Chapter XII: Operations on Pelvis (2)

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.

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2. _From the Rectum._--Except in cases of enlargement of the prostate, it is at once easier and safer to puncture the bladder from the rectum. The well-known triangular space uncovered by peritoneum, with its apex in front close to the prostate, and bounded on either side by the vasa deferentia and vesiculæ seminales, can be easily reached by a curved trocar. This should be guided by one, or, still better, by two fingers, into the rectum, with its concavity upwards, and the point should be pushed upwards by depression of the handle, whenever it is fairly behind the prostate. The trocar may then be withdrawn, and the canula retained for at least forty-eight hours by a suitable bandage. Mr. Cock, of Guy's Hospital, had a special canula for the purpose, which expands at its extremity after its introduction, and thus is not apt to slip.[160] Some surgeons insist that the surgeon should be able to ascertain the existence of fluctuation between the finger in the rectum, and the other hand above the pubes. This is exceedingly difficult to elicit when the bladder is very much distended, and from the constrained position of the finger in the bowel.

PHYMOSIS.--Elongation of the prepuce, with contraction of its orifice, in most cases congenital, sometimes so extreme as to cause difficulty in micturition, and frequently preventing the uncovering of the glans.

_Operation._--In all well-marked cases, the following is required:--The elongated prepuce should be pulled forwards by a pair of catch-forceps, and a circle of skin and mucous membrane removed by a single stroke of a bistoury, or by sharp scissors. Care should be taken lest the glans be included in the incision, as has happened in _at least_ one instance. The skin will then be found to retract very freely beyond the glans, but the mucous membrane is found still to cover the glans, and its orifice is still constricted. It must then be slit up (Fig. XXXVII. _b b_) on the dorsum of the glans, with probe-pointed scissors, as far as the corona, and the glans will then be thoroughly exposed. The edges of mucous membrane and skin should then be stitched to each other by at least five or six fine silk sutures, any bleeding points having been first carefully secured. The angles will in time round off, and a wonderfully seemly prepuce be obtained. This operation may be done as a method of cure for obstinate enuresis in cases in which the prepuce is very long and redundant, even when it is not too tight. The author has done this in more than twenty cases with excellent results.

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_Varieties._--When the prepuce is narrowed at its orifice without
being redundant in length, a milder operation will prove
sufficient. The principle is the same as in the former, but the
amount of incision is less, and nothing is removed. Two methods are
possible:--

1. _By scissors._--The blunt point of a pair of scissors is
introduced through the preputial orifice, the other blade being
outside, and the skin and mucous membrane are divided for about
half an inch; the skin being then retracted, the mucous membrane is
still further divided by one or two additional snips, and then the
edges of skin and mucous membrane are stitched together by one or
two points of suture.

2. _By knife._--A director being introduced within the prepuce, a
narrow-bladed knife is guided along it, and pushed through the
prepuce from within, and then made to divide skin and mucous
membrane from within outwards. Stitches as before.

_N.B._--Be careful lest the director pass into the meatus
urinarius, and the glans be split up.

Again, some surgeons prefer two lateral incisions instead of one
dorsal one. In this case skin and mucous membrane should be divided
by scissors for about a quarter of an inch, and then a single
stitch inserted in the angle of junction. This has been further
modified by Cullerier, who proposed the division of the tight
mucous membrane only, in three or four points. He used a pair of
scissors with one sharp and one probe-pointed blade, the sharp one
thrust in between skin and mucous membrane, the blunt one between
the mucous membrane and the glans.

AMPUTATION OF THE PENIS.--This exceedingly simple operation is performed by a single stroke of an amputating knife, drawn along from heel to point, while the penis is stretched in the operator's left hand. As there is more risk of redundancy than of deficiency of the skin, no attempt is made to save it. Numerous vessels in the corpora cavernosa require ligature. Amputation of the penis may be done bloodlessly by the thermo-cautery even close to its root. Transfix the root of corpora cavernosa by a needle; above this pass two or three turns of an elastic ligature; then slowly divide at a low red heat the skin and corpora cavernosa below the needles; split the urethra after dividing its mucous membrane with a knife. The author has done this several times with ease and rapid healing.

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The chief risk is stricture of the orifice of the urethra. To prevent this, several modifications of the operation have been introduced.

1. _Ricord's method._[163]--After the amputation the surgeon seizes with forceps the mucous membrane of the urethra, and with a pair of scissors makes four slits in it, so as to form four equal flaps, and with a silk ligature stitches each of these to the skin. Contraction of the cicatrix will thus tend to open rather than close the urethral orifice.

