Lithotomy and extraction of stone from the bladder, urethra, and prostate of the male and from the bladder of the female

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EXTEACTION OP , STONE

FROM THE

BLADDEE, UEETHRA, AND PROSTATE OF THE MALE

AND FROM THE

BLADDER OF THE FEMALE

W. POULBTT HARRIS, M.D.

LONDON

J. & A. CHURCHILL, NEAV BURLINGTON STREET o m

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SIR HENRY THOMPSON

8UROBON BXTBAOBDINARY TO H.M. TUB EIXO OP TUB BELGIANS PR0PBI80R OP CLINICAL SURGKRYt AND SURGEON TO UNIVERSITY COLLEGE HOSPITAL

THIS WORK

IS INSCBIBED, FROM A FEELING OF

ADMIRATION FOR HIS REMARKABLE SKILL

IN

LITHOTRITT AND LITHOTOMY

BY

THE AUTHOR

Preface

Mt eudeaTour has been to make tHs work a very complete one, and a record of all the knowledge acquired by the medical and surgical profession, up to the present time, on the subject of unnary calculi, for besides my own consider, able experience which has extended to 365 operations by myself, with many others performed under my immediate supervision by my subordinates, I was engaged for two months unng last year in the library of the Netley Hospital, in taking notes from all the works bearing on this subject; copious quotations rom which I have embodied in the following

No reference has been made to lithotrity, as I following the general custom of surgeons in ndia, have never practised it ; though, havinorecently enjoyed the advantage of witnessing bir H. Thompson’s admirable practice, I hope

to have the means of popularising the operation in India at some future time.

Vlll

PREFACE

T-tiougli the principal object of this work is to present to the reader a thoroughly practical treatise on the performance of the various operations for the extraction of calculus, and a guide in all the difficulties he may meet with ; yet I have added comprehensive chapters on causation of calculus, and other matters not immediately connected with operative procedures.

London ; February, 1876.

CONTENTS ft- '

Chapter XIX

Miscellaneous subjects, including prophylaxis ; choice of operation ; general maxims ; internal incision for large calculi ; treatment adapted to very small calculi ; the recurrence of calculus ; operation a deux temps ; right lateral lithotomy ; spontaneous fracture of calculus; incontinence of urine after operation ; sexual impotence after lithotomy ; treatment of last stages of calculous affections unfit for operation

Chapter I Causes Oe Ueinaet Calculi

Calculus may be looked upon as the same chap.

disease as gravel, the difference being that in the ~

former some circumstance has caused the particles of gravel to agglutinate. This was also exactly the opinion of Sir B. Brodie, who writes :

— “ Whether there be sand or whether there be actual calculi, the nature of the disease is essentially the same.” The predisposing causes of both states will consequently be identical, but before considering them it will be useful to notice the subject of gravel.

The formation of gravel depends upon a ten- . dency in the urine to throw down a deposit previously to its expulsion from the bladder.

This probably has, in the great majority of instances, a constitutional source, tliougb. resulting more immediately from mal-assimilation which produces a morbid state of the urine, the nature this determining the peculiar composition of the gravel. The character of the constitutional^ source of gravel is very obscure ; sometimes we know it to be hereditary, as in gout, but at other times it is less clear what it depends upon, though, since weak and puny children are the most liable to it, it may be allowable to speak of natural debility with impairment of the vital powers as one constitutional cause. This condition, though usually thought to predispose to the oxalic- rather than the lithic-acid diathesis, may I think, be looked upon as likely to cause the latter also, for it is the opinion of some eminent men that both substances are secreted under the same circumstances, and have the same pathological signification. Thus Beale writes : —

“ In the same case, at one period, we may find uric acid and urates ; after a time these mixed with oxalates ; and, lastly, they may give place to a deposit of oxalate alone.”

The only two urinary deposits that will be here treated of are the iithic acid and the oxalic acid, as it is one of these which almost invariably forms the nucleus of a calculus.

Dr Prout describes the immediate cause of the precipitation of lithic-acid gravel to be nearly

CAUSES OP URINAEY CALCULI always lactic acid secreted in excess, which throws down the lithic acid by combining with the base which retains it in solution.

