Two Chirurgical Questions, Stated and Answered by John Douglas, Surgeon, F. R. S.

IX. Two Chirurgical Questions, stated and answered by John Douglas, Surgeon, F. R. S. Q I. Whether it is not possible in some Measure to relieve those Persons (who by reason of their great Age, bad Habit of Body, &c. cannot submit to any of the great Operations for the Stone with tolerable hopes of Success) by making an Artificial Fistula in the Perinaeum? A. That a great many Patients offer, both young and old, who are afflicted with the Stone in the Bladder, whom we cannot with any tolerable hopes of Success, advise to submit to the great Operations for the Stone, daily Experience shews. It is inhuman to cut them, and shews a very great Imperfection in our Art, to say we can give them no Relief. Is there no Medium yet found out between living in extreme Misery and submitting to a desperate Operation? Yes; Thomas Fienus about 125 Years ago, proposed a Palliative Cure for such Patients, where a radicative Cure could not be expected; an Operation which may be performed with safety on the most Ancient; the Wound is so small, and the Parts cut off so little consequence to Life. An Operation by which we can prevent or alleviate the most lamentable Effects of the Stone, viz. The total suppression of Urine and the cutting Pains they endure in, and after making Water, &c. yet this Operation has been as little minded all this while by the Hospital- Lithotomists, as Roffet's most excellent Treatise before I introduced the Hypogastrick Section in 1719. Tho' I admire Fienus's design in making this Fistula, yet I can by no means approve of his way of doing it. It ought to be performed thus: Place the Patient as in Marianus's Operation; pass a Staff into the Bladder, then cut the Skin and Fat until you lay that Part of the Urethra bare, which reaches from the prostate Gland to the Cavernous Urethra; then make a small Incision into it with the point of your Knife; then withdraw the Staff, and pass a small flexible Canula into the Wound of the Urethra; then dress the Wound S. A. extract the Canula, clean it and introduce it again every Dressing, that so you may leave a Fistula in the room of the Wound. Through this Fistula the Patient himself or any one about him, may easily pass an Oiled Probe, and push the Stone back whenever he finds himself attack'd with a suppression of Urine, or when the Stone presses hard against the Sphincter, when endeavouring to make Water, which otherwise could not be done without the Ceremony of sending for, and staying in misery till a Surgeon comes to pass the Catheter, which in such cases is not always to be done, without a great deal of Pain, and sometimes Danger. By this Fistula we can also very easily inject any Liquor that may be thought proper either to prevent or allay the Inflammation of the Bladder, or cleanse it from the Gravel, or any other sort of filth that may collect there, by which the increase of the Stone will be prevented, &c. In Females all those advantages are obtain'd by the natural straitness and shortness of the Urethra, whence they never suffer the tenth part that Males do; which is an incontestable evidence that when the Passage into the Bladders of Males is made as straight and near as short (as is done by the forementioned Fistula) they will reap the same advantages by it. Therefore Artificial Fistula's in the Perinaeum ought to be made for those who by reason of their great Age, and bad Habit of Body, &c. cannot undergo any of the great Operations for the Stone, with any hopes of Success. Q. 2. Whether it is not possible to dilate the artificial Fistula in the Perinaeum of Males, and the Urethra of Females with Spunge or Gentian-Tents gradually increased for some time to such a width, that we may easily pass a pair of Forceps into the Bladder, with which the Stone when small may be extracted, and when large, or of an irregular Figure, broke, and the pieces extracted gradually and at different times, when they cannot be extracted at once, without fatiguing the Patient too much? A. To prove that both these Fistula's may be dilated to a sufficient bigness by the means proposed, (especially, if the parts are frequently bathed in a Semi-cupium or otherwise, as the Operator shall think proper, and some warm Oyl injected into the Fistula every time the Tent is changed, (the better to supple and relax the parts,) I shall only make use of three Arguments, viz. One from common Experience in Analogous Cases; Another from the Operations of Nature on the same Parts; And the third from Instances of this Operation being perform'd after the Method I propose. 1st, Common Experience shews to what a great width Fistula's in all other parts of the Body, tho' very small at first, may be dilated by Spunge or Gentian-Tents. 2dly, Nature herself with- without any Art has frequently perform'd this Operation on both Sexes; in Males who have been cut for the Stone after the old way, and had Fistula's remained in Perinaeo. It is often found that some considerable time afterwards, Stones of no small size have appeared which had made their way thro' the Sphincter of the Bladder into the Membranous Urethra, and stuck near the Orifice of the Fistula, whence they were easily and safely extracted. I saw a Stone lately as big as a Pullet's Egg that was expelled from the Bladder of a young Woman without any help, as her Physician assured me, and she had no inconveniency afterwards, which certainly would have happen'd if it had been extracted after the common violent Method. In the last Philosophical Transaction, Dr. Beard of Worcester gives an Account of a yet larger Stone, that passed after the same manner, but she had the common inconveniency afterwards, viz. an Incontinency of Urine, which was owing more to the roughness than the bigness of the Stone, which had lacerated the Parts as in the common Operation, which might have been prevented had she been assisted in time as above. 3dly. Mons. Collet in his Traité de la Taille, gives an Account of a Gentleman on whom he perform'd this Operation three different times, and extracted in all ten Stones. His Words are as follow: Enfin, Mons. Usson étant hors de danger & sa playe prête à se cicatriser, prévoyant bien ce qui pourroit arriver dans la Suite, je lui conseillai de tenir sa playe ouverte, pour y entretenir seulement une petite Canule, qui dans l'occasion donnecroît une entiere liberté de faire Injection pour nettoyer la Vesse de toutes les Immondices & pour qu'on pût calmer les nouvelles Pierres qui pourroient se former. Il prit ce parti, & il se trouva bien durant cin- cinque Années, qu'il a Vecu depuis avec assez de Santé Mais à trois différents reprises, je me suis vu Obligé de lui tirer jusqu'à dix autres pierres qui s'étoient formées dans la Vessie : une petite Tente d'éponge préparée mise pen- dant quelques heures dans la Fistule à la place de la Canule me facilitait l'Entrée d'une très petite tennette. Mons. Usson s'habillait dans ce Moment & il sortait pour aller par tout ou ses Affaires l'appelloient. I know a Gentleman that now keeps a Fistula in Pe- rinæo open for the very same reasons. Since then it is evident that Fistula's in all parts of the Body are dilatable to a great width, since Nature is often able of her self to dilate the very parts in dis- pute, to a very extraordinary Degree; and since this very Operation I here propose has been suc- cessfully performed three times on the same Person, Therefore Artificial Fistula's in Males and the Ure- thra of Females may be dilated so as to extract any Stone without cutting the Body of the Bladder, or lacerating any of the Parts. N. B. This Operation will appear much less surpri- zing, if we consider, that it is only dilating the Sphin- cter of the Bladder, &c. in a different manner from that daily done in Marianus's Operation, i.e. By this Method the Parts are dilated gently and gradually, af- ter being well bath'd and anointed, the better to relax them. Whereas in Marianus's Operation they are di- lated quickly and violently, and then the Stone, be it of what Largeness or Figure soever, is forcibly drawn out immediately; whence Contusions, Lacerations, Hæmorrhages, Inflammations, Mortifications, &c.