2. _Teale's method._[164]--He slits up, by a bistoury on a director, the urethra and skin over it for about two-thirds of an inch, and then stitches the one to the other, thus making it a long oval dependent orifice (Fig. XXXVIII.).

3. _Miller's proposed method._[165]--"A narrow-bladed knife is first used to transfix the penis between the spongy and cavernous bodies close to the root; the knife having been carried forwards for an inch and a half, its edge is turned perpendicularly downwards, and the urethra and skin flap are divided, the cavernous bodies and dorsal integument being then cut perpendicularly upwards where the knife was originally entered for transfixion. A button-hole is afterwards made in the lower flap, though which the corpus spongiosum and urethra protrude, while the flap itself is turned upwards, and attached dorsally and laterally, so as to cover in the exposed cavernous structure."

HYDROCELE.--The very simple operation necessary for hydrocele is thus performed:--The surgeon supports the tumour in his left hand so as to project it forwards, and make the scrotum as tense as possible in front. Having carefully ascertained the exact position of the testicle, which can generally be easily enough done by a finger accustomed to discriminate the difference between a soft solid, and a bag tensely filled with fluid, aided by the peculiar sensation of the testicle when squeezed, the surgeon enters a trocar and canula about an eighth of an inch in diameter into the distended cavity of the tunica vaginalis, near the fundus of the swelling. When it is evident the instrument is fairly entered, and not till then, the trocar is withdrawn, and the fluid allowed completely to drain off. When it ceases to flow the surgeon places his forefinger over the end of the canula to prevent the entrance of air, till he fits into its orifice a suitable syringe containing two drachms of the tincture of iodine, made according to the Edinburgh Pharmacopoeia: the tincture of the British Pharmacopoeia is not sufficiently strong. Having injected this cautiously into the cavity, the canula is withdrawn, and the surgeon, seizing the now flaccid scrotum in his right hand, gives it a thorough shake, so as to spread the iodine over as much as possible of the inner wall. When properly performed this very simple procedure very rarely fails to produce a radical cure; though less thorough operations, such as mere evacuation of the fluid, less stimulating injections, unguents introduced on probes, and the like, often fail of success, and thus give encouragement to absurdities, such as wire-setons, or to more severe operations, such as laying open the sac.

HÆMATOCELE.--When the contents of the sac of the tunica vaginalis are found to be grumous instead of simply serous, or when, as often happens, only pure blood escapes when the fluid is nearly evacuated, it is found that simple evacuation and injection are very rarely sufficient to effect a cure.

After they have been fairly tried, the sac of the hæmatocele should be laid open in its full extent; any large vessels which bleed should be tied, and the cavity then stuffed with lint. When the lint can be removed, which will be after two or three days, the edges of the wound should be brought closely together, and the cavity will then rapidly heal up from the bottom, and be obliterated by secondary union of granulations.

In cases where the walls of the cavity are enormously thickened, or even, as sometimes happens, almost bony in consistence, an elliptical portion may be removed with advantage.

EXCISION OF TESTICLE.--This operation is rarely required except for tumours of the testicle. Hence the size of the incision necessary must vary much with the size of the tumour; and the amount of skin to be removed (if any) on the amount of adhesions it has formed to the tumour.

One or two points must be attended to in every case of extirpation of a testicle:--

1. The incision should commence over the cord just outside of the external ring, and be continued fairly over the tumour to its base.

2. As to removal of skin, some surgeons advise that none should be taken away, others that a considerable quantity can be spared. There is certainly less risk of secondary hæmorrhage if a portion be removed, than when a flaccid empty bag is left. The author invariably removes a very large quantity of skin if the tumour is large, as there is much more rapid healing, and the resulting scrotum is much more comfortable for the patient.

3. The cord should be exposed at the beginning of the operation, raised from its bed and given to an assistant, who should compress it gently, not from any fear of its escape into the abdomen, but to prevent hæmorrhage. If the tumour has been very large and heavy, the cord will have been much stretched, and if divided too high up, may really give trouble by its elasticity, unless the above precaution is taken. The cord then having been divided close to the tumour, the latter is removed, care being taken not to include the sound testicle in the removal. All the vessels are then to be tied or twisted, and the spermatic artery is to be secured alone, not, as used to be the case, included in a common ligature with the other constituents of the cord. Secondary hæmorrhage is very apt to occur from small scrotal branches which may have escaped notice during the operation.