The cause of the deposit of oxalic acid may be,

^ he says, particularly in the predisposed, the too free use of sugar and the partaking of unwholesome farinaceous matters.

The predisposing causes are the following ! preuisposin g causes.

1st. Hereditary predisposition. — The hereditary nature of the disease is, the same author writes, very marked in the lithic-acid deposit, the children of gouty and dyspeptic parents, and of those suffering from lithic-acid diathesis, or other urinary diseases, being especially liable to it.

2nd. Sex. Urinary deposits are more common in the male than in the female, one cause of the comparative exemption of the latter being the more quiet and temperate lives they lead.

3rd. .^ge. “ Children and elderly people are

well known to be more liable to calculi than persons of the middle period of life. In the poorer classes children are afflicted with remarkable frequency ; but in the higher the disorder is more common in the old than young subjects ”

(Cooper’s ‘ Dictionary,’ 7th edition).

Sir H. Thompson says in the third edition of his clinical lectures Among the well-to-do and well-fed, although almost rarely found in childhood, it is almost common at advanced age.

Chap. I

This has been very much overlooked, and its frequency then is greater than most people believe.”

4th. Climate. — In those countries where it is prevalent it is most often met with in districts in which cold and piercing winds are prevalent, such as the county of Norfolk ; the eastern part of Scotland, from the Firth of Forth northwards ; Rohilcund and other districts of the North Western Provinces of India, which lie under the influence of the cold winds blowing ofiF the Himalayas. In very cold and in tropical regions which are not subject to sudden atmospheric vicissitudes, it is said to be rare.

Malarious influence is a predisposing cause both of lithic-acid and oxalic- acid deposits. With reference to the former Dr Prout writes : — “ Malarious influence in warm climates does not seem to lead to lithic deposits ; but in cold climates, where it operates more especially by inducing rheumatism and ague, it may be considered, especially when concurring with other causes, as a fertile source of such depositions.” “ Among exciting causes of the oxalic-acid diathesis,” he says, “ one of the most striking I am acquainted with, as before observed, is a residence in a damp and malarious district. In such a district the predisposed seldom escape, and even those who are not predisposed are apt, after a time, to become more or less affected.” The

CAUSES OF URINARY CALCULI way in which cold winds cause urinary deposits is by checking the action of the cutaneous vessels, and consequently the excretion of lactic acid, which, this writer says, failing to find an exit with the perspiration, is diverted to the urine.

5th. Water. — It has been repeatedly observed that urinary deposits are common in persons living in limestone districts, owing to derangement of the digestion caused by the use of hard water. The hurtfulness of such waters is spoken of by Dr Prout, who writes : — “ They operate in various ways and produce very different effects in difierent diseases and constitutions ; but their general influence in all forms of urinary deposition is, according to my observation, very unfavorable.”

6th. Food. — It has been frequently noticed that, in those parts of a country where gravel is a common disease, the food is in fault ; thus, in Norfolk, coarse dumplings are a usual article of diet, and in the North Western Provinces of India, where the disease is prevalent, the ordinary diet of the population is heavy unfermented bread, made from the admixture of several kinds of cheap grain.

7th. Occ-apaimw. — Sedentary employment is probably a predisposing cause, as it is -thought that seafaring people and soldiers who lead an active, out-of-doors life are much less liable than others to the afiection, though as yet this does not appear to be a well-ascertained fact.

8th. Bank of life. — Mr Gross, the American surgeon, is of opinion that the disease is much more common among the poor -than the rich, and says : — “ Upon what this difference depends is not positively ascertained ; the probability is that it is mainly due to derangement of the digestive organs, engendered by the use of unwholesome food, by irregular habits, want of cleanliness, intemperance, and deficient clothing.”

9th. Diseases of the liver. — Dr Beale has brought to ■'^otice that a deposit of hthic acid is common in diseases of the liver, and even in temporary congestion only of that organ. The reason of this is that, the liver not performing its excreting functions efficiently, the kidneys are called upon to compensate for its inactivity by forming so large a quantity of lithic acid that it can no longer be eliminated in solution, but is deposited in its crystalline forms in some parts of the urinary passages.

