Chapter XXIX: Part 29

On one occasion, when practising the operation on the dead body, I found that the instrument had got several stones in its grasp, and was kept so dilated as to be withdrawn with much difficulty—there being no means of disentangling the stones but by farther expansion of the blades, which was impossible. A great many foreign bodies—pieces of pebble—had been introduced; but had the same number of urinary concretions been laid hold of—which is scarcely possible—those farthest from the point and most compressed would have crumbled down, and thus the expansion of the blades would have been diminished. I have not experienced the least difficulty in operating with this instrument, in numerous cases, and at all periods of life. The preferable instrument for the purpose is, however, the small screw scoop. The concretion can by its use be crushed and reduced in volume, so that the urethra does not suffer in the extraction, and the patient is saved much pain. The safety of the proceeding is its greatest recommendation. It is very seldom that any unpleasant symptoms follow; there may, perhaps, be a trifling effusion of blood, and some slight pain in making water may continue for a day or two. Should either irritability of the bladder, or symptoms indicating inflammation of the mucous coat supervene, these must forthwith be combated.

Concretions of such a size as cannot be made to pass through the neck of the bladder, and along the urethra, and yet are not much larger than a filbert, may, if soft and friable, be laid hold of in the bladder by properly contrived instruments, and acted upon so as to be reduced to powder and fragments, which may either pass off along with the urine, or be extracted by means of forceps. This proceeding is not advisable in children, owing to the small size of the parts and their greater irritability, and in consideration also of the concretions in them being in general exceedingly dense; as formerly noticed, they are most frequently composed of the oxalate of lime. In the adult, it cannot be adopted with safety and propriety, when the bladder is irritable and will not bear a certain degree of distention, and when the prostate gland is large. The cases in which the concretion is small, soft, or brittle, and the parts sound and free from irritation, form but a small proportion of those labouring under stone who present themselves to an operating surgeon. However, the bruising, grinding, and rubbing down of stones has been tried in all kinds of cases, but with neither a satisfactory nor an encouraging result; a case will now and then be met with favourable to these proceedings, but they can never become generally applicable, and attempts to make them so will, as experience has shown, be followed by disappointment and disaster.

A stone of a larger size than I have indicated, and of dense structure, may be laid hold of in the bladder, and may by repeated and tedious operations be broken into fragments; but each sitting, as it is called, of the patient, and each attack upon the stone, is attended with more pain, greater risk, and far more exhaustion, than its removal by incision would inflict. The repeated introduction of the instruments, their expansion, and the turning of them about in the bladder, and, if their object is accomplished, the action of the angular and rough surfaces of the fragments on the mucous coat, are certainly followed by an attack of inflammation of the viscus, always tedious and annoying—often excruciating, dangerous, perhaps fatal. Attacks of inflammation of the testicle are also not uncommon, probably from irritation of the prostate, and from the pinching and bruising of the verumontanum, which it is almost impossible to avoid, whatever care and precaution be adopted, when the three-branched instrument is used. In turning to the records of _Lithotrity_—and under this term we shall include all attempts to break down stones within the bladder, whether by drilling, or filing, or hammering—it will be found that many patients have died from the mere exploration; and altogether, nearly a half of those who have fallen into the hands of the experimenters and adventurers have perished in consequence. Every successful case is well advertised; the dead men rest in peace.

But still the operation of breaking up a stone in the bladder is very advisable in certain cases, and may be resorted to with every prospect of a safe, speedy, and successful conclusion. But it can be recommended and employed only within certain limits; the case must be well chosen, and every circumstance must be perfectly favourable as regards the condition of the urinary passage and of the bladder, and the size and nature of the stone. Every operating surgeon should make himself well acquainted with the instruments and their mode of application, so that he may resort to them as occasion requires.

A great deal of ingenuity has been expended of late years in inventing and improving upon the apparatus. Many useless, inapplicable, and highly dangerous machines have been produced, a few efficient and perfectly safe.

The knowledge of the fact that the curvature of the urethra can be effaced, and a perfectly straight instrument, or one with a short curve can be passed into the bladder with equal ease and freedom from uneasiness as a largely curved one, has facilitated very much the application of means for seizing and acting upon a stone in the bladder.

