A Manual of the Operations of Surgery Part 30

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 pa.s.sing of a succession of bougies, gradually increasing in diameter, at intervals of three or four days, for the purpose of exciting an amount of interst.i.tial absorption in the new material const.i.tuting the stricture, sufficient to remove it.

Pa.s.sing 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 rec.u.mbent 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 p.e.n.i.s 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 p.e.n.i.s 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 While this is being done the operator's left hand should be withdrawn from the p.e.n.i.s, and the points of the fingers applied to the perineum.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 ca.n.a.l.[154]

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

(3.) The opposite error may force the point out of the urethra between the membranous portion and the r.e.c.t.u.m, 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 s.c.r.o.t.u.m, invariably use the forefinger of the left hand in the r.e.c.t.u.m as a guide.

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

An instrument may be pa.s.sed, 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 p.e.n.i.s 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 pa.s.sed, it consists of pa.s.sing 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 pa.s.sed 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 pa.s.sed 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 pa.s.sed into the bladder, and the grooved blades are separated to any extent that is desired by pa.s.sing 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 pa.s.sed 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 pa.s.sed into the bladder. This instrument, which is an improvement upon one invented by Perreve 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 pa.s.sed 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 pa.s.sed; 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 pa.s.sed 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 pa.s.s 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 pa.s.sed 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 a.s.sistant holds the staff in his right hand, drawing up the s.c.r.o.t.u.m 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 pa.s.sed 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 pa.s.sed into the bladder. This should _not_ be furnished with a stop-c.o.c.k 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 pa.s.sed at intervals of three or four, till the wound is healed. To prevent recurrence of the stricture, it is a wise precaution to pa.s.s 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 pa.s.s 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 pa.s.sed. A full-sized catheter must be pa.s.sed 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 a.n.u.s, 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 pa.s.sed through them; and the surgeon must endeavour to pa.s.s 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 s.c.r.o.t.u.m.

PUNCTURE OF THE BLADDER.--A patient and dexterous use of the catheter prevents this operation from being often required; still, circ.u.mstances 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.

[Ill.u.s.tration: FIG. x.x.xVI.[159]]

2. _From the r.e.c.t.u.m._--Except in cases of enlargement of the prostate, it is at once easier and safer to puncture the bladder from the r.e.c.t.u.m.

The well-known triangular s.p.a.ce uncovered by peritoneum, with its apex in front close to the prostate, and bounded on either side by the vasa deferentia and vesiculae seminales, can be easily reached by a curved trocar. This should be guided by one, or, still better, by two fingers, into the r.e.c.t.u.m, 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. c.o.c.k, 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 r.e.c.t.u.m, and the other hand above the p.u.b.es. 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. x.x.xVII. _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 st.i.tched 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.

[Ill.u.s.tration: FIG. x.x.xVII.[161]]