A Manual of the Operations of Surgery

The late Mr. George Bell, a most successful lithotomist, proposed to perform this operation in two stages. In a case of greatly enlarged prostate, where the bladder had been punctured above the pubes by a country surgeon for retention of urine, he dilated the track of the canula by means of sponge-tents gradually increased in size, and then succeeded in extracting through the dilated opening several large calculi. The case recovered, and may encourage similar attempts.

3. Operations through the Rectum.—(a.) Sanson's Recto-vesical Operation.—The principle of this operation consisted in laying the two canals, the rectum and the urethra, into one. A large staff, grooved on its convexity, being inserted into the urethra, the operator, with the forefinger of his left hand in the rectum as a guide to the knife, pierces the anterior wall of the rectum, reaches the groove of the staff just in front of the prostate, and cutting outwards divides the rectum, the anterior fibres of levator ani, and the sphincter, as well as the skin of the perineum in the middle line. Entering the knife again into the groove of the staff, it is to be pushed right onwards into the bladder, dividing the prostate, and avoiding if possible the seminal vesicles and ducts; the stone is then very easily removed.

Though this operation was supposed to lessen the risk of pelvic infiltration it is not found to do so, and it adds the additional inconvenience of almost inevitable rectal fistula, through which the urine escapes. It is certainly a very easy operation, but the mortality is found to be greater than in the ordinary lateral operation.

(b.) Lithotomy through the rectum above the prostate.—The presence of a small portion of bladder beyond the prostate in close relation to the rectum renders it possible, in cases where the prostate is not enlarged, to enter the bladder and remove a stone of moderate size, without interfering with the peritoneum, prostate, or neck of the bladder.

This ingenious but difficult operation was performed for the first time by Drs. Sims and Bauer in 1859.

I quote the brief notice of the operation by Dr. Sims from the Lancet of 1864 (vol. i. p. 111):—

"The patient was placed on the left side, and my speculum was introduced into the rectum, exposing the anterior wall of the rectum, just as it would the vagina in the female. A sound was passed into the bladder. The doctor entered the blade of a bistoury in the triangular space bounded by the prostate, the vesiculæ seminales, and the peritoneal reduplication. He passed the finger through this opening, felt the stone, and removed it with the forceps without the least trouble. The operation was done as quickly and as easily as it would have been in a female through the vaginal septum. After the removal of the stone, Dr. Bauer kindly asked me to close the wound with silver sutures, which I did, introducing some five or six wires, with the same facility as in the vagina. There was no leakage of urine. The patient recovered without the least trouble of any sort. The wires were removed on the eighth day, and on the ninth day the patient rode in a carriage with Dr. Bauer a distance of four or five miles, to call on, and report himself to, our distinguished countryman, Dr. Mott."

The chief risks in this operation seem to be the chance of wounding the peritoneal cul-de-sac, as the amount of free space between it and the prostate seems to vary much in individuals and in races. Dr. Marion Sims mentioned to me in conversation that he believed this operation impossible in the negro race, from the greater projection downwards of the peritoneal reduplication. An enlarged prostate would be an insuperable objection. The use of silver wire, to close up the wound at once, diminishes very much any risk of recto-vesical fistula.

Lithotrity or Lithotripsy.—There exist cases of stone in the bladder, which, under certain conditions, may be relieved without lithotomy, by an operation which crushes the stone into fragments small enough to be discharged through the urethra.

To enter with any fulness into the history, literature, and varieties of this operation, and the instruments required, would in itself require a large volume. Suffice it here to describe the case suitable for the operation, the essentials required in the instrument, and the method of performance.

1. For a case to be suitable the stone should not be too large, and especially not too hard, also there should not be too many of them.

The urethra should be capacious enough to let the instrument pass easily and painlessly.

The bladder should be large enough to contain four ounces of water at least, should not be much inflamed, and, on the other hand, should not be paralysed. Paralysis or want of tone in the bladder prevents the thorough evacuation of its contents, and still more the expulsion of the fragments of stone.

