Elements of Surgery

by Robert Liston

When the stone or stones have been extracted, and the surgeon has satisfied himself that no more foreign matter remains in the bladder, the next step in the lateral operation is the insertion of a gum-elastic tube, from four to six inches in length, according to the depth of the perineum, in calibre a little larger than a full-sized catheter, provided with a noose attached to each of two rings at its neck, and at its farther extremity open at both point and sides. It is introduced along the forefinger in the wound, and its extremity lodged fairly within the bladder; a double tape is attached to each of the nooses at its orifice; one is passed up in front, and secured to the fore part of a broad band round the loins; the other is brought under the thighs, and fixed behind. The object of its introduction is to facilitate the escape of urine externally, and prevent infiltration of the cellular tissue by this fluid. The wound, when made according to the directions which have been given, is both conical and dependent—the external opening is free, the internal small, the intermediate space gradually contracting as it approaches the bladder, and the inferior part of the wound of the integument is lower than the corresponding portion of the prostatic section; thus the draining away of the urine is favoured, but it conduces very much to the patient’s safety to ensure still farther its free escape by the insertion of a tube—part passes through the tube, and drops from its orifice, part flows by its side according to the laws of capillary attraction. For some hours after the operation, it is necessary to clear out the instrument frequently by means of a feather, otherwise its extremity will soon become obstructed by coagula; in short, this must be persevered in till colourless flow from the orifice shows that the internal oozing of blood has ceased, and that nothing is passing but urine. When by salutary effusion from the vessels the surface of the wound becomes consolidated and imperviable to the urine, the tube is to be withdrawn, but not till then; in young persons it may be removed after twenty-four hours, but in those advanced in life and of relaxed habit it must be retained for forty-eight or more.

The tube is also of service should bleeding continue from branches of the superficial pudic, from small arterial twigs in the neighbourhood of the prostate, or from venous ramifications and the plexus which surrounds the neck of the bladder; for it admits of the application of efficient pressure to the bleeding point, without interfering with the escape of urine, and so increasing the danger of infiltration. Slips of lint are pushed along it to a sufficient depth, and are retained, if necessary, by compress and bandage, the orifice of the tube being left clear. But, as already stated, it is indeed very seldom that this proceeding will be required, if the operation has been conducted with proper caution.

After the tube has been secured by its tapes, or during this process, the patient is unbound; he is placed in bed with the thighs separated and bent, and must be kept very quiet. Diluents are administered copiously, to encourage the secretion of urine; he cannot wet too much. His nourishment must be very sparing, consisting chiefly of bland fluids; and all sources of inquietude and irritation must be carefully avoided. Depletion, whether general or local, will very seldom be required; danger is not to be apprehended from inflammation so much as from infiltration of the cellular tissue by urine. In the fatal cases, unconnected with hemorrhage or exhaustion, the peritoneum is not found vascular or coated with lymph, nor is there collection of morbid secretion from this membrane within the abdominal cavity, but the cellular tissue, along the track of the wound, is black, disorganised, easily lacerable, putrid; or, if the infiltration has not been to such an extent or in such a site as to kill speedily as if by poisoning, unhealthy suppurations are found, extensive, uncircumscribed, composed of sanies, urine, and dead cellular tissue, horribly mixed. Should fixed and increasing pain be complained of in the hypogastrium, the part is to be leeched and fomented; this is the only indication of inflammatory action which has occurred in any of my patients, and it has yielded to the simple treatment here mentioned; so far as I recollect, in only three cases out of more than a hundred, was the leeching necessary. Some patients require support very soon, almost from the first; others evince sufficiency of action throughout, and in them it is very necessary to pay strict attention to the state of the stomach and bowels, lest the action should exceed; some proceed favourably for a time, and then become torpid and stationary, their spirits and constitutional power flagging, in consequence of confinement and the discharge and irritation of the wound,—such also require judicious support, and perhaps slight stimulation.

Union of the wound by the first intention is not desirable; attempts to procure it are dangerous, as conducing to infiltration; the presence of the tube effectually prevents both. Discharge and granulation take place, and the cavity contracts gradually and uniformly. By the sixth or eighth day—sooner in young people, and later in those far advanced in life—the urine begins to flow in part by the natural passage, causing considerable pain in consequence of the urethra having been for a time unaccustomed to its stimulus; and as the opening in the prostate contracts, the escape of urine by the wound proportionally diminishes. When the natural course is completely restored, the wound closes more rapidly than before, granulations soon fill it up, and cicatrisation takes place. Sometimes, though very rarely, a small fistulous opening remains for some time, through which a few drops of urine may occasionally distil; should it prove obstinate in not closing, it may be touched with a heated wire. And sometimes also, when the urine is unusually slow of coming by the urethra, this may be expedited by the occasional introduction of a catheter or bougie.

