of this, as already stated, has not been satisfactorily explained. But this disorder, like gout, seems also to adhere to families, to be transmitted from one generation to another. Some children seem almost to come into the world labouring under calculus.[59] The symptoms are noticed very soon after birth, and often patients labouring under stone are presented to the surgeon at the tender age of twelve or eighteen months.

The depositions from the urine are various. The deposit chiefly affecting children is of a dark colour, dense, hard, and crystallised; but one lighter coloured, and more friable, sometimes precedes the formation of this dark concretion. As seen here, the nucleus is surrounded by an oxalate of lime calculus, and then follows layer after layer of urate of ammonia. The dark sand or stone is occasionally, though much more rarely, met with in older individuals; but in them the red, dark brown, yellow, and white deposits are more common. And in them, too, the diathesis or disposition to the formation of one or other variety evidently alternates, as is well demonstrated by section of urinary concretions. An alternating calculus is here represented.

The red deposit, by much the most common, at least in adults, consists principally of uric acid, soluble by solutions of the alkalies. The brown and yellowish are also composed of uric acid, often in combination with a base, and are likewise soluble in alkaline solutions, or in alkaline carbonates. The white is most commonly the ammoniaco-magnesian phosphate, soluble in acids; rarely, it consists of phosphate of lime, not so white or friable as the preceding, but likewise soluble in acids; or it may be a compound of phosphate of magnesia, ammonia, and phosphate of lime, very white and soft, and imparting a stain to the finger, soluble in acids, but principally characterised by its fusible property. Specimens are here given of the phosphate of lime, and of the triple phosphate formed as is usual on a nucleus of uric acid, with some base, or upon the mulberry concretion. The dark, hard deposit, chiefly occurring in children, consists of the oxalate of lime, either pure, or in combination with one or other of the preceding, very dense and soluble in acids. When these, by accumulation within the bladder, are formed into concretions, they are always mixed with more or less of a peculiar animal matter deposited from the urine. Passed by the urethra, and settling at the bottom of the vessel as the urine cools, they are termed either morphous, or amorphous, according as they are crystallised or not.

To correct the calculous diathesis is an object of much importance; solution of the concretion in the bladder is now allowed to be impracticable. The principal attention is to be directed to the digestive organs and skin; these must be brought into a sound state by attention to diet, and the exhibition of laxatives, tonics, antacids, &c., as the individual case may require, by exercise and baths. And much benefit is also derived from the use of either alkalies or acids in solution, according to the nature of the deposit. The uric acid diathesis is the most frequent; in that, alkalies, as the carbonates of soda or potash, are to be employed; the potash is preferable. Diuretics and diluents are useful in carrying off the sand, and relieving the painful symptoms; Venice turpentine with squill is on this principle often a valuable remedy, and in some cases colchicum proves of benefit.

The symptoms attendant on the collection and passing of sand, or gravel, as it is commonly termed, are,—pain in the loins; heat in making water; heat in the urethra occurring afterwards, continuing for some time, and usually at the orifice; frequent desire to empty the bladder; and an occasional mixture of blood with the urine. When aggregations of the deposit, forming concretions of some size, pass along the ureters, violent pain is felt in the course of these tubes. Often the patient complains of colicky pains all over the abdomen, and of sickness without vomiting. There is pain in the thighs and testicles, with retraction of the testicle on the affected side.

The calculous deposit may, instead of passing off along with the urine, be accumulated in the body, forming concretions. It is produced by the kidneys, and in them the concretions may be formed and lodged; or it may not accumulate until it has reached the bladder. Usually the stones are produced in the former situation, and after having attained some size descend by the ureters, causing much pain. It is not often that they remain in the pelvis or infundibula till they have become too large to descend; in such cases they increase in their original situation, producing, in general, much more uneasiness and greater danger than if they had reached the bladder. Or they may enter the ureters, and lodge in these canals, distending and obstructing them.

The concretions may be caused by the lodgement of extraneous substances in the urinary passages. Foreign bodies introduced, even in the most healthy persons, are soon incrusted by calculous matter; and the rapidity of the incrustation is in proportion to the tendency to the calculous diathesis. At first the deposit is generally of a brownish colour. Catheters retained in the bladder are soon blocked up by it. Needles, bodkins, leaden bullets, seeds of vegetables, kernels of fruit, bits of catheters or bougies, have been found forming nuclei to urinary calculi—more frequently in females than in males, for obvious reasons.