The three-branched instrument, which it is unnecessary to describe, as it can be readily seen and obtained, can be without difficulty brought in contact with the stone, the bladder being partially distended by urine, or filled to the requisite extent by tepid water injected through the outer canula of the apparatus. The branches are then so far expanded, and the drill withdrawn; and by a little cautious management, turning the instrument, altering the degree of expansion, and sounding with the drill, the stone is seized, and then fixed by pulling back the inner canula. By turning the drill with the fingers, and pulling back forcibly the inner canula so as to close the branches, the concretion may at once be pulverised; or it may be again seized, and attacked by the drill on a different side. The operation may, if necessary, be repeated after the lapse of eight or ten days, or sooner, if the irritation caused by the former have subsided. Diluents are to be given so as to facilitate the washing out of the detritus, and strict rest and abstinence from stimuli must be observed for a few days.

Various forms of drill have been contrived for acting on a large surface of the stone; others for scooping it out, the shell to be afterwards broken into fragments and triturated; they are all unsafe and ineffectual. The instrument is also so constructed that a drill-bow may be used, and the apparatus may be fixed by what mechanics call a bench, or it may be attached, by complicated machinery, to the table on which the patient is laid, and be there secured in a proper position. But all this implies an intention of attacking large and dense stones, and a repetition of the attempts. So far as my experience goes—(and besides having seen Civiale and others operate, I have myself employed the instruments in many cases, and very successfully,)—I should dissuade from all endeavours to rid the patient of stone by such means, unless its size and consistence were such that it would yield to one or two attacks.

A plan of crushing the stone, by forcing one part of an apparatus against another by the stroke of a hammer, has been lately promulgated, and by a person who previously maintained that the grinding and rasping was quite perfect, though now regarding them as nought. This percuteur has a short bend at its farther extremity, one-half separates from and slides on the other, and both are provided with teeth. It is very possible to entangle a portion of the bladder betwixt its blades; and, besides, these may bend or break, as they have done in several very bad and abominable cases, in which incisions were required to disengage the instrument from the patient’s urethra or bladder A stone may also be laid hold of by the apparatus, and being so hard as not to yield to the impulse of the hammer, may become fixed in such a way as it cannot be freed from the grasp, there being no provision for pushing it out as in the lithotriteur.

It will be seen from what has been stated, that I am not so sanguine—and I trust I shall be excused of presumption in giving an opinion upon the subject—as to suppose that the breaking up of the stone in the bladder will ever entirely supersede lithotomy. That it would do so was at one time industriously represented, and perhaps believed, by some of the advocates and promoters of lithotrity. If, by some miraculous interposition of Providence, the deposits from the urine should uniformly be pulverisable, and that bladders be made of less irritable stuff than they are, and if, above all, the affected individuals could only be prevailed upon to apply in due time, then might such pleasant anticipations be entertained, and then might we with some reason hope to see them realised; but as matters now are, urinary concretions must, in a great many instances, be cut out of the bladder. Nor is it a circumstance to be very much deplored, since, in good hands, the patient neither endures so much suffering, nor incurs so much risk, as by the proceedings already detailed. The cure, besides, is far less tedious. The stone-grinders, whilst they conceal their own unfortunate results, endeavour to depreciate lithotomy by blazoning abroad the practice of some unlucky surgeon, who, perhaps, loses four in twelve, or six in twelve, of the patients who come under his knife.

It has been said that lithotrity is applicable, when, from the advanced age of the patients and the rigidity of the parts to be cut, lithotomy is not. This statement is incorrect, at least the latter part of it. Old people, from 70 to 80, and even beyond that age, recover, when the operation is conducted quickly, without loss of blood, and so as to guard against infiltration, as certainly and rapidly as young persons. Within the last few years the apparatus for breaking up stones has been very much simplified and improved upon. The screw lithotrite can with great propriety and safety be employed in cases in which the concretion has not attained any very large size, and in which also the urinary apparatus is healthy, and tolerably free from irritability. The cases for this operation must be well chosen, and the proceedings conducted throughout with great caution, gentleness, and judgment. Very full directions are given in the “_Practical Surgery_” for the performance of this operation.

Perhaps no operative procedure has been more canvassed than that of lithotomy. The subject has been discussed, and the operation attempted, by many not very eminently qualified. All sorts of contrivances have been made and promulgated in connexion with this operation; the greater number intended to supply the want either of anatomical knowledge or of operative dexterity. A volume would scarcely contain a catalogue even of the instruments which are in my possession,—crooked staffs, knives, spoons, and forceps. I shall content myself with describing what appears to me the most simple, safe, and certain procedure.

