A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗

the anus, upwards, crossing the raphe nearly an inch above the anus, and then curving downwards to a corresponding point on the opposite side. The skin, superficial fascia, and a few of the anterior fibres of the external sphincter, are thus divided, and the groove of the staff sought by the forefinger. The membranous portion of the urethra is then laid open in the middle line, and the beak of a double lithotome caché securely lodged in the groove. It is then pushed into the bladder with its concavity upwards, and when fairly in it is turned round, its blades protruded to the required extent, and withdrawn with its concavity downwards, thus dividing both lobes of the prostate in a direction downwards and outwards (Fig. xxiv. D D). The operation is finished in the usual manner. Though it is a comparatively easy operation, and theoretically may be proved to have many advantages, experience has shown that the results are not so favourable as those of the ordinary lateral operation.

2. Buchanan's medio-lateral operation on a rectangular staff.—The staff is bent at a right angle three inches from the end, and deeply grooved on its left side. This is introduced into the urethra so that the angle projects the membranous portion of the urethra close to the apex of the prostate and the terminal straight portion enters the bladder parallel to the rectum. The angle projects in the perineum, so that the operator with his left forefinger in the rectum is enabled, by a stab with a long straight bistoury (held horizontally and with the cutting edge to the left side), at once to enter the groove, and, by following the groove, the bladder. Whenever the escape of urine shows that the bladder is fairly reached, the knife is withdrawn so as to make a lateral section of the prostate, and then, with the finger still in the rectum, to make an incision in the ischio-rectal fossa, of sufficient size to allow the stone to be easily withdrawn.

The inventor claims for this method that it is easier, that there is less risk of hæmorrhage, wound of the rectum, and infiltration of urine.

3. Allarton's operation of median lithotomy suits admirably for stones known to be small, but is quite unsuitable for large ones. Probably in most cases it should be superseded by lithotrity.

Operation.—A large curved staff with a central groove is to be held firmly hooked up against the symphysis pubis, and then steadied by the left forefinger in the rectum. The operator pierces the raphe of the perineum with a long straight bistoury about half an inch above the verge of the anus, enters the groove of the staff, and cuts inwards, almost, but not quite, into the bladder. In withdrawing the knife the wound in the urethra is enlarged upwards towards the scrotum. A ball-pointed probe is then passed on the staff into the bladder, the staff is withdrawn, and the finger, guided by the probe, is used to dilate the neck of the bladder, to an extent sufficient for the removal of the stone by a small pair of forceps.

In this operation the prostate is hardly incised at all. The results are not better than those of the lateral operation.

2. Lithotomy above the Pubes, or the High Operation.—In cases where, from the known size of the stone, or from the deformity of the bones of the pelvis, it is impossible that the stone can be extracted entire in the usual manner; in cases where the prostate is very much enlarged, or where there is any real or supposed likelihood of inflammation of the neck of the bladder, the supra-pubic operation may be warrantable. Its performance is easy, it does not involve any wound of the peritoneum if properly performed, and there is no risk of hæmorrhage. There are certainly great risks attending it of peritonitis and urinary infiltration.

In more than one case this operation has been attended by wound of peritoneum and subsequent escape of intestines through the wound, even when dressed antiseptically and performed under spray.

Operation.—The patient lies on his back, with his head and shoulders slightly raised, so as to relax the abdominal muscles, and his legs hanging down over the edge of the table. If his bladder can bear it, it should be fully distended, either by voluntary retention of the urine, or by injection with tepid water. A vertical incision is then made in the middle line, separating the recti muscles from below upwards, care being taken to push the peritoneum well out of the way, which is easily done by the finger in the loose cellular tissue of the part. The anterior wall of the bladder is then exposed, uncovered by peritoneum; it must be opened with great care, also in the middle line, while the wound in the parietes is held aside by retractors. The wall of the bladder should be transfixed by a curved needle, and thus held in position before it is opened. The stone is then removed by a pair of straight forceps, generally with great ease. Attempts used to be made to leave a catheter or canula in the bladder wound to prevent infiltration. Probably the safest method now will be to close the bladder wound at once by metallic stitches, and stitching the abdominal wound carefully with deeply entered wires, to leave the patient on his back. When compared with the lateral operations the statistics of the supra-pubic operation are discouraging, the mortality being one in three and a half to one in four. But in cases where the stone is known to be very large and of firm consistence, the risks are probably less from this method than from lateral lithotomy, followed by efforts to crush the stone through the wound prior to its removal.

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