2. A good instrument should, as far as possible, combine strength with lightness. The curved portion of the fixed blade should be fenestrated to allow escape of the fragments and thorough closure of the instrument.

The movable blade must be so arranged as to combine perfect ease of movement up and down in seeking for the stone, with a powerful, slow, and gradual approximation in crushing it. This can be managed by an ingenious arrangement, which leaves the movable blade under the control only of the operator's thumb till the stone is found, and yet, by touching a spring, gives him the advantage either of a fine screw or of a rack and pinion movement for crushing the stone.

3. Operation.—The patient being prepared by a free evacuation of the bowels, and the urethra having been previously fairly dilated, he is asked to retain his urine as long as possible, or, if he cannot do so, a few ounces of tepid water may be injected per urethram.

He is then laid on a sofa or table, the breech being well raised by pillows, the shoulders low, the thighs and knees bent up and separated. The instrument, well warmed and oiled, is then introduced with the blades closed. When fairly into the bladder the search for the stone begins.

There are differences of opinion regarding the best method of fishing for the stone; great patience and gentleness, with a thorough previous acquaintance with bladder manipulation, are required, whichever method be chosen.

The two chief methods may be described as the English and the French, the latter, Civiale's, being now used by Sir Henry Thompson, and other English operators. Briefly, the two are:—

(1.) Heurteloup's and Sir B. C. Brodie's.—In this, after the instrument is fairly entered, its handle is elevated, thus depressing the curved extremity, the forceps are then opened, and, by being kept as low as possible in the bladder, it is hoped that the calculus will fall into the opened blades by its own weight. In this method the fundus is the scene of crushing, and there is a risk of injuring the sensitive neck of the bladder, especially at the moment of opening the blades.

(2.) Civiale's—Thompson's.—In this the pelvis is to be so elevated that the centre of the bladder and space beneath it give plenty of room for seizing the stone, and all contact with the wall of the bladder is (as far as possible) avoided.

The instrument is introduced closed, and carried fairly away in to the posterior part of the bladder before it is opened at all. It probably grazes the stone in passing, and, if so, is directed to the side of the bladder in which the stone is not lying. Then when nearly touching the posterior wall, the movable blade is withdrawn, the instrument inclined towards the stone lying unmoved in the most dependent part, and there seizes it generally with ease.

If not felt, the blades are again to be opened, turned a little to the other side of the bladder, and then closed. Sir H. Thompson lays the greatest stress on the importance of always having the blades fairly opened before shifting their position, for if moved when closed, the very opening of the movable blade is certain to drive the stone out of the way and prevent its seizure.

Certain rules are useful:—Move the axis of the instrument as little as possible; it should be kept in the centre of the bladder, so far in, that the movements of the male blade are quite free from the neck of the bladder and prostate, and the blades only should be moved in the bladder on the centre of the shaft as an axis. There should be no jerking once the stone is caught, and the crushing should be done as far as possible in the very centre of the bladder, the blades not touching any of the walls.

After the stone is seized, do not crush till, by a turn of the blades from side to side, you discover that none of the mucous membrane of the bladder is caught in the instrument.

The lithotrite is not meant to extract stones, but to crush them, hence never attempt to withdraw it unless the blades are in absolute apposition.

Never attempt too much at one time. Sir H. Thompson holds that five minutes is the longest time that should be given, perhaps in most cases three minutes being long enough.

While many surgeons will still agree with the above advice, Dr. Bigelow of Boston has lately been highly commending a method which he has called Litholapaxy, in which, at one sitting under chloroform, the stone is crushed and aspirated, or sucked out of the bladder at once.153

Since the above was written the operation of Litholapaxy has made great strides in the favour of surgeons, and many stones that would have been removed by lithotomy are now broken down by powerful instruments at a single sitting, and removed piecemeal by the suction apparatus.