The bladder may be opened, for the removal of stone, in various situations; at its forepart, by incisions above the pubes; in the posterior fundus, by division of the sphincter ani and a portion of the bowel; at its neck, by cutting upon it through the perineum. The first mode is termed the high operation, the second the recto-vesical, the last the lateral. The lateral shall be first considered: it is the safest, the most advisable, and the most frequently resorted to.

Keeping the patient in suspense for days after operation has been agreed on, with the view of preparing him as it is called, is prejudicial. Unless his digestive apparatus be in disorder, or he be labouring under some other affection incompatible with his safety should an operation be performed, the sooner he is cut the better. Delay often inflicts much mental suffering, is apt to induce despondency, and to weaken the defensive and reparative powers of the system. On the night before the operation, a dose of castor-oil, or other mild purgative, is to be administered, so as to obtain an empty state of the lower bowels; should this fail, an enema must be given.

The existence of a stone should be ascertained immediately before proceeding to the operation; it is not enough that the sounding was satisfactory the day before, or at any former period; and the operator will also, for his own sake, satisfy those who are met as his advisers and assistants of the fact that there is a stone in the bladder. All apparatus that may be required should be at hand. A grooved staff, a knife, forceps, a scoop, and an elastic-gum tube, are in general sufficient. A Read’s syringe should also be provided, lest the stone should prove brittle, and crumble under the forceps. When the operator has, by previous examination, ascertained that the stone is of an unusually large size, then he must be provided with a narrow, straight, and probe-pointed knife, with forceps of considerable length and grasp, and also with forceps so constructed as to effect crushing of the stone, should this prove necessary.

The staff should be curved, of a size sufficient to fill the urethra, or nearly so, and with the groove placed betwixt the convex surface and the side presented to the left of the patient. This form of instrument will prove the most convenient guide into the bladder. It is introduced fairly into the viscus, and made to touch the stone audibly. Its concave surface is raised towards the arch of the pubes, and retained thus, firmly hooked under the bones—as if with the intent of lifting the patient from the table—perpendicularly straight, without any inclination of the handle, or any bulging of the convexity towards the perineum. After being properly placed, the instrument is intrusted to an experienced assistant, who keeps it exactly in the same position from the beginning to the conclusion of the incisions. He at the same time elevates the scrotum, and standing behind the patient, leaves the surgeon with both his hands at liberty, and with the patient’s perineum all clear. The operator is thus enabled to guide the knife by the left hand; whereas, if he use a straight staff, his left hand must be solely devoted to the management of this instrument during the most delicate part of the incisions.

The staff is introduced either before or after the patient has been secured. The fixing of the patient is in this operation very necessary and important; on the proper management of that depends much the facility of completing the operation quickly and satisfactorily. Children are easily and conveniently held on the lap of an assistant, who, grasping the knees, places and secures the limbs so as to expose the perineum. In adults ligatures are indispensable; the hands and ankles are to be fixed together by means of strong and broad worsted tapes; and, in addition, the pelvis requires to be secured, and the limbs must be retained well separated, by two steady and powerful assistants, pressing obliquely down towards each other. A band may also with advantage be passed under the hams, and tied round the patient’s neck: the proper position is thus still further secured. The patient is placed on a firm table, of a height convenient to the operator, who is seated on a low stool. A table from two feet and a half to three feet in height, with a stool about a foot lower, will be found to suit very well. The instruments likely to be required are disposed in the folds of a towel placed on the floor, on the right side of the operator, and at a convenient distance.

Before proceeding to incise, the finger is introduced into the rectum to ascertain that it is in an empty state, and also to promote its contraction. A knife is used, with blade and handle somewhat longer than those of a common dissecting knife, and without any edge till within an inch and a half from the point,—held lightly in the fingers, the end of the handle resting on the palm. It is introduced close to the raphe, on the left side, and nearly opposite to where the erector penis and accelerator urinæ approach each other. Its point is made to penetrate through the skin, fat, and superficial fascia of the perineum, and is carried downwards with a slight sawing motion, by the side of the anus—about midway betwixt the anus and the point of the tuberosity of the ischium—and is continued till nearly past the lower part of the orifice of the bowel. The forefinger of the left hand is then introduced into the wound, and the resisting fibres of the transverse muscle of the perineum, and of the levator ani, are touched with the edge of the knife directed downwards. Wound of the rectum is avoided by pressing it downwards and to the opposite side by the finger; indeed the finger should be constantly in the wound as a guide to the knife. In this stage of the proceedings, incision upwards would be likely to interfere with the artery of the bulb, whatever its distribution may be,—whether the vessel come from the pudic, or from the posterior iliac. It occupies nearly the same relative situation in either case, and by care can always be avoided during the second incision. Division of it occasions most profuse, alarming, and dangerous hemorrhage. I have seen the patient lose much blood in consequence during the incisions; and after the occurrence of reaction, have seen the blood soaking through the mattrass, dropping from the foot of the bed, and collecting in pools on the floor. The bleeding is difficult to arrest; the application of ligature is very troublesome, if not impracticable, and efficient pressure cannot be made with safety.

