Chapter XII: Operations on Pelvis (1)

LITHOTOMY.--However interesting and even instructive it might be, any history of the various operations for the removal of calculi from the bladder would be quite out of place in a manual such as this. It will be sufficient here to describe the operations recommended and practised in the present day.

There are three different situations in which the bladder may be entered for the purpose of removing a calculus:--

1. The perineum, where access is gained through the urethra, prostate, and neck of the bladder.

2. Above the pubes, where the portion of bladder not covered by peritoneum is opened from above.

3. From the rectum.

1. LITHOTOMY THROUGH THE PERINEUM, by far the most frequent position for the operation.--Very various methods for its performance have been devised, differing in the nature and shape of the instruments employed, the direction and size of the incisions, the nature of the wound; but all resemble each other in certain very cardinal and important particulars. Thus all agree that it is absolutely necessary to enter the bladder at _one_ spot--the neck of the bladder; and that to do this safely the urethra must be opened, and some instrument previously introduced by the urethra is to be used as a guide for the knife. But an instrument in the urethra and bladder is surrounded for at least an inch of its course by the prostate; and thus the knife, gorget, or finger, which, guided by the instrument in the urethra, is intended to cut or dilate the entrance to the bladder for the purpose of allowing the calculus to be removed, cannot do this without also cutting or dilating this prostate gland. Experience has proved that much of the success of the operation depends upon the position and amount of incision made in this prostate gland. But it might be asked, Why can we not enter the bladder by one side, avoiding altogether its neck and this prostate gland? For this, among other reasons, that the bladder normally contains, and so long as the patient lives must contain, a certain quantity of a very irritating fluid. It is surrounded by the loose areolar tissue of the pelvis, into which, if any of this fluid escapes, abcesses will form and death probably ensue; this result will almost certainly follow any opening made into the bladder except at one spot. This spot is the neck of the bladder. Why does urinary infiltration not occur there? Because the fascia of the pelvis (which when entire can resist infiltration) is prolonged forwards at the neck of the bladder, over the prostate (Fig. XXXIV. PF), for which it forms a very strong funnel-like sheath. So long as this sheath is not cut where it covers the sides of the prostate, urinary infiltration of the pelvis is impossible, the urine being carried forwards and fairly out of the pelvis in this urine-tight funnel.

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But it may now be said, If this be the case, we are very much limited in the size of the incision we may make into the bladder. We cannot remove a large stone, for the prostate ought not to be larger than a good-sized chestnut, and any cut we might make through a chestnut without cutting out of its side must be very small. Very true; but fortunately the sheath of the prostate, unlike the rind of the chestnut, is very freely dilatable, and will allow the passage of a very considerable stone.

Again, an inquirer might ask, If it is so dilatable, why should we run the risk of cutting the prostate at all? Why should we not introduce instruments gradually increasing in size into the membranous portion of the urethra, and thus dilate prostate and neck of bladder? For this reason, that the urethral canal passing through the prostate is itself lined immediately outside of the mucous membrane by a firm membranous sheath (Fig. XXXIV. RR), which resists dilatation to the utmost. Experience tells us that any attempts to dilate or even forcibly to tear this ring of fibrous texture are both ineffectual and dangerous, while a clean cut into it and through it into the substance of the prostate is at once effectual and comparatively safe.

In a word, we can describe the relation of the prostate to the operation of lithotomy somewhat in this manner:--Its fibrous sheath surrounding the urethra must be cut freely. The gland substance may be cut and freely dilated by the finger. Its fibrous envelope must, as far as possible, be preserved intact, but this interferes the less with the operation, as it is comparatively freely dilatable.

The firm lining of the urethra, which must be cut, is specially strong at its base, forming a tough resisting band just at the aperture of the bladder, which, unfortunately, is often so high up in the pelvis in tall patients, or in cases in which the prostate is much enlarged, as to be almost out of reach of the finger, and so far up the staff as perhaps to escape division. You will be warned of such an occurrence by the urine in the bladder failing to make its appearance; and if any attempt be made to dilate the opening and introduce the forceps without further incision of the base of the prostate, the result will very likely be fatal, generally from pyæmic symptoms depending on a suppurative inflammation of the prostatic plexus of veins (Fig. XXXIV.). In fact, upon a recognition of this fact is founded the aphorism, "that cases in which the forceps have been introduced before the bladder fairly begins to empty its contents are generally fatal."

