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 pyaemia, 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 r.e.c.t.u.m 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 r.e.c.t.u.m and the urethra, in which the contents are apt to be interchanged in a most disagreeable manner, flatus pa.s.sing per urethram, and urine per r.e.c.t.u.m.

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 a.s.sociated 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 a.n.u.s, upwards, crossing the raphe nearly an inch above the a.n.u.s, 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 cache 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 r.e.c.t.u.m. The angle projects in the perineum, so that the operator with his left forefinger in the r.e.c.t.u.m 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 r.e.c.t.u.m, 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 haemorrhage, wound of the r.e.c.t.u.m, 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 r.e.c.t.u.m. The operator pierces the raphe of the perineum with a long straight bistoury about half an inch above the verge of the a.n.u.s, 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 s.c.r.o.t.u.m. A ball-pointed probe is then pa.s.sed 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 p.u.b.eS, _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 haemorrhage. 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 st.i.tches, and st.i.tching 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 p.u.b.es 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 r.e.c.t.u.m.--(_a._) _Sanson's Recto-vesical Operation._--The principle of this operation consisted in laying the two ca.n.a.ls, the r.e.c.t.u.m 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 r.e.c.t.u.m as a guide to the knife, pierces the anterior wall of the r.e.c.t.u.m, reaches the groove of the staff just in front of the prostate, and cutting outwards divides the r.e.c.t.u.m, 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 r.e.c.t.u.m above the prostate._--The presence of a small portion of bladder beyond the prostate in close relation to the r.e.c.t.u.m 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 r.e.c.t.u.m, exposing the anterior wall of the r.e.c.t.u.m, just as it would the v.a.g.i.n.a in the female. A sound was pa.s.sed into the bladder. The doctor entered the blade of a bistoury in the triangular s.p.a.ce bounded by the prostate, the vesiculae seminales, and the peritoneal reduplication. He pa.s.sed 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 v.a.g.i.n.al 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 v.a.g.i.n.a. 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 s.p.a.ce 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 pa.s.s 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 s.p.a.ce 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 pa.s.sing, 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.