Volume 4, Slice 1 Part 9 (1/2)
The a.s.sociation of any of these symptoms leads the surgeon to suspect the presence of a stone in the bladder, and he confirms his suspicions by introducing a slender steel rod, a ”sound,” by which he strikes and feels the stone. Further confirmation may be obtained by the help of the X-rays, or, in the adult, by using a cystoscope. In a child the stone may often be felt by a finger in the r.e.c.t.u.m, the front of the bladder being pressed by a hand on the lower part of the abdomen. The _cystoscope_ is a straight, hollow metal tube about the size of a long cedar pencil, which the surgeon introduces into the adult bladder, which has already been filled with warm boracic lotion. Down the tube run two fine wires which control a minute electric lamp at the bladder end of the instrument. At that end also is a small gla.s.s window which prevents the fluid escaping by the tube, and also a prism; at the other end of the tube is an eye-piece. By the use of this slender speculum the practised surgeon can recognize the presence of tubercle or tuberculous ulceration of the bladder, stone, or other foreign material, and innocent or malignant growths. He can also watch the urine entering the bladder by the openings of the ureters, and determine from which kidney blood or pus is coming.
The _treatment_ of stone in the bladder is governed by various conditions. Speaking generally, the surgeon prefers to introduce a lithotrite and crush the stone into small fragments, and then to flush out the fragments by using a full-sized, hollow metal catheter and an india-rubber wash-bottle. Even in children this operation may generally be adopted with success, the stone being crushed to atoms and the fragments being washed out to the last small chip. But if the stone is a very hard one (as are some of the oxalate of lime calculi), or if it is very large, or if the bladder or the prostate gland is in a state of advanced disease, or if the urethra is not roomy enough to admit instruments of adequate calibre, the crus.h.i.+ng operation (_lithotrity_) must be deemed unsuitable, and the stone must be removed by a cutting operation (_lithotomy_).
_Lithotomy_.--Cutting for stone has been long practised; but up to the beginning of the 19th century it was performed only by a few men, who, bolder than their contemporaries, had specially worked at that operation and had attained celebrity as skilful lithotomists. Patients went long distances to be operated on by them, and certain of the older surgeons, as William Cheselden, performed a large number of operations with most excellent results. The operation was by an incision from the perineum, and is ordinarily spoken of as _lateral_ lithotomy. It was splendidly designed, and gave good results, especially in children. But it is now a thing of the past, having almost entirely given place to the _high_ or _supra-pubic_ operation. In the high operation the patient, being duly prepared, is placed upon his back and the bladder is washed out with hot boracic lotion, and when the lotion returns quite clean a final injection is made until the bladder is felt rising above the p.u.b.es. Then the india-rubber tube is removed from the silver catheter by which the injection has been made, and the end of the catheter is plugged by a spigot. An incision is then made in the middle line of the abdomen over the bladder region. The incision must be kept as low as possible, so that the bladder may be reached below the peritoneum, which, higher up, gives it an external, serous coat. As the bladder is approached, a good many veins are seen to be in the way, some of which have to be wounded.
The bladder-wall is recognized by its coa.r.s.e network of pale muscular fibres, through which, on each side of the middle line, a strong suture is pa.s.sed, so that when the bladder is opened and the lotion comes rus.h.i.+ng out, the opening which has been made into the bladder may not sink into the depths of the pelvis. A finger introduced into the bladder makes out the exact size and position of the stone, or stones, and the removal is effected by special forceps. Bleeding having ceased, the bladder-wound is partly or entirely closed by sutures and allowed to fall into the pelvis, the catheter having been removed. It is advisable to leave a drainage tube in the abdominal wound for a while, so that if urine leaks from the bladder-wound it may find a ready escape to the dressings.
