A Manual of the Operations of Surgery by Joseph Bell (best e reader for epub txt) 📕

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 passed 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 pass 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 passed 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 assistant holds the staff in his right hand, drawing up the scrotum 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 passed 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 passed into the bladder. This should not be furnished with a stop-cock 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 passed at intervals of three or four, till the wound is healed. To prevent recurrence of the stricture, it is a wise precaution to pass 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 pass 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 passed. A full-sized catheter must be passed 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 anus, 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 passed through them; and the surgeon must endeavour to pass 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 scrotum.

Puncture of the Bladder.—A patient and dexterous use of the catheter prevents this operation from being often required; still, circumstances 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.