In my own practice I have had little or no trouble from hemorrhage—chiefly, I believe, from never cutting upwards after the first incision. One instance of secondary bleeding occurred. The patient was sixty-one years of age, and had laboured under symptoms of stone for eight years. He had been dyspeptic for some weeks before the operation, but otherwise appeared a favourable subject. Very little blood was lost during the operation, but on the fifth day hemorrhage occurred to the extent of seven ounces; on the eighth day, the same amount was lost; on the twelfth, a pound; on the sixteenth, five ounces; on the seventeenth, about a pound. The bleeding was uniformly preceded by a feverish attack; and the blood had a florid, arterial appearance, and flowed rapidly. It proceeded from the interior of the wound, and a suppurating cavity in the neighbourhood of the prostate was felt by the finger. From the prostatic side of this abscess the blood appeared to spring; probably a considerable branch of the pudie ramifying in this situation had been opened by unhealthy ulceration. Pressure proved always effectual at the time, the hemorrhage recurring on the loosening and separation of the lint. After the last bleeding the dressing was retained for some days, and on its removal no recurrence took place. The patient had been much exhausted by this severe loss of blood, but, notwithstanding, made a good, and by no means tedious, recovery. In one case, also, troublesome hemorrhage occurred within twelve hours from the operation on a patient advanced in life. The bleeding was arrested with some difficulty by ligature and pressure. The patient died on the third day. The cause of the bleeding was found to be ossification, as it is called, or earthy degeneration of the coats of the vessels. The bleeding was from the external hemorrhoidals. The artery of the bulb was untouched.

Many patients have perished within the first day or two from bleeding, owing to the using of the knife too freely, and in an improper direction. By very slight application of the edge to the resisting fibres, and by gentle dilatation with the finger, the membranous portion of the urethra is reached. The knife is passed over the back of the forefinger in the wound, and lodged in the groove of the staff; it is then carried forwards through the prostate, with the edge directed downwards and outwards, cutting the gland obliquely. In this incision the knife is raised very little from the groove, the object being to divide the gland to the extent of no more than barely three-quarters of an inch. By so doing, the reflection of the pelvic fascia remains uninjured, and the boundary is left entire betwixt the external cellular tissue, and that loose and very fine texture immediately exterior to the bladder—betwixt it and the fascia lining the pelvis; thus the risk of urinary infiltration is done away with, at least much diminished. There is great danger in dividing the base of the prostate completely, and much more in cutting any part of the coats of the bladder. When the knife enters the groove of the staff, this latter instrument must be held very steady; if it be at all withdrawn, its point may escape through the wound, and mislead the knife.

There is no great risk of wounding the trunk of the pudic artery, unless by using either a broad instrument called the gorget, or a concealed knife. The former is now almost wholly abandoned. Besides endangering the pudic, it is apt to lacerate the neck of the bladder, pushing the prostate before it, and so tearing its cellular connexions. The latter, the lithotome caché, makes the internal wound larger than the external; the coats of the bladder are slit up to an unnecessary extent, being cut much more easily than the prostate, and the instrument not affording sufficient resistance to the gland.

Through the prostatic opening the finger is easily passed into the bladder, and the stone felt. The staff is then withdrawn. Sometimes it is a troublesome matter to reach the bladder with the finger, in consequence of the straining and struggling of the patient, causing the organ to ascend in the pelvis; the difficulty is overcome by patiently waiting till these exertions cease. By steady and gradual movements of the finger in the wound of the prostate, the opening is much dilated, so as to admit of the ready introduction of instruments for laying hold of and removing the stone. Indeed, the neck of the bladder is capable of dilatation without any incision. In a case of perineal abscess containing a portion of exfoliated bone, on account of which incision was made, it was found that the cavity communicated with the urethra; lest other foreign matter should remain, I introduced my finger into this aperture in the membranous portion, and found that by the most gentle movement I could not only easily reach the bladder, but dilate the opening in it to a very considerable extent.