_Litholapaxy_.--Lithotrity consists of two parts--the crus.h.i.+ng of the stone, and the removal of the detritus. The two stages are now carried out at one ”sitting,” without an interval being allowed between them, as was formerly the practice, and the term ”litholapaxy” designates this method. The patient having been anaesthetized, 10 oz. of hot boracic lotion are injected, and the crus.h.i.+ng instrument, the lithotrite, is then pa.s.sed into the bladder. The lithotrite has two blades, a ”male”
and a ”female,” the latter fenestrated, the former solid with its surface notched. When the stone is fixed between the blades the screw is used, and great pressure is applied evenly, gradually and continuously to the stone. The lithotrite is made of very tough steel, so that hard stones may be crushed without danger of the instrument breaking or bending. Care must be taken not to catch the bladder-wall with the lithotrite. This danger is avoided by raising the point of the lithotrite immediately after grasping the stone and before crus.h.i.+ng. The stone breaks into two or more pieces, and these fragments must be crushed, one by one, until they are powdered fine enough to escape by the large evacuating catheter. If the stone be large and hard, half an hour or longer may be required to crush it sufficiently fine. When the surgeon fails to catch any more large pieces, the presumption is that the stone has been thoroughly broken up. The lithotrite is then withdrawn and the detritus is washed out by an ”aspirator,” which consists of a stiff elastic ball which is connected with a trap, into which fragments of stone fall so as not to pa.s.s out on the instrument being used at later periods in the operation. A large catheter, with the eye very near the end of the short curve, is pa.s.sed into the bladder; the aspirator, full of boracic lotion, is attached to the catheter, and a few ounces of the fluid are expressed from the aspirator into the bladder by squeezing the rubber ball. When the pressure is taken off the ball, it dilates and draws the fluid out of the bladder, and with it some of the detritus, which falls into the trap. This is repeated until all the fragments have been removed. After the operation the patient sometimes suffers from discomfort. His urine should be drawn off by a soft catheter at regular intervals for a few days. If the pain be severe, it can generally be relieved by fomentations. The patient must be kept in bed after the operation, and in cases where the stone has been large and the bladder irritable, the surgeon should insist on his remaining there for at least a week; in those cases which go on favourably the patients are soon able to perform their ordinary duties.
Fatal terminations, however, do now and again occur from suppression of urine, the result of the old-standing kidney disease which so often complicates these cases.
To Brigade-Surgeon Lieutenant-Colonel Dennis Francis Keegan, of the Indian Medical Service, is due the fact that the operation of crus.h.i.+ng and promptly removing all fragments of a vesical calculus is as well suited for boys as for men. In entire opposition to long-standing European prejudices, Keegan's operation is now firmly and permanently established. The old operation (Cheselden's) of cutting a stone out through the bottom of a boy's bladder is now seldom resorted to, and if a stone in a boy is found too large or too hard to lend itself to the crus.h.i.+ng operation, it is removed by a vertical incision through the lower part of the anterior wall of the abdomen, as described above. For a successful performance of the crus.h.i.+ng operation in a boy a small lithotrite has, of course, to be used, and it must be of the very best English make. The operation has to be done with the utmost gentleness and thoroughness, not a particle of the crushed stone being left in the bladder, since otherwise the piece left becomes the nucleus of a fresh stone and the trouble recurs.
The treatment of vesical calculi by other means than operative surgery is of little value. Attempts have been made to dissolve them by internal remedies, or by the injection of chemical agents into the bladder; but, although such methods have for a time been apparently successful, they have invariably been found worthless for removing calculi once actually formed. Nevertheless, much can be done towards _preventing_ the formation of calculi in those who have a tendency to their formation, by attention to diet, by taking proper exercise, and by the internal administration of drugs.
_Rupture of the bladder_ may be caused by a kick or blow over the upper part of the abdomen, or by a wheel pa.s.sing over it; or it may be a complication of fracture of the pelvis. If the rupture is in that part of the bladder which is uncovered by the peritoneum, the extravasated urine may be cut down upon and let out with good prospect of success; but if the rupture is in the upper or hinder part of the bladder the urine is let loose into the general peritoneal cavity and sets up peritonitis, which is more than likely to prove fatal. If the surgeon knows that the bladder is ruptured he should operate at once in order to provide escape for the urine, and also to sew up the rent.