OPERATIONS ON THE ANUS AND ITS NEIGHBOURHOOD.--FISTULA IN ANO.--While much might be written on the pathology of fistula, and a good deal even on its diagnosis, a very few words will suffice to describe the simple and effectual operation for its relief.

Dismissing at once all so-called palliatives, drugs, unguents, pressure, and injections, as mere waste of time, and holding that the only method of cure consists in laying the fistula fairly open, the question narrows itself into this: What is the best method of laying it open? Prior to the discovery by Ribes of the great principle that the internal orifice of the sinus is always within an inch or an inch and a half of the orifice of the anus, the operations for fistula were most unnecessarily severe; the gut used to be divided as far up as the sinuses extended; and large portions of the anus used to be excised bodily along with the sinuses. It is now a much simpler and more satisfactory operation.

_Operation._--A common silver probe bent to the required shape is passed into the external opening, or, if there are more than one, into the largest and oldest one. The forefinger of the left hand being introduced into the rectum, the probe is passed through the internal orifice, and its point brought out by the anus. The portion of tissue raised by the probe can then be easily divided with the certainty that the fistula is laid fully open. Anal fistulæ have been divided by the elastic ligature, but it seems slower in action and more painful, with no counterbalancing advantages.

The author has for last few years operated almost exclusively by a
long knife which is continued into a steel probe. The probe is
passed up the fistula, then into the bowel, and is hooked out at
the anus, and in being simply pushed on the knife cuts the
fistula--tuto, cito, et jucunde, the patient rarely knowing that
more has been done than an exploration.

In cases where, from the hardness and density of the parts it is
impossible to pass the probe and bring it out at the anus, a strong
probe-pointed bistoury may be passed in by the external orifice
till its probe-point can be felt by the finger in the bowel at the
internal opening. Supported by the finger it can then be made to
cut outwards till the whole septum is divided.

FISSURE OF THE ANUS, ULCER OF THE ANUS, resemble each other alike in the exceeding annoyance which they give to the sufferer, and in the simplicity of the treatment needed.

_Operation._--Once the presence of either is determined by the finger in the anus, a sharp-pointed curved bistoury should be introduced, transfixing the base of the fissure or ulcer, and then guided on the finger, completely dividing it, so as to change the ragged ulceration into a simple wound which will rapidly heal.

PROLAPSUS ANI, _Operation for_.--Complete prolapsus in which the whole gut is involved, as seen in the very young and the very aged, is suited for palliative rather than radical treatment.

Cases of prolapsus of the mucous membrane only, as is not uncommon in connection with or as a result of hæmorrhoids in adults, give opportunity for operative interference.

We may act on either the skin or mucous membrane, or both at once.

1. _The skin_ is often found loose, and arranged in radiating folds round the anus. In such cases, as recommended first by Dupuytren, some of these projecting folds may be removed. Again it may be prolapsed in a great loose ring or circular fold round the margin, forming an exaggerated external pile; in such a case the loose fold may be fairly excised with curved scissors, as recommended by Hey of Leeds.

The first of these methods is apt to be insufficient, the second again has the risk of removing too much.

2. If the protrusion is chiefly mucous membrane exposed in folds, or a ring, which is generally outside, one of two methods of treatment may be tried:--

_a._ By ligature, as recommended by Mr. Copeland. Raising a longitudinal fold of the mucous membrane, he passed a ligature round it as if it were a pile. There is less chance of the ligature slipping if a double thread be used and its base thus transfixed. Three, four, or even more folds may be thus treated.

_b._ When the mucous membrane has been so long exposed as to have lost many of its characters, and to resemble leather in its toughness, excision will be found less painful and much more rapid than ligature.

A longitudinal fold at each side of the anus should be pinched up and excised by a pair of probe-pointed curved scissors. There is always a certain amount of risk of hæmorrhage following such an operation. The risk is lessened and the result improved by stitching up the wound in the mucous membrane before the protruded portion of bowel is returned.

POLYPI OF THE RECTUM.--Pedunculated growths varying in consistence, shape, and size, but resembling each other in having a distinct stalk, and in frequently being protruded at stool.

_Operation._--Invariably by ligature, which may be single round the stalk, if the tumour be globular and with a distinct narrow stalk, or by transfixion, if (as sometimes happens) the tumour be of uniform thickness throughout, like a worm.

HÆMORRHOIDS OR PILES.--In the treatment of piles it is the differential diagnosis that is troublesome and occasionally difficult; the operative interference required is generally very simple, if the nature of the case be rightly determined.