It is not often that the operation of lithotomy requires to be repeated. In some few cases, however, the calculous diathesis continues, a new concretion is formed, and the patient again applies for relief, perhaps several years afterwards. In such circumstances, the incisions are to be made in the right side of the perineum; for the track of the former wound is now consolidated, firm, and hard, and would be cut with difficulty. But when, from neglect or want of dexterity, the first operation has been imperfectly performed, one or more stones being left behind, the wound may not heal, nor even contract to any considerable extent; and then dilatation of the existing opening, with fresh section of the prostate, will probably be sufficient, though at an interval of many months.

It has been proposed to divide the operation into two parts, with an interval of several days between; first to make the incisions, leaving the stone undisturbed, and after suppuration has been fairly established, and the parts become relaxed, then to extract the foreign body, provided it have not in the mean time been discharged spontaneously—in short, to perform the operation à deux temps. This method is liable to serious objections. Two operations must in general be more severe than one. The patient is rendered despondent and miserable after the first, by knowing that the object of his suffering has been imperfectly accomplished, or rather not accomplished at all. Much, and often serious irritation is produced by the wounded bladder being contracted on the hard and rough foreign body; patients have sunk under this torture, and the cure is always tedious. From the earliest times it has been quite well understood, that when the stone cannot be got out it must be left in; but the proposal of always leaving it in, on principle and not from necessity, is really absurd. There is room for suspecting that this mode of operation originated as a virtue from necessity; the extraction of the stone is always the most difficult part of lithotomy, requiring much skill and dexterity, and the operator, finding himself baffled in his attempts to effect it, wisely desists from his futile efforts at the time, and waits for another opportunity. This is certainly better practice than the using of much force, or dilating the wound by incision to a dangerous extent, but it is very far from being so good as the immediate removal of the foreign body, smoothly and quickly, skilfully, and without violence; and it has been already observed, that the cases are very few indeed in which the stone cannot be removed through the prostatic opening without the employment of any force, and, without inflicting any injury to the parts through which it passes—without hazard and without delay. The sooner the method à deux temps is expunged from the list of surgical operations, the better will it be for suffering humanity and the credit of our art.

In those rare cases in which the stone is so large that it cannot be brought through the outlet of the pelvis, it must either be broken into fragments, or removed entire through incision above the pubes; as already stated, it is probable that the high operation is the safer proceeding. It is, however, an operation attended with much danger. The wound is necessarily extensive, and important parts are liable to be interfered with; and, from not being dependent, the escape of the urine by it is almost certain to cause infiltration of the cellular tissue surrounding the bladder—an occurrence almost always proving fatal and that rapidly. The first part of the procedure is to insure distention of the bladder, so that it may rise in the pelvis, and afford sufficient space between its lower part and the anterior reflection of the peritoneum; but this may prove either very difficult or altogether impossible, even with the aid of injection by the urethra, in consequence of the unyielding contracted state of the viscus, and the great thickening of its coats. An incision is made through the integument and fatty matter, from three to four inches in length in the mesial line, and terminating over the symphysis pubis; the recti and pyramidal muscles are then separated, the cellular tissue cautiously divided, and the fore and lower part of the distended bladder exposed. The coats are pierced at the most inferior part, and an opening made sufficient for the introduction of the finger. By the finger the dimensions of the stone are ascertained, and then the wound is enlarged upwards to such an extent as will by dilatation admit of the extraction. Forceps are introduced, of sufficient length and grasp, and the foreign body removed without laceration or bruising of the parts. The patient is then laid on his side, a piece of dressing being interposed between the edges of the wound to favour the discharge of the urine externally. The escape of this fluid maybe free and copious, and the wound may close favourably; but the majority of the patients on whom this operation has been performed, have perished either from urinary infiltration, from peritoneal inflammation, or from exhaustion. Fortunately, I have never had occasion to resort to it.

It has been proposed to combine this mode of operation with wound of the posterior part of the urethra from the perineum, in order that a free and depending outlet may be afforded to the urine, and also, that by introducing instruments into the bladder from the lower opening, the organ may be elevated and stretched so that its fore part may afford sufficient space for the high incision without danger to the peritoneum. With this view the perineum is incised, similarly but to a less extent than in the lateral operation, and the membranous part of the urethra opened. Through this aperture the sound with a stilet for elevating the bladder is passed, and intrusted to an assistant; the incision above the pubes is then made, the stone extracted, and a tube is left in the perineal wound for discharge of the urine. The plan, though complicated, appears feasible, and likely to diminish hazard by preventing infiltration.