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We have thus traced the necessary guiding principles as to our incisions from the bladder outwards through the prostatic portion of the urethra. We have next to discover what sort of an opening is necessary in the membranous portion of the urethra consistent with the fulfilment of the same conditions, namely, freedom of escape for the urine, and room enough to remove the stone. Both of these are gained at once by a free incision of the membranous portion, dividing especially those anterior fibres of the great sphincter muscle of the pelvis, the levator ani, which embrace the membranous portion, under the special names of compressor (Fig. XXV.) and levator urethræ (Guthrie's and Wilson's muscles).

The principles which guide the position and size of the preliminary incisions which enable the urethra to be opened are very simple:--(1.) The wound in the perineum should be large enough to give free access to the urethra, and easy egress to the stone; (2.) It should be conical, with its base outwards, so as to favour escape of urine and prevent infiltration; (3.) It should not wound any important organ or vessel; that is, it must avoid the rectum, the corpus spongiosum, especially the bulb, if possible, the artery of the bulb, and in every case should leave the pudic artery intact.

So far for broad general principles, which must guide all methods of successful lithotomy.

THE LATERAL OPERATION.--_Operation of Cheselden._--(1.) _Instruments required._--A staff with a broad substantial handle, and a longer curve than the ordinary catheter requires, furnished with a very deep and wide groove, which occupies the space midway between its convexity and its left side. The one used should invariably be large enough to dilate fully the urethra.

A knife, with its blade three or four inches in length, but sharp only for an inch and a half from its point, its back straight up to within a sixth of an inch of its point, and there deflected at an angle to the point, which again curves to the edge. The angle from the back to the point permits the knife to run more freely along the groove in the staff.

A probe-pointed straight knife with a narrow blade may occasionally be useful in enlarging the incision in the prostate, when this is required by the size of the stone.

Forceps of various sizes and shapes, some with the blades curved at an angle to reach stones lying behind an enlarged prostate, all with broad blades as thin as is consistent with perfect inflexibility, the blades hollowed and roughened in the inside, but without the projecting teeth sometimes recommended, which are dangerous from being apt to break the stone.

A scoop to remove fragments or small stones, sometimes useful with the aid of the forefinger in lifting out a large one.

A flexible tube of at least half an inch calibre, and about six inches long, rounded off and fenestrated above, fitted at its outer end with a ring and two eyelet-holes for the tapes, with which it is tied into the bladder.

Prior to the operation the patient's health should be attended to, the stomach and bowels regulated, and any disorder of the kidneys or bladder as far as possible alleviated. If his health has been good and habits active, three or four days' confinement to his room on low diet, with a full purge the evening before the operation, is all the preparatory treatment that is necessary.

It is of the utmost importance for the safety of the operation and the patient's comfort after it, that the rectum be completely unloaded before the operation, and the bowels so far emptied as to permit three or four days after the operation to elapse without any movement of the bowels being necessary. If there is any doubt as to the effect of the laxative, a large stimulant enema should be administered on the morning of the operation.

_Position._--Much depends on the proper tying up of the patient. He should be placed with his breech projecting over the edge of a narrow table, with head slightly raised on a pillow, but the shoulders low. The hands are then to be secured each to its corresponding foot, by a strong bandage passing round wrist and instep, or by suitable leather anklets, the knees should be wide apart, and on exactly the same level, so that the pelvis may be quite straight. An assistant should be placed to take charge of each leg.

The staff is next introduced and the stone felt; if there is little water in the bladder a few ounces may be injected, but this is rarely necessary, for the patient should be ordered to retain as much water as possible, and when he cannot retain it, injection of water may do harm, and will probably not be retained, but at once come away along the groove in the staff. The staff is then committed to a special assistant, who must be thoroughly up to his duty, and attend to the staff alone.

Some surgeons direct the assistant to make the convexity of the staff bulge in the perineum, to enable the groove to be struck more easily. It will be, however, safer both for the rectum and the bulb, if the staff be hooked firmly up against the symphysis pubis, as advised by Liston. The same assistant can also keep the scrotum up out of the way.

If the perineum has not been previously shaved, this is now done.

The operator sits down on a low stool in front of the patient's breech, his instruments being ready to his hand, and then steadying the skin of the perineum with the fingers of his left hand, enters the point of the knife in the raphe of the perineum, midway between the anus and scrotum (one inch in front of anus--_Cheselden_, _Crichton_; one and a quarter--_Gross_, _Skey_, and _Brodie_; one and three-quarters--_Fergusson_; one inch behind the scrotum--_Liston_), and carries the incision obliquely downwards and outwards, in a line midway between the anus and tuberosity of the ischium. The length of the incision must vary with the size of the perineum, and the supposed size of the stone, but there is less risk in its being too large, so long as the rectum is safe, than in its being too small. Its depth should be greatest at its upper angle, where it has to divide the parts to the depth of the transverse muscle of the perineum, and least at its lower angle, where a deep incision is not required, and would be almost sure to wound the rectum.