Some concretions are formed on the nucleus of condensed vitiated secretion from the mucous coat of the bladder, and partly consist of this deposit from the membrane. Such are generally of a dirty white colour, soft, friable, small, and numerous; it is seldom that they are collected into masses of any considerable size. They are usually adherent to the mucous membrane, sometimes forming a broad and thin sheet covering it extensively; other stones, though composed of calculous deposit from the urine, are equally friable as the preceding, and also both numerous and small. So brittle is their structure that they frequently break up by rubbing upon one another, or by being compressed one against the other by the action of the muscular coat of the bladder. Their laminæ in fragments, and the nuclei entire, are, in consequence, often evacuated along with the urine in considerable numbers. Even large and apparently very solid concretions break up most unaccountably in the bladder. This may be, perhaps, so far understood when more than one stone is present. A sketch from a specimen in my collection is here introduced. It was obtained from the body of a medical man. He had, it seems, laboured under symptoms of stone for a long period, and ten years previously to the attack which terminated fatally, had himself ascertained by sounding the existence of calculus in his bladder. One Sunday morning I met this gentleman in consultation about a case of injury of the hip-joint. In three days afterwards I was called to visit himself, nearly moribund, from inflammation of the urinary apparatus, his urethra being blocked up by large fragments of stone. It appeared that on parting with me he had been suddenly summoned to an urgent case of midwifery. He ran quickly down a steep street, and at the bottom of it was seized with an urgent desire to make water, which he did in small quantity, mixed with much blood. He passed some pieces of stone with very sharp angles. He went on from bad to worse; he had retention, and the urethra was found much obstructed; suppression followed, and death terminated his sufferings in a very few days. Many portions of the calculus were voided; much stone, with the nucleus, occupied the bladder and urinary passage; the kidneys were dark-coloured, and one approached to a gangrenous appearance. The practice in the first instance, and so soon as the nature of the case was fully ascertained, should have been to cut into the bladder and clear it of the nucleus and fragments.

It has been elsewhere noticed, that cysts are apt to form in bladders which have been long subjected to irritation from any cause; it need therefore excite no surprise that such formations should be found in patients afflicted with calculous disorders. In one of these unnatural cavities a stone may lodge, both at first small. The concretion receives gradual increase, fills the cyst completely, and then dilates it in proportion to its own enlargement. So long as it is covered by the cyst, the patient suffers but little from it; but when, from the addition of calculous matter, it projects through the opening of the cyst, coming in contact with the coats of the bladder during contraction of the viscus, the usual symptoms of stone are manifested. Sometimes there are several encysted calculi in the same bladder, but in such cases they are seldom of large size.

The stone in the bladder—whether formed in the kidney, and having descended, or originally concreted in the bladder, either spontaneously or in consequence of the presence of foreign matter—produces very marked and distressing symptoms. There is frequent desire to empty the bladder, and the uneasiness is not relieved by doing so. There is pain during and after the evacuation, referred to the course of the urethra, particularly to the orifice. In children, the patient is induced by the pain to grasp the penis, and pull forwards the prepuce, often so habitually as after a time to cause considerable elongation of the latter part. The flow of urine often stops suddenly, and immediately afterwards the pain is unusually severe; the stream reappears on change of position. The body is usually inclined much forwards during the attempts to make water; sometimes the patient rests on his knees and elbows, or on the top of his head, having found that he obtains most ease in these postures. The urine is mixed with ropy mucus, and in long-continued cases with a puriform fluid. After exercise, or unusual exertion, the urine is bloody, a bearing down pain is complained of during the making of water, and often there is simultaneous and involuntary evacuation of the contents of the rectum; the close sympathy between the bowel and the bladder has been already adverted to. In young persons afflicted with stone, prolapsus of the rectum is common, and sometimes it occurs also in adults. Occasionally there is pain in the testicle, or in the back of the thighs, and very frequently a burning heat in the hollow of one or both feet; sometimes there is a fixed pain in the last situation.

Some of the symptoms are more prominent than others, nor is the severity of these uniform. At times the patient is tolerably free from uneasiness; but then a fit of increased suffering supervenes, often attributable to intemperance, or to over-exertion. The intensity of the symptoms also depends on the nature and size of the concretion, and on the idiosyncratic irritability of the patient; in some people the bladder is naturally so acutely irritable as to be thrown into the utmost disorder by the most trifling cause, whilst in others sources of greater irritation produce but very little uneasiness. The mulberry or oxalate of lime calculus, a specimen of which is here sketched, is of very rough surface, and gives rise to the most violent symptoms. But the projecting portions of this, or of other rugged concretions, may become covered by additional and smoother deposit—or the surface may become smooth, polished, and water-worn, receiving no addition for a long time—and in such circumstances the sufferings are mitigated. However, in consequence of fresh incrustation, they may soon become again much aggravated, and almost intolerable.