_External piles._--_Operation._--The apex of the soft flabby excrescence should be seized by a pair of catch-forceps, and it should be cut off close to its base with a knife, or, what is better, a pair of curved scissors. Any little vessel which jets may then be secured. If, instead of numerous individual tumours, a ring of skin round the anus be involved, the whole of it should be shaved off, but not very close to its base, lest too great contraction of the anal orifice should ensue.

If the surgeon, after excising a pile or piles, will take the
trouble to stitch up the wound with catgut, he will find the cure
much more rapid and less painful than when this is omitted.

_Internal piles._--Incision is extremely dangerous, from the vascularity of the parts, and their being so inaccessible from their position within the sphincter ani. Hence ligature is safer and equally effectual. The patient should be directed to sit over hot water, and strain till the whole of his piles are fairly protruded. The surgeon should then transfix the base of each separately with a curved needle bearing a strong double thread. The needle being cut off, the threads should be very firmly tied, each isolating its own half of the pile. The tying should be exceedingly tight, so as to cause instant and complete strangulation and death of the tumours. All the piles should be tied at the same sitting. If the piles are very small they may be secured without transfixion in a single noose after being seized by a hook or forceps. There is greater risk of the noose slipping than when the base has been transfixed.

The strangulated masses must then be returned into the bowel, and the patient kept in bed or on a sofa till the ligatures separate, which is generally not till the fourth or fifth day. A certain amount of urinary irritation, showing itself sometimes in strangury, sometimes in complete retention, occasionally follows this operation.

Mr. Smith of King's College, and many other surgeons, treat internal piles by means of an ivory clamp to hold them tight, while they are burned off by the actual cautery or the thermo-cautery at a low red heat. They claim that pyæmia more rarely follows this mode.

There are certain cases in which the lower inch or two of the
rectum are found red and congested, and in which every stool is
followed by the loss of a certain quantity of florid arterial
blood, and yet no distinct hæmorrhoidal tumour is to be seen. In
such cases the ligature is not applicable, and relief is obtained
by the application of pure nitric acid, or other potential caustics
to the bleeding surface, as recommended by Houston, Lee, Smith,
Ashton, and others. These cases are comparatively rare, and
whenever they can be applied, the ligature is much simpler, safer,
and more certain.

_Venous piles._--When a sudden effusion of blood has occurred into one of the varicose veins or sinuses of a congested anus, an oval or rounded tumour is felt, very tense, shining, and painful. To slit it freely up with an abscess lancet, and evert the clot inside, at once relieves all the symptoms.

FOOTNOTES:

[150] Diagram of section of prostate seen from the inside:--PF, pelvic fascia or prostatic sheath; RR, ring which must be cut; L, position of incision in the lateral operation; DD, position of incisions in the bilateral operation.

[151] Diagram of muscles of membranous portion of urethra seen from the inside:--SS, section of os pubis; U, urethra; G, Guthrie's muscle, compressor urethræ; W, Wilson's muscle, levator urethræ.

[152] _Boston Medical and Surgical Journal_, May 29, 1879.

[153] Gross, _Surgery_, 6th ed. vol. ii. p. 736.

[154] Holmes's _Surgery_, vol. iv. p. 392.

[155] See Miller's _Practice of Surgery_, p. 212.

[156] Solly's _Surgical Experiences_, pp. 537, 538, etc.

[157] _The Immediate Treatment of Stricture._ By Bernard Holt, F.R.C.S. London. Third Edition, 1868.

[158] Holmes's _System of Surgery_, 1st ed. vol. iv. p. 403.

[159] Diagram of puncture of the bladder:--B, bladder; SP, symphysis pubis; SC, scrotum; _b_, bulb; _pr_, peritoneum; P, prostate; R, rectum; S, sacrum and coccyx.

[160] _Med. Chir. Trans._, vol. XXXV.

[161] Diagram of operation for phymosis:--_a_, glans penis; _b b_, mucous membrane exposed by retraction of the skin, and slit up; _c d_, sutures introduced and ready to be tied, uniting the skin and mucous membrane.

[162] To illustrate Teale's operation:--_c_, section of penis _b_, thread inserted uniting mucous membrane and skin; _a_, thread tied.

[163] _Med. Times and Gazette_, vol. xix. p. 354.

[164] Miller's _System of Surgery_, p. 1255.

[165] Miller's _System of Surgery_, p. 1256.