The forefinger of the left hand is now to be deeply inserted into the wound, and any remaining fibres of the levator ani in front are to be divided, the edge of the knife being directed from above downwards. The left forefinger being still used to push its way through the cellular tissue, the groove in the staff is now felt in the membranous portion of the urethra covered by the deep fascia of the perineum. Now comes the deeper part of the incision. Guided by the finger-nail of the left hand, the surgeon introduces the point of the knife into the groove of the staff. He then takes hold of the staff for a moment to feel that it is held up properly against the pubis, and in the middle line, and also that the knife is fairly in the groove. Giving the staff back again to the assistant, and keeping the rectum well out of the way by the left hand, he now steadily directs the knife along the groove of the staff till the bladder is fairly entered, and the ring at the base of the prostate completely divided. When this is the case a gush of urine takes place, following the withdrawal of the knife.

When making the deep incision, and in the groove of the staff, the blade of the knife should lie neither vertical nor horizontal, but midway between the two, so as to make the section of the left lobe of the prostate in its longest diameter, that is, in a direction downwards and backwards (Fig. XXXIV. L).

The knife is now withdrawn, and the left forefinger inserted. In most cases it will be long enough to reach the bladder and touch the stone, and may then be freely used by gradual pressure to dilate the wound; this may be done very freely when necessary for a large stone, if only the ring of fibrous tissue surrounding the urethra be first cut and the bladder fairly entered. Whenever the stone is felt by the finger, the assistant may withdraw the staff.

When the operator has thus felt the stone and sufficiently dilated the wound, the next step is to introduce the forceps; this should be done under the guidance of the finger, and with the blades closed. When the stone is felt the blades should be opened very widely, slightly withdrawn, and then pushed in again, the lower one, if possible, being insinuated under the stone. The blades must be made fairly to grasp and contain the stone in their hollow, for if they only nibble at the end of an oval stone, extraction is impossible. Extraction should then be performed slowly, with alternate wrigglings of the forceps from side to side, so as gradually to dilate, not to tear, the prostate, and the operator must remember to pull in the axis of the pelvis, not against the os pubis or the promontory of the sacrum.

If there is much resistance, it may possibly be caused by the stone having been caught in its longer axis, and this may be remedied by careful manipulation by means of the finger and forceps. If the stone is still too large to be extracted without greater force than is warrantable, there are still various expedients (see _infra_, pp. 265, 270).

In most cases, however, the stone is removed rapidly enough by the single incision. The finger, or a sound, must then be introduced to feel if any more stones are present. The closed forceps make a very effectual instrument for this purpose. Much information may be gained from the appearance of the first stone, the presence or absence of facets. Its smoothness or roughness enables us to form a pretty certain opinion; yet the bladder should always be carefully searched; and if the stone has been friable or broken in extraction, should be washed out by a current of water. Where the calculi are very numerous, or where many fragments have separated, the scoop will be found useful, both for detecting and removing them. All the stones being extracted, there is in most cases little or no bleeding (see _infra_, Hæmorrhage). The tube already described may now be inserted and tied into the bladder. It may be retained for forty-eight or seventy-two hours, according to circumstances. Care must be taken lest it be closed up by coagula during the first hour or two after the operation. In children the tube is not necessary, and from their restlessness might possibly do harm, but in adults (though neglected by some surgeons) experience shows it is a valuable adjunct in the after-treatment.

Having thus traced the course of an ordinary uncomplicated case of lithotomy by the lateral operation, a brief notice is suitable of some of the obstacles and difficulties, some of the dangers and bad results which may be met with, and the best methods of overcoming them.

1. _Large size of the stone_, as an obstacle to extraction. When, either from the enormous size of the stone, generally to be made out before the operation, or from some congenital or acquired deformity of the pelvis, it is obvious beforehand that the calculus cannot pass through the bony pelvis entire, a choice of two courses remains, either--

(1.) The high or supra-pubic operation (_q.v. infra_); or (2.) Crushing of the calculus in the bladder, and removal piecemeal. Instruments of great strength have been devised for this latter operation. The risk to the bladder is very great, and fragments are apt to be left behind; these are sure to form nuclei of new calculi.

2. _Peculiarities in the position or relations of the stone_ in the bladder:--

(1.) It may lie in a sort of pouch behind the prostate, and thus be out of the reach of the forceps. This may be remedied by the use of curved forceps, or, better still, by the finger in the rectum to tilt up the stone into the bladder.