S. W. Gross has collected 312 cases, of which 17 died or 5.45 per cent., but of 180 done by experienced surgeons, Thompson, Bigelow, Van Buren, Weir, and Stevenson only five died, or 3.33 per cent., while of 1470 cases of lithotrity, as formerly practised, 159, or 10.81, per cent. died.154

Operations for Stricture of Urethra.—Under this head many manipulations and operations might be described; the very instruments devised being exceedingly numerous and complicated. Enough here to detail a few of the more simple and practical procedures under the different heads of—1. Dilatation gradual and forced. 2. Internal Division. 3. External Division.

1. Dilatation.—Under this head we have—

a. Vital dilatation.—The passing of a succession of bougies, gradually increasing in diameter, at intervals of three or four days, for the purpose of exciting an amount of interstitial absorption in the new material constituting the stricture, sufficient to remove it. Passing a bougie, though certainly often very difficult, perhaps should hardly come into the category of surgical operations, yet to preserve a certain completeness in the account of stricture, a very brief description may be here inserted.

The recumbent posture is in most cases to be preferred. The patient should lie flat on his back, with the knees slightly bent and separated, and the head and shoulders slightly raised on a pillow. The operator standing on the patient's left side, raises the penis in his left hand, and with the right introduces the instrument, previously warmed and oiled, into the meatus. He then pushes it very gently onwards, at the same time stretching the penis with the left hand, just so far as to efface any wrinkles in the mucous membrane, till the point reaches the bulbous portion. The axis of the instrument, which at first for convenience was over the left groin, has now gradually been approaching the middle line. When this is reached, the instrument should be raised from the abdomen, and the handle cautiously carried in the arc of a circle first upwards and then downwards, till, when the instrument is fairly into the bladder, the handle is depressed between the patient's thighs. While this is being done the operator's left hand should be withdrawn from the penis, and the points of the fingers applied to the perineum.

In cases of difficulty certain points may be remembered:—

(1.) That the point of the instrument may in the first inch or two be occasionally entangled in a lacuna in the roof, especially when a small instrument is used; hence the beak should be at first maintained against the inferior wall of the canal.155

(2.) That the handle should not be depressed too soon; if it is, there is a risk of a false passage being made through the upper wall.

(3.) The opposite error may force the point out of the urethra between the membranous portion and the rectum, and onwards into the substance of the prostate gland.

And certain cautions may be given:—

(1.) In every exploration of an unknown urethra the surgeon should commence with an instrument of medium size, certainly not less than No. 7 or 8.

(2.) In cases of difficulty occurring in the urethra behind the scrotum, invariably use the forefinger of the left hand in the rectum as a guide.

(3.) Expression of pain on the part of the patient is no indication that a false passage is being made, nor its absence that the instrument is in the passage, for it is a remark of Mr. Syme, that passing an instrument through a stricture is generally more painful than making a false passage through the walls of the urethra.

An instrument may be passed, while the patient is erect, with the following precautions:—The patient should stand with his back against a wall, his arms supported on the back of a chair on each side, heels eight or ten inches apart, and four or five inches from the wall; his clothes thoroughly down, not merely opened. The bougie should then be held nearly horizontal, with its concavity over the left groin of the patient, the penis being raised in the surgeon's left hand. Introduced thus for four or five inches, the handle is gradually raised into the middle line of the abdomen, and to the perpendicular; it is then to be lightly depressed, and, as the point enters the bladder, brought down towards the operator until it sinks beneath the horizontal line.

b. Mechanical dilatation is of two kinds, both very rarely used:—(1.) When an instrument cannot be passed, it consists of passing down day after day the point of an instrument (sometimes armed with caustic, sometimes not), and pressing it against the stricture till it is overcome.156 (2.) When an instrument is introduced through an intractable stricture, and is left there either for some hours, or for some days, to excite what is called "suppuration" of the stricture.157

c. Forced dilatation.—Under this head we might describe at great length mechanical contrivances to force or rupture a stricture. A word or two on a few of the most important:—

(1.) Conical bougies of steel or silver.