The increase of the stone is in some cases exceedingly slow; after many years, the size may not exceed that of half a walnut. In others, large dimensions are attained within a short period. The mulberry is always of gradual formation; and the rapidly increasing are generally of the alkaline and earthy or alternating character.

The symptoms above detailed—many, and sometimes all of them—may be produced by other causes than stone in the bladder. Irritation of the bowels, more particularly of the lower, by worms, foreign bodies, or feculent matter of a bad kind—irritation of the kidney—alteration of structure of this viscus, and the lodgement of concretions in its pelvis—are all attended by many of the symptoms of vesical calculus. Irritability of the bladder, the nature of which has been elsewhere detailed, also possesses somewhat similar indications; but the pain is usually referred to the hypogastric region and the perineum, as well as to the point of the penis, perhaps more frequently, and is generally relieved after evacuation of the urine: such is not the case in calculus.

The symptoms and sizes of stone, when severe, will lead the patient to take such means as are necessary to ascertain the cause of them—to ascertain whether or not stone exists in the bladder. The term _sounding_ is applied to such examination. In this proceeding the bladder should contain some urine, so that the object may be effected more readily, and with less pain to the patient; he should be desired to retain his urine for one, two, or three hours, as he may be able; or from four to six ounces of tepid water may be injected. In the contracted state of the viscus, the stone may escape detection, if of no great size, from being embraced by the bladder, and concealed in its folds; or, on the contrary, it may be discovered either after or during evacuation of the urine, having eluded the surgeon’s search during an over-distended state of the viscus. Also, it may be discovered in one position of the patient, whilst it is lost in another. When the symptoms are decided, examination is to be made, both during the recumbent posture, and during the erect, with the body bent forwards, and likewise with the bladder in various states of fulness; and if unsuccessful, the search is to be repeated. But in general no difficulty is experienced in discovering the stone. The instrument used should be pretty large, with a smooth metallic handle, and either with a large curve and long point, or straight till near the farther end, and then having a short curve. The latter form is preferable, as admitting of the curved part being introduced completely within the bladder, and turned in all directions and into every part of the viscus—the urethra being brought into a straight line by the remaining part of the instrument. The posterior fundus, behind the prostate, is the situation most commonly occupied by the stone during the recumbent posture; and there it is in a measure concealed, when small and the gland enlarged. The surgeon, aware of this, examines that part of the organ very carefully, and, as already stated, explores every corner with the utmost gentleness, and at the same time minutely, never employing the slightest force or rudeness of search. Upon bringing the instrument in contact with the foreign body, or moving it quickly upon it by turning the handle, the sharp clear sound of the stroke can be distinctly heard; and this is one reason why the instrument should be throughout metallic. The prudent surgeon is not satisfied of the existence of calculus in the bladder without this sign.

Not a few practitioners have been deceived, and have subjected their patients to incision of the bladder when no stone was there. A false and deceptive grating is sometimes felt during the passage of the instrument through the prostate; or the point may be made to rub against dense and rough fasciculi of the bladder; or a more distinct feeling, as of stone, may be communicated from the instrument being brought in contact with particles of sabulous matter entangled in mucus, and adherent to the inner coat. The last deception is to be expected only in those advanced in life. But the greater number of those cut necessarily have been young persons. In them the symptoms of stone are closely simulated by irritations of the alimentary canal, and the crying of the patient prevents the stroke on the stone from being distinctly heard.

Perhaps the practitioner may be very anxious to discover a stone and have the glory of removing it, and is satisfied with feeling a rubbing or grating of the instrument; he cuts into the bladder, and to his dismay and discomfiture nothing is found. No foreign body may have existed; or perhaps some small particles of sand which gave rise to the feeling may have escaped detection, being carried off along with the urine and blood. On the contrary, cases have occurred in which a stone actually existed, but was overlooked; and the patient, after recovering from the first incisions, has been relieved by a second and better conducted operation. In diseases of the urinary organs, the surgeon cannot be too cautious and considerate in all his proceedings and interferences. For example: I on one occasion went to see an operation for stone in the bladder, and was asked to feel the stone, but could not. There was merely a sense of grating during the introduction of the instrument; and the operator was dissuaded from his intention. The patient did not live many weeks; a small ulcerated cavity was found in the situation of the verumontanum, but no stone.