10th. Diseases of the shin. — While diseases of the liver give rise to lithic- acid deposit, skin diseases, particularly impetiginous or allied affections, appear to predispose to a deposit of oxalic acid.

in The correctness of the above as predisposing causes is borne out by Mr Cadge, of the Norfolk

CAUSES OE URINARY CALCULI

Hospital, who is of opinion that the local influences ".Ifi ' which contribute to renal and vesical calculus in Norfolk are the universal consumption of malt liquors, the constant daily use of exceedingly hard drinking water, and the accumulated effect of hereditary predisposition.

As the exciting causes act by leading to the Nucleus, aggregation of the particles of gravel, the manner in which this takes place and other matters connected with the formation of the nucleus will first be dwelt upon.

Dr Beale’s views on the formation of the Dr Beaie>s views, nucleus is that in many cases it is a microscopic calculus, and that it depends on the concentration of the fluids of the body leading to the deposition of the least soluble substances in a solid form ; and he supports this opinion by the frequency of cases of calculous disease in those who have suffered from cholera.

Microscopic calculi are also found in cases of phosphate-of-lime calculi which occur in the kidney, Beale says, “ mixed with a considerable quantity of pulverulent matter like fine sand.

Each particle of this is found, upon microscopical examination, to consist of a minute calculus, containing a certain quantity of organic matter, probably mucus and disintegrated epithelium, for its nucleus.”

This author says “ Any solid matter may

't form the nucleus of a calculous concretion — inspissated mucits from any part of the urinary organs, crystals which have been deposited, cells of epithelium, ova of entozoa, pieces of fibrin and small clots of blood, foreign bodies which have been introduced from without.”

The nucleus of the microscopic calculus of oxalic acid does not depend, like that of the phosphatic calculus, on mucus or epithelium ; but consists of crystals of oxalic acid which have aggregated in the uriniferous tubes, and finally find their way into the pelvis of the kidney as a nucleus where it may become entangled in the mucus of the mucous membrane, and then further increasing in size, pass down the ureter into the bladder, and if the urine contain much oxalate of lime may receive additions which "NYill render it too large to escape by the urethra.

Dr Beale’s opinion is that oxalic acid, especially in its form of dumb-bell crystal, is the substance which is generally deposited in the uriniferous tubes, and forms the microscopic calculus. He writes : — “ Many small uric-acid calculi, which appear to be composed entirely of this substance, will be found on careful examination to possess a nucleus consisting of oxalate of lime, and not unfrequently well-defined dumb-bell crystals may be obtained .... From recent analyses I have made I have been led to the conclusion that the dumb-

CAUSES OF URINARY CALCULI bell crystals form the nucleus around which the uric * acid is deposited, more frequently than any other substance. ... A microscopic calculus may consist of only two dumb-bells. . . . These

minute calculi remain probably for some .time in the kidney, and slowly increase until they form the concretions known as hempseed calculi.

. . . Having arrived at the bladder the slow

deposition of the oxalate may continue, or layers of uric acid or phosphate may be deposited.”

This author mentions another fact, in addition to that of the concentration of the fluids, which would lead to a deposition of crystals. He says that a nucleus of the purest calculus contains a certain quantity of animal matter which is deposited with the hard material, and seems to agglutinate the particles, and in this, after the hard matter has been dissolved out, fungi have been found, and he thinks it probable that they developed an action in the fluid around them during their growth which caused the continual precipitation of the soluble matter.

The most frequent mode in which renal con- Dr Prouf cretions of oxlate of lime are formed are thought by Dr Prout to be by the influence of cutaneous disease, particularly of the scaly kind. He writes : “ In certain states of the system frequently connected with cutaneous disease, and with the presence of oxalic acid, the mucous membranes of

Chap. I.

Concrete form of liihic acid.

E.Yciting causes.

the urinary organs, and particularly of the kidneys, are disposed to throw off large quantities of lime, either in the shape of carbonate or phosphate of lime or of a mixture of the two. Now, when this is the case, and when oxalic acid, in any state of combination, is at the same time eliminated by the kidney, the formation of the oxalate-of-lime concretion is inevitable ; for, from the great excess of lime present, and from the tendency in the urine to alkalescence on such occasions, the oxalate of lime formed, no longer capable of being retained in solution, is deposited in the solid form.'^

Though, according to Beale’s theory, lithic acid is generally deposited in the kidney around dumb-bell crystals of oxalic acid, yet it is evident that this is not invariably the case, for Dr Prout states that “ about the middle period of life the lithic acid begins to assume the amorphous concrete form, and to give occasion to the formation of renal ind vesical calcidi ; and, lastly, that in more advanced age, there is occasionally a tendency to form numerous small calculi by the deposition of lithic acid round minute nuclei,” called pisiform concretions.