(2.) Mr. Wakley's method, on which many others have been founded. He passed a small bougie or wire into the bladder, over which were slipped straight tubes of varying size, with perfect certainty that they could not leave the urethra.

(3.) Mr. Holt's method.158—The principle of it is to rupture the stricture at once, so that a No. 12 catheter can immediately be passed into the bladder.

He attains this object by means of an instrument composed of two grooved blades, united about one inch from their apex, into a conical sound, which at its apex is about the size of a No. 2 bougie. This is passed into the bladder, and the grooved blades are separated to any extent that is desired by passing down between them a straight rod equal in size of a No. 8, 10, or 12, bougie. To guide this properly it is made hollow, and it is passed down over a central wire which lies between the grooved blades of the instrument and is welded to the apex. A great improvement is effected on Mr. Holt's later instruments by this wire being made hollow, and fitted with a stilette, for by this means we can with certainty ascertain whether or not the instrument has been passed into the bladder. This instrument, which is an improvement upon one invented by Perrève nearly forty years ago, has been used on very many occasions by Mr. Holt and others with success. The risk to life, if the case be properly managed, is trifling, but, like every other means of treating stricture, it has the objection that the stricture is liable to recur, unless bougies be passed at intervals for months and years.

Sir Henry Thompson has introduced and described another very ingenious instrument for the same purpose, constructed on somewhat similar principles. His account of it, to which I must refer, will be found in Holmes's System of Surgery, 1st ed. vol. iv. p. 399.

2. Internal Division of Stricture is a mode of treatment which by many surgeons is highly disapproved, yet of late years it has been more used than formerly, especially in resilient strictures. It may be done in two ways:—

(1.) From before backwards.—This method, to be at all admissible, requires a guide to be previously passed; a lancet-shaped blade may then be slipped down a groove in this guide till the stricture is divided. This is least objectionable in cases of stricture close to the meatus.

(2.) From behind forwards.—To make the incision thus, it is of course necessary that the stricture should be so far dilatable as to admit an instrument the point of which is large enough to contain the blade by which the stricture is to be divided. This will be found to be at least equal in size to a No. 3 or No. 4 catheter. In many instruments it is much larger.

Civiale's instrument for internal incision of the urethra from behind forwards has the very high recommendation of Sir H. Thompson.159 It consists of a sound with a bulbous extremity (as large as a No. 5 bougie) which contains a small blade, which can be made to project for such a distance as the operator wishes. It is passed through the stricture with the blade concealed, till the bulb is carried about one-third of an inch or more beyond the stricture; the blade is then projected, and the incision made by drawing it slowly but firmly outwards towards the meatus, with the blade towards the floor of the urethra, till the stricture is divided in its whole extent. Sir H. Thompson recommends this to be used in cases where it is not that the stricture is of very small calibre, but that it is undilatable, that prevents the cure. Many modifications of above have been devised by Lund, Teevan, and other surgeons, on similar principles.

3. Mr. Syme's Operation of External Division.—Mr. Syme held that no stricture through which the water can escape should be called impermeable, for by patience and care the surgeon should always be able to pass a slender director through the stricture on which it may be divided with ease and certainty. The old operation of "perineal section" for so-called impermeable stricture is very different, being difficult, dangerous, and uncertain in its results.

Operation.—A director is passed into the stricture. Mr. Syme's directors are of different sizes, the smallest being in diameter less than an ordinary surgical probe. They are made of steel, are grooved on the convexity, and have this peculiarity, that while the lower half is small, the upper is of full size (No. 8 or 10), the difference in calibre occurring quite abruptly. The presence of this "shoulder" on the staff enables the operator to ascertain exactly the position of the stricture, and also to tell when it is fully divided without the necessity of withdrawing the instrument.

This being fairly in the stricture, the patient is put in the position for lithotomy, an assistant holds the staff in his right hand, drawing up the scrotum with his left.