The recto-vesical method should never be resorted to in preference to the lateral; in other words, it is unwarrantable, in my opinion, in those cases to which lateral operation is applicable. It consists in exposing the neck of the bladder by division upwards of the sphincter ani and lower part of the rectum, and then either making a section of the prostate in the usual way, or dividing also the coats of the bladder in the posterior fundus, when the concretion is large. The cure is tedious and harassing: the urine and feces are discharged together, and hardened feculent matter may accumulate within the bladder; the wound is long in contracting, and often cannot be made to close completely without much trouble, and after a long time; often a fistulous opening remains, communicating with the bladder and rectum, and through this the urine continues to be in part discharged. It has been argued, that the recto-vesical method is advisable, with the view of obtaining more room for extraction of the stone; but to me it appears that the divided rectum will occupy just as much space in the outlet as when entire and empty. Circumstances may, however, occur, rendering this operation, or a modification of it, absolutely necessary, as in the following case—the only instance in which I have encountered an encysted stone. The patient, aged 64, of a spare habit of body, was seized with symptoms of stone in the bladder about twenty-four years previously to my seeing him; at that time he was sounded, but no stone could be discovered. The symptoms gradually subsided, and ultimately disappeared, and he remained for considerably more than twelve years totally free from any affection of the urinary organs. But, about three years previous to the operation, the symptoms returned, and again attentive examination of the bladder was made, without detecting any stone; on introducing the finger into the rectum, however, as high as possible, a firm substance was felt, globular, of considerable size, and very slightly moveable. From this time the symptoms gradually increased in severity, ultimately becoming almost intolerable. At length the presence of a stone was distinctly ascertained by sounding, and the instrument was passed beneath as well as over the calculus; from simultaneous examination by the rectum, it was evident that the hard bulging body was connected with the foreign matter struck by the sound. The lateral operation was performed, and, expecting to meet with a large stone, both sides of the prostate were divided. The forceps were introduced, but the stone, though easily laid hold of, could not be moved. Attempts with the instrument were accordingly abandoned, and further examination made by the finger, when it was found that the stone lay fixed in the lower and anterior part of the viscus, that it was firmly enveloped by a cyst situated between the rectum and posterior part of the prostate, and that only a part, small in proportion to its body, projected into the cavity of the bladder. Of this unusual and untoward circumstance, the medical gentlemen present were also satisfied by manual examination. It was quite apparent that it would be impossible to divide the cyst sufficiently without wounding the rectum, and I therefore determined to lay the bowel, the cyst, and the track of the wound into one cavity. This was effected by cutting the upper and anterior part of the cyst, passing a blunt-pointed and curved bistoury behind the remainder of the cyst, insinuating it through the coats of the gut at that part, meeting the point with the forefinger of the left hand passed per anum, and then carrying the instrument forwards to the surface. A strong scoop, much curved, was passed behind the stone, and without much difficulty extraction was thereby completed. Not above a few tablespoonfuls of blood were lost during the operation, in which not much time was occupied, and no bleeding took place after reaction was established. The cure proceeded favourably, though necessarily slow and tedious, the more so since the patient had been very much reduced by the previous suffering. Some superficial sloughing took place in the wound, but the sloughs soon separated, and healthy discharge and granulation followed. By keeping the bowels gently open, the annoyance from feculent evacuation by the wound was in some measure diminished. The patient was daily out of bed, and took food in good quantity and with relish. At the end of the fifth week, however, he was seized with a severe bowel attack—vomiting, purging, cold extremities, &c.—and the effects of this were never surmounted. The real Asiatic cholera was at that time prevalent, and the patient was under great apprehension of an attack. The weak state in which it left him continued and increased: he was soon confined entirely to bed, the wound made no progress in closing, sloughing of the back took place, and he sank about the end of the eighth week from the operation.

Calculi sometimes lodge in the urethra, obstructing the flow of urine, becoming firmly impacted, and increasing in size. If in the perineal portion of the canal, they are to be fixed and made prominent by being grasped with the fingers, and then exposed by an incision made in the raphe: they are turned out, either with the finger, or by means of a small scoop. If situated in the part covered by the scrotum, the opening should be made, if possible, behind, not anterior to it, for a wound in the latter site will be closed with difficulty. When in the posterior part of the canal, they are reached by incision on the left side of the perineum and opening of the membranous portion. After such operations, the wound, if not anterior to the scrotum, usually closes in a few days.