By the finger in the bladder, the size and position of the stone is ascertained; and no extracting instrument should be employed till after the finger is in contact with the stone. When it is of moderate size, and after having been turned, if necessary, into the most favourable position for extraction, the forceps are introduced. This instrument should be tolerably long, so as to afford power in its use; and the extremities of its blades should be covered with coarse linen, for thus it is not so likely to slip or to chip the stone as those with raised and projecting teeth. For flat stones, the forceps should be flat-mouthed; for round, more open, hollowed, and bent at the points; or for the latter description of stone, forceps with a sliding joint may be used. The object is to lay hold of the concretion by as many points as possible—to bring a large surface in contact with the instrument. Those with the sliding joint are of no service when the stone is flat, as it either cannot be caught by them at all, or merely by their points, or near the joint; they are applicable only to round stones of considerable size, but they are very troublesome to manage. The instrument is introduced shut, along the finger, and on reaching the prostate is gently insinuated, whilst the finger is at the same time withdrawn. It is brought in contact with the stone, and carefully opened, the handles being raised. One blade is passed under the stone, the other remaining above, and then the instrument is closed, firmly but not forcibly. By the finger, again introduced, along the side of the forceps, it is ascertained whether or not the stone is held securely, and in the proper direction; if not all right, it may then be turned by using the point of the finger and slightly relaxing the grasp. Now the handles of the instrument are depressed, so as to avoid resistance from the bones in the front of the pelvis, and the extraction is commenced, in a steady and gradual manner; if difficulty is experienced, dilatation is effected, and the process facilitated, by moving the forceps gently backwards and forwards; no force or violence is required, either in pulling or dilating; all should proceed smoothly and with deliberation.

The forceps must be proportioned in length to the size of the stone; a large concretion requires long forceps, both that it may be grasped securely, and that sufficient power may be afforded for the extraction.

Some stones are of such a size as will not admit of passage through the section of one side of the gland. By using the blunt-pointed knife, directed by the finger, without any additional external incision, a wound is made on the right side of the prostate, in the same direction and to the same extent as that on the left. Thus a triangular flap is formed, the apex towards the membranous portion of the urethra, and through the opening thereby afforded any stone, which will pass through the bones of the pelvis, can be extracted without much difficulty. But no benefit can result from cutting both sides of the prostate, either by the double lithotome or in the manner just detailed, in all cases. It is time enough to incise the opposite side when, by introduction of the finger through the usual wound, it has been ascertained that the stone is too large to pass through it. Then it is safer to cut the other side, than to enlarge the original opening, either by the knife, or by laceration in cruel attempts to extract the stone through an insufficient opening.

When the stones are small, the scoop is the preferable instrument. By it the bladder may be soon cleared, even when the concretions are numerous. It is introduced along with the finger, is brought in contact with the foreign body, and passed beyond it or beneath it. Then the point of the finger is placed on the lower part of the stone, so as to steady and secure it, and the scoop and finger retaining this relation are gradually withdrawn along with the stone. More than one, perhaps, may be removed at each withdrawal of the instrument. The flat and slightly bent lever, usually forming the handle of the scoop, is useful should the forceps unfortunately slip during extraction, leaving the calculus impacted in the wound; by insinuating this instrument behind the stone, and employing it partly as a lever, partly as an extractor, removal is completed.

If the stone break, which should not often happen if the forceps be used properly, the fragments must be carefully brought away, the larger by the forceps, the others by the scoop. The sand and detritus which may remain are washed away by injecting tepid water into the bladder, afterwards promoting copious secretion of urine by diluents.

After almost every operation for stone, particularly when the concretions are numerous, or when they have broken into fragments, a searcher is useful to ascertain whether or not all have been removed. It is a slightly curved sound, with a bulbous point. Having been introduced by the wound, it is passed into every part of the bladder with great care, with the view of detecting small calculi, or fragments, which may have escaped the search of the finger, forceps, and scoop. Besides this precaution, the extracted fragments should be carefully examined, and the stones built up, that the surgeon may better judge if they be all there. The surface of the stone affords considerable information; if it be uniformly rough, the likelihood is that it is solitary; if one or more points are smooth, it is probable that these have been occasioned by the attrition of other calculi. If suspicion still exist of part remaining, examination may be made through the wound, during the suppurative stage, six or eight days after the operation, before it has closed much.