The surgeon then makes an incision in the middle line over the stricture for the necessary distance, from above downwards, till he exposes the urethra, and feels exactly the shoulder of the staff. Care must be taken not to go past the urethra at either side. When he distinctly feels the outline of the staff, he takes it in his left hand, and a short sharp-pointed bistoury in his right. It should be held firmly in the palm of the hand, with the back of the blade resting on the forefinger, the pulp of which guides the point to the groove, and guards it when making the incision; the knife is to be placed on the groove beyond (on the bladder side) of the stricture, and brought forwards, slowly cutting through the whole stricture; till the shoulder of the staff is reached. It requires strength and precision to divide thoroughly the indurated stricture, which is apt to elude the knife.

The shoulder of the staff can now be passed through the stricture if the operation is complete; if not, the incision must be extended, always in the middle line, and guided by the groove. When thoroughly divided, the staff is now to be withdrawn, and a full-sized catheter with a double curve passed into the bladder. This should not be furnished with a stop-cock or plug, lest the bladder should by inadvertence be allowed to be too full, and extravasation into the cellular tissue of the urethra take place along the side of the instrument.

The catheter should be tied in, and left for two, sometimes for three days, when it can generally be removed with safety, and a bougie should be passed at intervals of three or four, till the wound is healed. To prevent recurrence of the stricture, it is a wise precaution to pass an instrument at intervals for many months after the cure is apparently complete.

In certain cases, where the stricture is far back and the urinary symptoms severe, Mr. Syme found advantage from the introduction of a shorter double-curved catheter (only about nine inches long) through the wound into the bladder, where it should be left for three days. This seems to diminish the risk of rigors, and other symptoms of fever, which are apt to occur when the urine is allowed for the first time to pass over the wound.

Perineal Section is an operation both dangerous and difficult; as Sir Astley Cooper used to say, "the surgeon who performs it requires to have a long summer's day before him."

No director or guide can be passed. A full-sized catheter must be passed as far as possible up to the stricture, and held firmly in the middle line. The patient must be tied up in lithotomy position on a table in the very best light that can be obtained. The perineum being shaved, an incision must be made in the middle line from over the point of the catheter to the verge of the anus, if the stricture extends far back.

The urethra should then be opened over the catheter, the edges of the mucous membrane held to each side by silk threads passed through them; and the surgeon must endeavour to pass a fine probe into the opening of the stricture; if this can be done, it is comparatively easy to slit the stricture up. If not, the surgeon must simply seek for the remains of the urethra by slow, cautious dissection in the middle line. If successful, a catheter must be secured in the bladder in the usual way.

A stricture near the orifice, or, as it is not uncommon, involving merely the meatus, can be treated with great ease in the above manner by division on a grooved probe. When quite close to the orifice, with a well-defined hardness, as of a ring round the urethra, it may be divided subcutaneously by a tenotomy knife or other narrow-bladed instrument. It is not necessary to keep a catheter in the bladder in cases where the stricture has been in front of the scrotum.

Puncture of the Bladder.—A patient and dexterous use of the catheter prevents this operation from being often required; still, circumstances may arise in which it is found impossible to enter the bladder per vias naturales. In such a case the bladder may be punctured from the outside by a curved trocar and canula, in either of two situations.

1. From above the pubis.—This operation is a very simple one, and when the bladder is distended need not imply a wound of the peritoneum.

Operation.—A preliminary incision, varying in length according to the amount of fat, should be made above the pubis exactly in the middle line; the edges of the recti should be separated, the peritoneum pushed out of the way and upwards by the finger, and a curved trocar plunged into the distended bladder obliquely backwards. The canula should be retained for a day or two, and then a flexible catheter with a shield inserted instead. Such instruments have been worn for years. The aspirateur pneumatique of Dr. Dieulafoy will be found an exceedingly useful instrument for puncture of bladder and removal of urine. The author has now used it very frequently with the best results. Its advantage is that the urine is removed through an aperture so small as to allow of the withdrawal and reintroduction of the canula as often as is necessary.