If the possibility of the bladder being ruptured be even suspected, the surgeon should pa.s.s a catheter. Perhaps he draws off an ounce or two of blood-stained urine. This makes him doubly suspicious, so he injects into the bladder five, eight or ten ounces of warm boracic lotion, and, leaving it there for a few minutes, he measures the amount which he is able afterwards to withdraw; if he finds that a certain amount is lost he is a.s.sured that a leakage has taken place and he at once proceeds to operate. If only the diagnosis is made promptly, and the operation is at once undertaken, the outlook is not unfavourable. A generation or so back nearly all the cases of rupture of bladder ended fatally.
_Villous disease_ of the bladder is innocent; that is to say, it does not spread to the neighbouring structures or implicate the lymphatic glands. The villi are slender, branched, filamentous processes which, springing from the floor of the bladder, float in the urine like seaweed. They are freely supplied with blood-vessels, so that when a piece of a villus is broken off there is likely to be blood in the urine. Indeed, painless haemorrhage is one of the characteristic features of the disease, and when fragments of the ”seaweed” are found in the urine the diagnosis is clear. If the bladder is opened from the front, as already described, the villi may be nipped off by special forceps and the disease permanently cured.
_Malignant disease_ of the bladder is almost always the warty form of cancer known as epithelioma. It springs as a sessile growth from the mucous membrane of the floor near the opening of one of the ureters, and, worrying the sensory nerves, causes irritability of the bladder and incontinence of urine. In due course septic germs reach the bladder, either from the urethra, the bowel, the kidneys or the blood-stream, and cyst.i.tis sets in. When ulceration has taken place, blood occurs in the urine, and the patient--generally beyond middle age--suffers dull or lancinating pains. Eventually the r.e.c.t.u.m may also be involved and the distress becomes extreme. The presence of the growth may be determined by sounding the bladder, by the cystoscope, and by the finger in the r.e.c.t.u.m. If the growth invades the outlet, retention of urine may occur, and the surgeon may be compelled to open the bladder from the front of the abdomen. In cases where operation is out of the question, was.h.i.+ng the bladder with hot boracic lotion may give great relief. The treatment of cancer of the bladder by operation is, as a rule, unsatisfactory, because of the close proximity of the growth to the ureters and to the r.e.c.t.u.m. If, however, the disease were recognized early and had not invaded the neighbouring structures, and if it were upon the upper or the anterior part of the bladder, its removal might be hopefully undertaken.
_Hypertrophy and Dilatation._--When there is long-continued obstruction to the flow of urine, as in stricture of the urethra, or enlargement of the prostate, the bladder-wall becomes much thickened, the muscular fibres increasing both in size and number; the condition is known as ”hypertrophy.” Hypertrophy may be accompanied by dilatation of the bladder, a condition which the bladder may a.s.sume when the voiding of its contents is interfered with for a length of time.
_Paralysis_ of the bladder is a want of contractile power in the muscular fibres of the bladder-wall. It may result from injuries whereby the spinal cord is lacerated or pressed upon, so that the micturition centre, which is situated in the lumbar region, is thrown out of working order. The result may be either retention or incontinence of urine; sometimes there is at first retention, which later is followed by incontinence. Paralysis is also met with in certain nervous diseases, as in locomotor ataxia, and in various cerebral lesions, as in apoplexy.
_Atony_ of the bladder is a paresis or partial paralysis. It is due to a want of tone in the muscular fibres, and is frequently the result of over-distension of the bladder, such as may occur in cases of enlargement of the prostate. The patient is unable to empty the bladder, and the condition of atony gets increasingly worse.
In both paralysis and atony the indication is carefully to prevent over-distension by the urine being retained too long, and at the same time to treat by appropriate means the cause which has produced or is keeping up the condition.