It has been proposed to break the stone when very large, to facilitate its extraction, and many instruments have been contrived for the purpose. I have had no experience of the proceeding, but consider the following description of instrument as the best adapted for the purpose—strong, massy forceps, of considerable length; the blades proportionally narrower, but much thicker, than those of the extracting forceps, and armed with several strong teeth, thick at their origin, tapering gradually, and terminating in a sharp ridge; the handles also thicker than they are broad, that they may not yield to the compressing force, and approximated by means of a combination of the lever with the screw. The foreign body is secured firmly between the blades closed on it; the handles are then fixed by a screw and nut, and compressing force is exerted by the lever acting both as a lever and a wedge. The screw, turned by the fingers, will suffice to crush many concretions; and none can withstand the full power of the instrument. But it is, perhaps, safer to open the bladder above the pubes, and extract the stone through a wound in that situation, when it is too large to pass betwixt the rami of the ischia.

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.

_Calculus of the female_ is exceedingly rare. Concretions are not so apt to be retained in the bladder as in males; they are passed by the urethra. The symptoms are similar to those which have been described as indicating stone in the other sex. Sounding is easy; it is performed with an instrument slightly bent at the farther extremity, and considerably shorter than those employed in the male. Even when the calculi are of considerable size, they can be removed, as well as other foreign matter, by dilatation of the urethra, effected gradually. Portions of gentian root, and sponge tents, were formerly used for this purpose; but of late years various dilators have been contrived. Some are really new, others have been published as such, though correctly represented in works some hundred years old. Their blades are made to separate in a parallel direction by peculiar adaption of the screw; and, by gradually and very slowly increasing their separation, uniform dilatation is effected. Very soon the opening is sufficient to admit the finger; then the size of the stone is ascertained, and, if necessary, the dilatation is continued to a sufficient extent. When thus the canal has been widened so as to admit of the passage of the stone, forceps are introduced, and extraction accomplished in a direction downwards, that is, towards the vagina. Incontinence of urine is apt to continue for some time after this operation, if the dilatation have been considerable, as well as after the removal of larger stones by incision.

Incision has been proposed in various directions—into the vagina, or by the side of it, upwards and outwards; and it has also been recommended to cut the bladder, on the fore and lateral part of its neck, without interfering with the urethra.

By the latter method the chance of incontinence remaining is diminished, but there is a risk of urinary infiltration, and this will require to be provided against by the use of a tube, as after the lateral operation in the male. A staff is introduced, and by it the urethra is depressed towards the vagina. An incision is then made by the side of the crus clitoridis, and through this the finger reaches the neck of the bladder, more by dilatation than by additional use of the knife.

In one case I removed a very large stone by incision. By a straight grooved staff the urethra was depressed; a straight blunt-pointed bistoury, being slid along the groove» was carried upwards and outwards, first on the left side, and then on the right—dividing the urethra and parts exterior, so as to form a track of wound, which, after dilatation, would admit of the ready passage of the stone. Extraction was easy. Incontinence continued for many months, but ultimately was in a great measure removed by promoting farther contraction of the opening by the cautery. The preferable plan, and one I have since then followed in a few instances, is dilatation to some extent, and by a proper instrument; then slight incision on each side upwards and outwards; then further dilatation; in a few minutes, without much pain, the finger is admitted, then the forceps. The stone is then extracted quickly, with but little pain, and no bad consequences follow.

_Gonorrhœa in females_ is often confounded with _Leucorrhœa_, which is a very common complaint both in married and unmarried women. Leucorrhœa sometimes occurs at a very early period of life, at the age of ten or sooner; and in such circumstances affections of the glandular and osseous systems often supervene. Frequently it precedes the accession of the coloured menstrual discharge, and in many instances is substituted for it; it is always most profuse after the menstrual period. In leucorrhœa there is generally neither heat nor pain during the passing of urine, and the colour of the discharge differs from that of gonorrhœa, though sometimes very slightly; the stain of gonorrhœal matter is yellow with a black border; leucorrhœal is white or yellowish, but does not possess the latter characteristic. The application of leucorrhœal matter will induce discharge from the urethra or from the external parts of some males, but the affection thus caused is, perhaps, not so violent, nor of so long duration, as that which arises from specific contagion. The effects of leucorrhœa on the system are very troublesome. There is general debility, disorder of the stomach, pains of the back, sides, and limbs, a sallow bloodless complexion, paleness of the lips. It is often a cause, at other times a consequence, of miscarriage. Sometimes it is accompanied with a prolapsus uteri, sometimes with thickening of the os uteri. The discharge which attends ulceration of the parts, from whatever cause, is generally bloody, sometimes it is thick, and of a laudable aspect, sometimes thin and fetid. More or less discharge attends polypus, and is often profuse and coloured.