(2.) It may lie above the pubis in the anterior wall of the bladder. Pressure on the hypogastrium, or the use of a strong probe as a hook, will generally suffice to dislodge it.

(3.) The stone may be encysted. This is extremely rare, and, as Fergusson says, we hear more of these from bunglers who have operated only several times, than from those who have had large experience.

3. _An enlarged prostate_ is at once a source of difficulty and of some danger.

The distance of the bladder from the surface may be so very much increased by enlargement of the prostate as to render even the longest forefinger too short to reach the stone or even the bladder. This renders the introduction of the forceps more difficult and uncertain, the dilatation more prolonged, and the extraction more dangerous. If very large, the groove of the staff may not reach the bladder, and thus the deep incision may fail of cutting the ring at the base of the gland, and the urine may thus not escape, and all the dangers of laceration of the ring may result. Such cases may be well managed by the insertion of a straight deeply grooved staff into the insufficient incision, and fairly into the bladder, and on this, pushing a cutting gorget through the uncut portion of the gland. This insures a sufficient yet not dangerous incision, which we cannot so safely perform with the knife, as the parts are so far beyond the reach of the guiding forefinger.

Under the head of risks after lithotomy we may class the following:--

1. Sinking, or shock. In the very aged or very young, or after a very prolonged or painful operation, shock may now and then kill the patient within a few hours. Since the days of chloroform this result is extremely rare.

2. Hæmorrhage seems to be a very infrequent risk. The transverse perineal artery, which is always cut in the operation, is small, and rarely bleeds much. If the bulb is wounded, as no doubt frequently occurs, the flow from it can easily be checked. The pudic is so well protected from any ordinary incision as to be practically safe; and if wounded by some frightfully extensive incision, it can be compressed against the tuberosity of the ischium.

There is an abnormal distribution of the dorsal artery of the penis, in which, rising higher up than it ought, and coursing along the neck of the bladder, and the lateral lobe of the prostate, it may be divided. This may give trouble, and even result in fatal hæmorrhage. Fortunately it is rare. The author has met with one case in a boy of eleven, in whom a very severe hæmorrhage was not to be explained. The patient recovered without another bad symptom.

Again, a general oozing may often appear a few hours after the operation, when the patient is warm in bed, apparently from the substance of the prostate. If raising the breech and the application of cold fail to arrest it, it may be necessary to plug the wound. This is done by stuffing it with long strips of lint round the tube. Great care must be then taken lest the tube become occluded.

3. Infiltration of urine may occur as a result of a too free incision of the vesical fascia (in adults), and still more frequently of a too small external wound.

Here it should be noticed that in children it is fortunately of very little consequence to preserve the integrity of the prostatic sheath of vesical fascia. In them the prostate is so exceedingly small and undeveloped, that even the forefinger could not be introduced into the bladder without a complete section of the prostate. Probably from the blander nature of their urine, and the greater vitality of their tissues, this is of less consequence, as it is rarely found that any bad effects result from this section.

Among other risks we find peritonitis, inflammation of neck of bladder, inflammation of prostatic plexus of veins, resulting in pyæmia, suppression of urine, and other kidney complications. For the symptoms and treatment of these there is no place in a mere manual of surgical operations.

_Wound of rectum and recto-vesical fistula._--Such wounds were not uncommon, and in many cases unavoidable, before the days of chloroform, from the struggles of the patient; now they are comparatively rare, and should be still rarer. They probably occur in more cases than the surgeon is aware of, and heal up without his knowledge; we may arrive at this conclusion from the fact that small wounds are found in _post-mortem_ examinations of cases in which no such complication has been thought of.

They occasionally heal without giving any trouble, but, at other times, as the external wound contracts, a communication forms between rectum and the urethra, in which the contents are apt to be interchanged in a most disagreeable manner, flatus passing per urethram, and urine per rectum.

When it is evidently not going to heal spontaneously, the septum between the external orifice of the wound and the communication with the gut should be laid open, as in the operation for fistula _in ano_.

There are certain modifications and varieties in the method of
operating for stone through the perineum, which deserve at least a
brief notice:--

1. _The bilateral operation._--Though he was not the inventor,
Dupuytren's name is justly associated with this operation. The
principle of it is to divide both sides of the prostate equally, so
as to give more room for extraction of a large stone, without the
necessity of much laceration, or the risk of cutting through the
prostatic sheath of fascia.

_The operation._--A semilunar incision is made transversely across
the perineum, extending from a point midway between the right tuber
ischii and 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 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.[152]

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.[153]

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.[154]

(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.[155] (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.[156]

_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.[157]--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.[158] 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.