_Incontinence of urine_ may occur in the adult or in the child, but is due to widely different causes in the two cases. In the child it may be simply a bad habit, the child not having been properly trained; but more frequently there is a want of control in the micturition-centre, so that the child pa.s.ses its water unwittingly, especially during the night. In adults it is not so much a condition of incontinence in the sense of water being pa.s.sed against the will, but is a suggestion that the bladder is already full, the water which pa.s.ses being the overflow from a too full reservoir. It is usually caused by an obstruction external to the bladder, e.g. enlarged prostate or stricture of the urethra; a calculus may produce the condition. In the child an attempt must be made to improve the tone of the micturition-centre by the use of belladonna or strychnine internally, and of a blister or faradism externally over the lumbar region, and every effort should be made to train the child to pa.s.s water at stated times and regular intervals.
In the adult the cause which produces the over-distension must be removed if possible; but, as a rule, the patient has to be provided with a catheter, which he can pa.s.s before the bladder has filled to overflowing. A soft flexible catheter should be given in preference to a rigid or semi-rigid one. The best form is the red-rubber catheter, and he should be taught the need of keeping it absolutely clean. In the case of children incontinence of urine means irritability; in adults it means overflow.
The condition termed by Sir James Paget _stammering micturition_ is a.n.a.logous to speech stammering, and occurs in those who are nervous and easily put out. It would seem to be due to the sphincter of the bladder not relaxing synchronously with the contraction of the detrusor, and is sometimes caused by external irritation, such as preputial adhesions. Occasionally not a drop of urine can be pa.s.sed, or a little pa.s.ses and then a sudden stoppage occurs; the more the patient strains the worse he becomes, until at last there is complete retention of urine. The trouble can sometimes be cured by the removal of irritating causes, and in these cases, as well as in those in which no such cause can be discovered, care should be taken to avoid those difficulties which have given rise to the patient's worst failures. If at any time he should fail to perform the act of micturition, he ought not to strain, but should quietly wait for a little before making any further effort. Regularity in the times of making water is also of much importance.
_Retention of urine_ may occur in paralysis of the bladder, or in conditions where the patient is suffering from an illness which blunts the nervous sensibility, such as apoplexy, concussion of the brain, or typhoid fever. It is, however, more commonly due to obstruction anterior to the bladder, as in stricture of the urethra or enlargement of the prostate. The distended bladder can be felt as a rounded swelling above the p.u.b.es, and perhaps reaching to the level of the navel. Percussion over it gives a dull note. When the bladder is distended, it is necessary to evacuate it as soon as possible. If there is no obstruction to the flow of urine, the retention being due to atony or paralysis, a soft catheter is pa.s.sed and the water drawn off. But when there is an obstruction which cannot be overcome, aspiration has to be resorted to, the needle of the aspirator being pushed through the abdominal wall into the bladder. The point of puncture in the abdominal wall is in the middle line a few inches above the symphysis pubis. The bladder may be emptied in this way very many times in the same person with only good result.
_Diseases of Prostate Gland._
The prostate gland may become acutely inflamed as the result of the backward extension of gonorrhoeal inflammation of the urethra; it may also be attacked by the germs of ordinary suppuration as well as by the bacilli of tuberculosis. A sudden enlargement of a large gland lying against the outlets of the bladder and the bowel renders micturition difficult, painful or impossible, and interferes with defaecation.
Pressure of the seat of the chair upon the perineum also causes distress, so the man sits sideways and on the edge of the seat. If abscess forms, it should be incised from the perineum; if allowed to run its course it may burst into the bladder, the urethra or the r.e.c.t.u.m, and set up serious complication. The treatment of prostat.i.tis (inflammation of the prostate) consists in rest in bed, sitz-baths and fomentations.
If retention of urine takes place a soft catheter must be pa.s.sed. In the early stage of an acute attack a dozen leeches upon the perineum may do good. The bowels must be kept freely open, and from time to time, as the pain demands, a morphia suppository may be introduced into the bowel.