Fig. xxxvi. [159]
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 The trocar may then be withdrawn, and the canula retained for at least forty-eight hours by a suitable bandage.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.
Fig. xxxvii. [161]
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.