Elements of Surgery

by Robert Liston

In all cases of retention when the urine cannot be brought away per vias naturales, and when no farther assistance or advice can be procured immediately, the surgeon should puncture the bladder rather than leave the patient to his fate; and the operation should be performed early. He must not temporise till all chance of recovery has gone by. By not operating till late, in this or any other disease, when by the delay no reasonable chance of saving the patient remains, our department of the profession is brought into discredit and contempt. Delay is more dangerous than even the worst mode of making an opening into the bladder; and while life exists, the patient should have his chance. Some defer extreme measures from day to day, either from hesitation or from a false hope that matters may ultimately change for the better, but the delay of one hour is in many cases most hazardous. In retention from disease of the prostate extravasation of urine is more dangerous—more certainly fatal—than in other circumstances. Here a part of the vesical parietes gives way by sloughing, and the fluid is effused within the ilio-vesical fascia; in other cases the extravasation is usually beyond that fascia, and beneath the fascia of the perineum.

Puncture by the Rectum is, in cases of enlarged prostate, inadmissible and highly dangerous; the operator must either perforate the gland, or enter the cavity of the abdomen. Even in the healthy state of parts, there is very little space between the posterior part of the prostate and the reflection of the peritoneum. The operator having ascertained that the prostate is sound, and the rectum empty, introduces the fore and middle fingers of the left hand into the bowel, and along these passes a trocar and canula from four to five inches in length, of moderate calibre, and of a curve rather greater than that of the sacrum. He places the point of this instrument on the part to be perforated, and fixes it there, the point of the trocar being hitherto withdrawn within the canula; the stilet is then protruded, and both carried onwards into the bladder. The part to be perforated is immediately behind the prostate and in the mesial line. Puncture above the Pubes is easily enough performed when the bladder is capacious, but it is at best a dangerous operation. The wound is made through loose cellular tissue; urinary extravasation into that tissue is apt to occur, and often proves fatal. If the bowels are inflamed, or evince a tendency towards inflammatory action, the danger is increased, for a formidable wound is made in the immediate vicinity of the bowels. The operation has been resorted to when the catheter might have been passed without much difficulty; this statement may appear harsh, but it is too true, and can be borne out by indisputable facts. It is brought forward more as a caution to the young than as a reflection on the senior members of the profession. Some patients have recovered from the operation, and lived in misery for months and years, passing their urine through a canula retained in the wound. An incision is made above the symphysis pubis, in the mesial line, dividing the integuments and cellular tissue, to the extent of from one to two inches; on thus exposing the coats of the bladder, a flat trocar with a canula is pushed into the cavity of the viscus, at the lower part of the wound; the trocar is withdrawn, and the urine evacuated.

The treatment of enlarged prostate is palliative—attention to the general health, the occasional administration of anodyne suppositories or enemata, prevention of accumulation in the lower bowels, either by gentle laxatives or the throwing up of bland fluid, and the avoiding as far as possible all sources to excitement, of mind as well as body. The radical cure, it has been said, is extirpation of the gland, but the cool proposal of such an operation would indicate either ignorance, or dereliction of principle, or mental obliquity, or all combined.

In retention from effusion of blood into the cavity of the bladder, a long catheter will sometimes evacuate the urine, and after some time also the blood; for the latter, though at first coagulated, ultimately becomes dissolved in the urine, and passes off along with it, even through a catheter of no very large calibre. Should this fail, and the symptoms continue urgent, an exhausting syringe should be employed, well adapted to the extremity of the catheter. After the urine has been thus evacuated, should a suspicion remain of coagula being still in the bladder, tepid water may be injected with the view of promoting the breaking down of the clots, and then the exhaustion may be repeated.

