Part 68

By a dexterous use of the sound the size of the foreign body can be tolerably well judged of, as well as the state of its surface, and it may also be known whether there are more stones than one. The bent part of the instrument is passed over and beyond the calculus, and then under it, if possible, so as to ascertain its thickness; and by moving it on each side, the other dimensions are also arrived at. No information can be obtained as to the size of the stone—at least in adults, and when it is not encysted—from any examination by the rectum.

Concretions resembling horse-beans in size, and even larger, can be brought through the adult urethra without incision, by means of properly constructed forceps. The facility with which this is accomplished will depend much on the state of the passage, whether naturally capacious and free from morbid contraction or not, and also upon the condition of the prostate gland. Notwithstanding the greater irritability of the parts in young persons, this operation may be readily performed on them; on several occasions I have removed from children concretions of considerable size through the natural passage. Various contrivances have been used for the purpose. Modifications of what are called Hunter’s forceps have been recommended,—two elastic blades shut by being withdrawn into a canula, and made either straight or curved; but they are not so applicable as the forceps of Sir A. Cooper, as modified by Weiss. These are of different curves and sizes, and the handles should be made of metal, smooth on the flat surfaces; for thus the concretion will be more readily felt. The instrument is passed along the urethra, and used in the bladder as a sound; when it has touched the stone the blades are opened, and by raising the handle, pressing the convex part downwards, and then allowing the blades to close slowly, the concretion is embraced. If the stone lie on the forepart of the instrument, on its concavity, it will fall between the blades as soon as they are sufficiently separated. By observing whether or not the wire goes home into the canula, it is ascertained whether or not the foreign body is between the blades; if it is not, the manœuvring must be repeated; if it is, the instrument is to be withdrawn carefully—of course bringing the concretion along with it. Some slight resistance is felt in passing the prostate, as also anterior to the sinus; and on reaching the orifice, some little force is requisite to complete the removal, or the orifice may be dilated by a slight incision so as to facilitate the disentanglement of the forceps with the concretion. By one or more operations of this, nature many stones may be removed, and the patient thus freed entirely from the disease. There is no great risk of seizing and pinching the coats of the bladder with this instrument, whilst there is a tolerable certainty of doing so with most of the others.

On one occasion, when practising the operation on the dead body, I found that the instrument had got several stones in its grasp, and was kept so dilated as to be withdrawn with much difficulty—there being no means of disentangling the stones but by farther expansion of the blades, which was impossible. A great many foreign bodies—pieces of pebble—had been introduced; but had the same number of urinary concretions been laid hold of—which is scarcely possible—those farthest from the point and most compressed would have crumbled down, and thus the expansion of the blades would have been diminished. I have not experienced the least difficulty in operating with this instrument, in numerous cases, and at all periods of life. The preferable instrument for the purpose is, however, the small screw scoop. The concretion can by its use be crushed and reduced in volume, so that the urethra does not suffer in the extraction, and the patient is saved much pain. The safety of the proceeding is its greatest recommendation. It is very seldom that any unpleasant symptoms follow; there may, perhaps, be a trifling effusion of blood, and some slight pain in making water may continue for a day or two. Should either irritability of the bladder, or symptoms indicating inflammation of the mucous coat supervene, these must forthwith be combated.

Concretions of such a size as cannot be made to pass through the neck of the bladder, and along the urethra, and yet are not much larger than a filbert, may, if soft and friable, be laid hold of in the bladder by properly contrived instruments, and acted upon so as to be reduced to powder and fragments, which may either pass off along with the urine, or be extracted by means of forceps. This proceeding is not advisable in children, owing to the small size of the parts and their greater irritability, and in consideration also of the concretions in them being in general exceedingly dense; as formerly noticed, they are most frequently composed of the oxalate of lime. In the adult, it cannot be adopted with safety and propriety, when the bladder is irritable and will not bear a certain degree of distention, and when the prostate gland is large. The cases in which the concretion is small, soft, or brittle, and the parts sound and free from irritation, form but a small proportion of those labouring under stone who present themselves to an operating surgeon. However, the bruising, grinding, and rubbing down of stones has been tried in all kinds of cases, but with neither a satisfactory nor an encouraging result; a case will now and then be met with favourable to these proceedings, but they can never become generally applicable, and attempts to make them so will, as experience has shown, be followed by disappointment and disaster.

A stone of a larger size than I have indicated, and of dense structure, may be laid hold of in the bladder, and may by repeated and tedious operations be broken into fragments; but each sitting, as it is called, of the patient, and each attack upon the stone, is attended with more pain, greater risk, and far more exhaustion, than its removal by incision would inflict. The repeated introduction of the instruments, their expansion, and the turning of them about in the bladder, and, if their object is accomplished, the action of the angular and rough surfaces of the fragments on the mucous coat, are certainly followed by an attack of inflammation of the viscus, always tedious and annoying—often excruciating, dangerous, perhaps fatal. Attacks of inflammation of the testicle are also not uncommon, probably from irritation of the prostate, and from the pinching and bruising of the verumontanum, which it is almost impossible to avoid, whatever care and precaution be adopted, when the three-branched instrument is used. In turning to the records of _Lithotrity_—and under this term we shall include all attempts to break down stones within the bladder, whether by drilling, or filing, or hammering—it will be found that many patients have died from the mere exploration; and altogether, nearly a half of those who have fallen into the hands of the experimenters and adventurers have perished in consequence. Every successful case is well advertised; the dead men rest in peace.

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.