The following are causes which may lead directly to the formation of calculous nuclei in cases of gravel —

1st. Congestion ot injldTnmation of the kidneys.

CAUSES OF URINAIIY CALCULI

The secretion of inflammatory mucus or lymph, the elfusion of blood, or desquamation of epithelium from the congested and inflamed mucous lining of the infundibula, pelvis, or other part of the kidneys, may act as a nucleus upon which the crystals of oxalic or lithic acid are deposited, or by which the crystals of those substances become cemented together immediately after secretion, forming a nucleus “ soliciting further additions. This state of the kidneys may result from any of the common causes of disease, especially sudden chill, or it may follow injury.

2nd. Congestion and inflammation of the bladder. — The congested and inflamed mucous membrane of the bladder may produce adhesive mucus or may lead to the effusion of blood, by which the particles of gravel in the bladder become coherent into a calculus as by a kind of cement ; or those substances may. Holmes says, “ cause a precipitation of the ordinary salts of the urine around them, viz. the uric acid, urates and oxalates, and thus form stone.”

3rd. Enlargement of the prostate gland and stricture of the 7ire^/ira.— These states may prevent the renal calculus, after it has found its way into the bladder, escaping by the urethra, and the urine being supersaturated with the salts of lithic or oxalic acid throws them down upon the calculus, and thus rapidly increases its dimensions. Besides

■ wliicli eflfect, tlie above-mentioned diseases give rise to pbospbate-of-lime calculi as explained by Sir B. Brodie : — “ In cases of disordered prostate gland, the mucous membrane of the bladder sometimes becomes inflamed, and the mucus secreted by it deposits phosphate of lime in small masses, and each of these becomes the nucleus of a calculus, but such calculi may unite and form large ones.” 4th. Foreign bodies in the bladder. — Solid substances introduced into the bladder irritate and inflame its mucous membrane, and even in the most healthy persons soon become encrusted with calculous matter.

Author's observations. Many of the cuuses, such as the above, which

predispose to and which excite stone in the bladder are fully recognised, but it is not understood why, under apparently the same conditions of climate, water, &c., the disease should be common in some districts of a country and rare in others. For the elucidation of this subject the theory propounded by Dr Beale is very suggestive, and is the direction in which I think an inquiry should be made into it. His views are that the calculus generally commences in the uriniferous tubes by an aggregation of microscopic particles of oxalic acid (he has seen two dumb-bells only forming the starting-point), and that the precipitation of the crystals results both from the concentration of the fluids of the body, as well as fiom

CAUSES OP URINARY CALCULI the development of fungi, the latter having also the property of agglutinating the deposit. If this opinion that a microscopic oxalic-acid nucleus is generally the starting-point of all calculi be a correct one, it would explain why in limestone districts calculus is common, for supposing the microscopic calculus to be present, it could scarcely be washed out of the tubes by the drinking of hard water, as it might be if plenty of soft water were taken, but would be likely to form concretions of oxalate of lime, the affinity of oxalic acid for lime being such that Dr Prout says it takes this earth from all its forms of solution.

The latter author’s views, as quoted above, on

the influence of cutaneous disease in producing

renal concretions of oxalate of lime are worthy of

attention, as they may explain the starting-point

of the microscopic calculus in some cases. It

would therefore be interesting if surgeons who

have the opportunity would make observations as

to whether skin diseases, especially of the scaly

kind, are common in the calculous districts of countries.

Chap. I.

Chap.

Dissection.

Chapter II Anatomy Of The Parts Concerned In Lithotomy

n. Every surgeon who is likely to be called upon to operate for the extraction of calculus should freshen up his knowledge of the anatomy of the parts concerned in lithotomy by making the following dissections.

Having introduced a staff into the bladder, raise the scrotum upwards, moderately distend the rectum with tow, and place the subject in the lithotomy position.