Incontinence of Urine, as already observed, is a common result of distention of the bladder and of stricture. But it also occurs as a primary affection, particularly in young people, from irritability of the posterior part of the urethra not suffering the urine to accumulate within the bladder as in ordinary circumstances. It is sometimes removed by the application of a blister to the perineum, and by the patient attending to empty the bladder at intervals during the night. Attention to the state of the bowels is necessary in such cases. The clearing them of worms or sordes, and the exhibition of tonics is sometimes also useful. Children, and even mothers, sometimes have recourse to a more effectual method, the application of a tight ligature round the penis. But of the folly and danger of such practice, the following may serve as an example. A. R., when 8 years old, passed a brass curtain-ring over his penis to prevent incontinence of urine during the night, and thereby escape chastisement, to which he had been frequently subjected. Great swelling soon took place round the ring, and he was unable to remove the jugum. He experienced much pain and difficulty in voiding his urine; the integuments under the ring gradually ulcerated, the ring appeared to sink into the substance of the penis, and the swelling subsided. The integuments met and adhered, the foreign body was concealed, and all uneasiness soon ceased. The penis performed well all that was required of it; the urine passed easily, and after a while he became the father of a fine family. When between fifty and sixty years of age, he applied to me. For some years previously difficulty in making water had been coming on, and frequent desire to pass it in the night-time rendered him very uncomfortable. He was under the necessity of having a vessel constantly in bed, and was generally disturbed every half hour. The penis had become very unserviceable, and he was now anxious to have the ring removed. A broad hard substance was felt surrounding the penis, close to the symphysis; an incision was made into the urethra at that part, and a calculus easily extracted. The uneasy symptoms quickly disappeared, and the patient recovered with a small fistula at the incised part, which could have been removed without difficulty, had not all treatment been obstinately resisted. The calculus resembled a prune in size, of a crescentic form, with one of the apices detached, and was apparently composed of uric acid, coated with the ammoniaco-magnesian phosphate. On making a section of it, about two-thirds of the brass curtain-ring, partially decomposed, were found firmly impacted in the centre. It would appear that a portion of the ring had speedily made its way into the urethra, had been acted upon and washed away by the urine; while the remainder, coming more gradually in contact with that fluid, had become incrusted with deposit, and formed the nucleus of the calculus. It is strange that the penis should have been efficient,—that the erectile tissue should have remained pervious—after having been cut completely through near the symphysis.

Of Gonorrhœa Præputialis vel spuria.—By this term is understood discharge of puriform matter from the lining membrane of the prepuce, and from the surface of the glans, accompanied with an itching and smarting sensation. The affection may arise from mere inattention to cleanliness, the natural secretion being allowed to collect and deteriorate; or from the application of acrid matter, gonorrhœal, or leucorrhœal. It often attends discharge from the urethra, and is usually met with in those who, from the natural tightness of the prepuce, uncover the glans with difficulty, if at all. It may occur without impure connexion; mucous discharge accumulates, becomes acrid from stagnation, and is washed away by profuse secretion of puriform matter; the parts then become quiet, and resume their healthy functions, but are apt from slight causes to be again the seat of discharge. Generally, the surfaces of the prepuce and glans are relaxed and turgid, but there is no breach of continuity; in neglected cases there is superficial patchy ulceration, and sometimes a deep and sloughing sore. The matter is often confined by tightness of the præputial orifice, and mischief thereby occasioned to the glans; a large purulent collection forms, and, if the case is neglected, ulceration takes place, either of the glans or of the prepuce, or of both; the latter becomes thin, and at length gives way; the aperture thus formed extends, and occasionally is of such a size as to admit of protrusion of the glans. Œdematous swelling generally takes place to a great extent in such cases. The glands of the groin sometimes swell, and through inattention may suppurate. The absorbents of the penis may also become turgid and painful. Tenderness of the glands and prepuce often exists, in a greater or less degree, for years; in such circumstances the affection may be termed gleet of the prepuce, and is usually the consequence of irritable urethra.

The treatment consists in cleanliness and rest, applying astringent washes to the parts, and suspending the organ. When swelling of the prepuce or inflammation of the lymphatics is threatened, constant rest must be enjoined. In obstinate cases, disease of the urethra is to be suspected as the cause, and the state of that canal should therefore be ascertained; if derangement of structure or function is detected, then means must be forthwith adopted for its removal, the applications to the prepuce and glans being at the same time not neglected. Mercury can be of no use.

Phymosis and Paraphymosis are often connected with gonorrhœa of the prepuce, or of the urethra. The edge of the prepuce may be rendered tight by inflammation, swelling from effusion, or cicatrisation of sores; the tightness also attends irritability of the urethra, particularly in young subjects; often it is congenital. The affection is termed Phymosis when the prepuce occupies its natural relative situation, but cannot be drawn back so as to uncover the glans. The contraction exists in various degrees; sometimes the orifice is so tight that the flow of urine is obstructed, the præputial cavity becoming swelled and distended every time the patient attempts to make water. In other instances the uninjected glans can be exposed either in part or entirely, though with difficulty. In consequence of the præputial cavity being frequently filled with urine, in cases of great contraction, urinary concretions have even formed or been detained there or in the orifice of the urethra, giving rise to very annoying, and sometimes alarming, symptoms. In consequence of Phymosis, the urethra and bladder may become diseased. It is often attended with profuse puriform discharge, with sores of different kinds, or with warty excrescences on the glans and prepuce; sometimes the whole surface is completely covered with granulated prominences of various sizes, some large, but the majority small, some broadly attached, others suspended by narrow necks; all generally furnish discharge of thin acrid matter. Adhesion may take place between the raw surfaces of the prepuce and glans, provided the parts be not frequently displaced for the purpose of ablution.