Make an incision along the middle line of the perineum from the back of the scrotum to the anterior margin of the anus, carry it around the anus, and continue it backwards to the tip of the

coccyx.

A transverse incision should now be made along the back of the scrotum from one thigh to the other, a second similar one in front of the anus, and a third in front of the coccyx, the flaps of skin corresponding to these incisions being

removed.

ANATOMY OF THE PARTS CONCERNED

The superficial fascia now lies exposed, con- ch^p^u. sisting, as in other situations, of two layers — one the superficial or fatty layer, and the other the deep or membranous layer. The latter layer will be *'‘®

'' V superficial fascia.

found to blend in front with the dartos of the scrotum ; at the sides to be firmly attached to the margin of the rami of the pubes and ischium, and posteriorly to extend backwards as far as the transversalis perinei muscle, around the posterior margin of which it turns, to be united to

the deep perineal fascia upon which the muscle lies.

This attachment of the deep layer of the suvev- attachment of deep

’ I n • , At/ layer of superficial

Jiciat fascia to the deep perineal fascia prevents fluid extravasated under the former passing back into the posterior half of the perineum, but allows it to extend into the scrotum and up over the abdomen.

The superficial fascia having been removed on ^'yciesofthepems one side, the muscles of the genital region of the perineum will be laid bare ; these are the transversus perinei muscle, extending across the back part of the perineal space in front of the anus, the erector penis on the outer side, covering in the unattached part of the crus penis, and the accelerator urin£E on the middle line of the perineum the posterior fibres of which have an attach’

ment to the anterior layer of the triangular li»ament. °

Cn^ii. incisions in lithotomy are made obliquely

Triangular space. acFOSS the triangular space formed by these muscles (fig. 1), dividing a few of the posterior fibres

{Wilson.)

Fig l.-ThemuBcleBof the perineum. 1. The acceleratoreB urinm muBcleB • the figure restB on the corpus spongiosum penis 2. The of the accelerator urinae muscle, and some of those of the transversus perinei muscle. n.,pp.r«r~» A clear idea of the connections of the deep

it supports I

the parts concerned in lithotomy and constitutes a boundary which prevents extravasation of unne. ,, It forms the triangular ligament by dividing into |, two layers of fascia which coalesce at the posterior

J'.a

ANATOMY OF THE PAETS CONCEENED border of tbe transversus perinei muscle, but are elsewhere separated from each other by nearly three quarters of an inch. Between the two layers of the triangular ligament thus formed lies the membranous portion of the urethra traversing the interval from above downwards and forwards ; the compressbr urethrge muscle and a plexus of veins are also here found ; at the outer part lying along the border of the ramus of the os pubis the internal pudic artery is situated, and running across the space from without inwards close to the anterior layer, about sixteen lines in front of the anus, is the artery of the bulb, and close behind the bulb Cowper’s gland is placed.

In order to display this fascia, clear away the above-mentioned muscles, and on dissecting away the posterior fibres of the accelerator uringe muscle a dense aponeurotic structure will come into view (fig. 2), which is the anterior layer of the triangular ligament, or, in other words, of the deep perineal fascia, extending across and closing the anterior part of the perineum completely, with the exception of the opening for the passage of the urethra about an inch below the symphysis pubis. It is triangular in shape, attached above by its apex to the subpubic ligament; on each side to the rami of the pubes and ischium, and below at fis base, after coalescing with its posterior layer.

It joins the deep layer of the superficial fascia

Chap. II. ( Wilson.)

Fig. 2. — The pubic arch, with the attachment of the perineal faaciae,

1, 1, 1. The superficial perineal fascia divided by a A-shaped incision into three flaps ; the lateral flaps are turned over the ramus of the os pubis and ischium at each side, to which they are firmly attached ; the posterior flap is continuous with the deep perineal fascia. 2. The deep perineal fascia. 3. The opening for the passage of the membranous portion of the urethra previously to the entrance of the latter into the bulb. 4. Two projections of the anterior layer of the deep perineal fascia, corresponding with the position of Cowper’s glands.

at the posterior border of the transversus perinei muscle.

Posterior layer of the Now rcmove the auterior layer of the tri-

perinciil fascia or

triangular ligament, ligament, with all the muscular and other

structures which lie in the interval between it and the posterior layer, when the latter will come into view.

Then dissect away this layer of fascia and the strong fibres of the levator ani muscle covering the sides of the prostate will be seen, some of which are always divided in lithotomy.

Lastly, dissect off the anterior part of the

ANATOMY OF THE PARTS CONCERNED levator ani muscle, so as to expose to view tlie cn^ii. prostate gland enclosed in its sheatli of fascia.

The only part of the triangular ligament incisions of the wau-

^ o o gular ligament in

incised in lithotomy should be the lower part of the anterior layer, and the knife should be made to enter the membranous portion of the urethra between it and the posterior layer without wounding the latter. Any such wound would be dangerous, and must be carefully guarded against, as it would open up the recto-vesical fascia which is connected with the posterior layer of the triangular ligament, and extravasation of urine would be the result.

The liability to this accident is increased if the breech of the patient is not kept in a horizontal position during the operation, but is allowed to tilt upwards : the apex of the prostate gland no longer then remains anterior in position, but being raised, its place is taken by some part of the lower surface of the prostate covered with its capsule. A somewhat similar but still more serious malposition of parts takes place when, as sometimes recommended in books, the staff is made to project underneath the skin of the perineum, for the prostatic portion of the urethra may then be displaced in such a way as to cause the lower surface of the prostate to face anteriorly, or the gland itself to come to be placed underneath the membranous portion of the uretlira in the line of the incision usually made into that part. Figs. 3 and 4, copied from a

( Wilson.)

Fig. 3. — A side view of the viscera of the pelvis, showing the distribution of the perineal and pelvic fasciae. 1. Symphysis pubis. 2. The bladder. 3. The recto-vesical fold of the peritoneum, passing from the anterior surface of the rectum to the posterior part of the bladder ; from the upper part of the fundus of the bladder it is reflected upon the abdominal parietes. 4. The ureter. 6. The vas deferens, crossing the direction of the ureter. 6. The vesicula seminalis of the right side. 7, 7. The prostate gland divided by a longitudinal section. 8, 8. The section of a ring of elastic tissue which encircles the prostatic portion of the urethra at its commencement. 9. The prostatio portion of the urethra. 10. The membranous portion enclosed by the compressor urethras muscle. 11. The commencement of the corpus spongiosum penis, the bulb. 12. The anterior ligaments of the bladder formed by the reflection of the pelvic fascia, from the internal surface of the os pubis to the neck of the bladder. 13. The edge of the pelvic fascia at the point where it is reflected upon the rectum. 14. An interval between the pelvic fascia and deep perineal fascia, occupied by a plexus of veins. 15. The deep perineal fascia; its two layers. 16. The Cowper’s gland of the right side, situated between the two layers below the membranous portion of the urethra. 17. The superficial perineal fascia ascending in front of the root of the penis to become continuous ■with the dartos of the scrotum (18). 19. The layer of the deep fascia,

which is prolonged to the rectum. 20. The lower part of the levator ani; its fibres are concealed by the anal fascia. 21. The inferior segment of the funnel-shaped process given off from the posterior layer of the deep perineal fascia, which is continuous with the recto-vesical fascia of Tyrrell. The attachment of this fascia to the recto-vesical

fold of peritoneum is seen at 22. • , ,

(a) Indicating the line of incision into the membranous portion of the urethra quite in front of the apex of the prostalo.

ANATOMY OF THE PARTS CONCERNED

4. — Showing displacement of the prostate gland, a. Line of incision in lithotomy wounding lower surface of the capsule of the gland, when the prostate is pushed by the staff downwards underneath the membranous portion of the urethra.

figure in ‘Wilson’s Anatomy,’ but the latter, somewhat altered, are here inserted to demonstrate the displacement which would take place : in fig. 3 the body of the patient is supposed to be kept horizontally on the table, and the parts in the most favorable position for operating with safety, the letter a indicating the fine of incision into the membranous portion of the urethra quite in front of the apex of the prostate; in fig. 4 the prostate is shown pushed downwards by the staff underneath the situation of the membranous portion of the urethra, the letter a indicating the line of the incision cutting through the lower surface of the prostate and consequently opening up the recto- vesical fascia.