Paraphymosis arises from the same state of the orifice of the prepuce as the former affection, only the parts are in different relations to each other. In phymosis the prepuce covers the glans, the tight part is anterior to it; in paraphymosis the prepuce is reflected over the glans, the tight part acts as a ligature round the penis behind the glans, and such swelling speedily arises in consequence of the constriction so as to prevent reduction. The glans and lining membrane of the prepuce swell anteriorly to the stricture, the integuments of the penis swell behind, and the stricture is depressed and concealed between. The cellular tissue there is necessarily very loose, so as to admit of free motion and change of relative position, and consequently the engorgement is often very great. The infiltration is at first serous, and the swelling is easily compressed; but, from continuance of the inflammatory action, lymph is effused, and becomes organised, and the turgescence is more solid and unyielding. When the stricture is very tight, the patient cachectic and irregular in his mode of life, and the case injudiciously or inertly treated, sloughing takes place rapidly, or phagedenic ulceration occurs anterior to the stricture. But in most cases the prepuce is not so tight as to cause complete strangulation, yet obstructs the flow of blood sufficiently to induce swelling of the included parts, breach of surface more or less extensive, and an unhealthy appearance of the ulceration. The ulceration is generally in the neighbourhood of the stricture, at first limited and superficial, but increasing both in depth and extent so long as the cause remains. The stricture is not situated anteriorly to the swelling, as has been sometimes supposed, but near its middle—where the tight orifice of the prepuce grasps the penis, and causes a depression in the swelling. On separating the anterior and posterior tumours, the stricture is readily exposed, though previously effectually concealed.

In slight cases of phymosis, the orifice may be dilated by frequent fomentation, and perseverance in withdrawing the prepuce as far as possible. When ulceration or secretion of matter has occurred, astringent injections, at first mild, and gradually strengthened, should be frequently thrown into the præputial cavity. Suspension of the penis should be enjoined, along with rest—of the whole body, as well as of the affected organ in particular. When much inflammation exists, antiphlogistic remedies must be put in force, followed by fomentations. In bad cases, the prepuce must be divided in order to expose the seat of morbid secretions, of ulceration, and vegetations. The preferable situation for incision is close by the side of the frænum, much less deformity ensuing than when the prepuce is divided either laterally or in front. The flaps are at first loose and flabby, but shrink as the œdematous swelling subsides. A straight director is introduced within the præputial orifice—the groove pointing downwards—and passed down to the reflection, close to the frænum; a sharp-pointed curved bistoury is slid along the groove till it also reaches the reflection; by raising the handle and pushing it forwards, the integuments are transfixed there, and withdrawal of the knife by a rapid sweep completes the incision. Care must be taken not to pass the director into the urethra instead of into the præputial cavity. It is very seldom that ligature is required to arrest bleeding. Should the cellular tissue of the divided part not have been the seat of solid effusion, the integument and the lining membrane of the prepuce separate, leaving a large raw surface; and to prevent this a small suture should be passed between the membrane and skin on each side of the wound; these may be withdrawn on the second or third day, the cellular tissue having then become consolidated, so as not to admit of retraction. A warm bread poultice, or water dressing, is the best application for the first few days; afterwards healing of the cut surfaces may be promoted by the application of a gently stimulating lotion. Should œdema of the prepuce remain, this may soon be effaced by bandaging. By this operation sufficient space is obtained for uncovering the glans, under any circumstances; and besides, to this part of the organ is still preserved its natural investment, not in the least curtailed either in size or in efficiency—the glans can be uncovered and covered at will; whereas by any other mode of incision the unseemly flaps always fall away, leaving the greater part of the glans constantly uncovered, and placing the patient, if not in a worse, at least in the same predicament, as if he had been subjected to regular circumcision.