f.n 
)e:t hand, while with his tight ha introduces 
it with its concave side turned towards the 
holly ; the left hand is now to draw the penis 
gently forward, and upon the instrument, 
which is tints gradually inserted into the 
bladder. ]t the sound drop immediately 
upon the stone, the surgeon will teel a tre- 
mulous motion. In this, however, lie must 
he careful that lie is not deceived. If the 
instrument have not, at its lirst introduction, 
hit upon the stone, it is to be moved in va- 
rious directions, or the finger may be passed 
into the anus, or the body of the. patient pla- 
ced in different postures. Even if after these 
trials, the existence of stone does not appear 
obvious from sounding, the operation may in 
a day or two be repeated. 
To dissolve stone in the bladder various 
expedients have been practised, but without 
success. All that art has hitherto been able 
to accomplish, is in some measure to obviate 
the constitutional tendency towards its pro- 
duction, and nothing appears more effectu- 
ally to operate in this manner than a long 
continued use of vegetable or mineral alkali, 
saturated with carbonic acid. (See Materia 
Medic a and Pharmacy). The pain of 
stone may sometimes be temporarily reliev- 
ed by opiates and other antispasmodics, as 
well as by aupdynie fomentations. 
Of the operation for extracting stone. 
(Lithotomy). Two methods only of per- 
forming this operation are in the present day 
spoken of: the one, the high ; the other, the 
lateral operation ; and, indeed, the former, 
“which consists of making an incision into the 
bladder above the pubes, is almost entirely 
laid aside. It cannot be done without wound- 
ing the peritoneum, and, consequently, en- 
dangering inflammation of this membrane, 
the mischiefs from which have been already 
expatiated on. See the section on wounds. 
The lateral operation was first performed 
by Frere Jacques, a French priest. It was 
practised and improved by Cheselden, and 
has recently undergone some alterations. 
The patient, properly prepared by laxa- 
tives, enemas; &c. without being too much 
reduced, should be directed to retain his 
urine some hours previous to the operation. 
The perinaeum and neighbouring parts are to 
be shaved. 
A table, a little more than three feet in 
height, is to be covered with blankets, pil- 
lows, &c. upon which the patient is to be 
laid, and secured in the following manner: 
Two pieces of broad tape, about five feet 
Jong, are to be doubled, and a noose formed 
upon them, to be passed over the patient’s 
wrists ; the patient is then to lay hold of the 
middle of his foot upon the outside ; one end 
-of the tape is to be passed round the hand and 
foot, and the other round the ancle and 
hand, and the turns repeated in the reverse 
way ; each hand and foot is then to be tied ; 
the buttocks are to be brought an inch or 
two over the edge of the table, and by pillows 
to be raised higher than the shoulders. One 
pillow should be placed under the patient’s 
head. 
The surgeon is now to introduce a grooved 
staff (fig. 51) through the urethra into the 
bladder, with this he feels the stone ; he 
then inclines the staff oblicjuely over the right 
groin, so that its convex part may be felt in 
the perinaeum, on the left of the rapine. He 
SURGERY. 
then fixes it, and gives it to an assistant, who 
holding it with his right hand, is to press it 
gently, until, with his left hand, he raises 
and supports the scrotum. The operator, 
now seated or kneeling between the patient’s 
thighs, makes an incision with a convex-edged 
scalpel through the skin and cellular texture, 
immediately below the symphisis pubis, which 
is just under the scrotum, and where the crus 
penis and bulb of the urethra meet; and on 
the left side of the rapine, and in a slanting 
direction, continues it downwards and out- 
wards to the space between the anus and 
tuber of the ischium, terminating somewhat 
lower than the base of that process. As soon 
as the integuments are thus divided, two 
fingers of the left hand are to be introduced, 
with one keeping back the lips of the wound 
next the raphaj, and with the other pressing 
down the rectum. The surgeon should be 
particularly careful not to cut the crus of 
the penis, which can be easily felt and sepa- 
rated with one of the fingers at their under 
part. The surgeon now makes a second in- 
cision almost in the same direction as the 
first, but rather nearer the rapine and anus. 
The transversalis penis will by this second in- 
cision be divided, with as much of the levator 
ani and cellular texture as will make the 
prostate gland perceptible to the finger. 
The operator now has a view of the mem- 
branous portion of the urethra; he i to seek 
the groove of the staff with the fore finger of 
the left hand, the point of which is to be 
pressed along from the bulb of the urethra to 
the prostate giand. It is to be kept there, 
and turning the edge of the scalpel ^upwards, 
he cuts upon the groove of the staff, and 
divides freely the membranous part of the 
urethra, from the prostate gland to the bulb, 
till the staff can be perceived perfectly bare, 
and the point of the finger admitted. 
The prostate and neck of the bladder 
are now to be divided, which may be done 
by a scalpel, but the gorget (51) is more usu- 
ally employed. The membranous part of the 
urethra being divided, and the fore finger 
retained in its position, the point of the 
gorget, previously adapted to the groove, is 
to be directed along the nail of the finger, 
which will serve to conduct it into the groove 
of the staff; to this particular attention is to 
be given. The operator now rises, takes the 
staff from the assistant, raises it to nearly a 
right angle, and presses the concave part 
against the symphisis pubis ; again satisfies 
himself that the beak of the gorget is in the 
groove of the staff, and then pushes on the 
instrument till its point slips from the groove 
into the bladder ; further than this the 
gorget is not to be carried, lest the opposite 
side of the bladder be wounded. The en- 
trance of the gorget into the bladder will be 
shewn by the intermediate discharge of the 
urine from the wound ; the staff is now to 
be withdrawn, and the finger pushed up along 
the gorget to search for the stone, that the 
manner of introducing the forceps may be 
known ; at least that the finger serves to di- 
late the wound in the bladder. A pair of 
forceps (fig. 52) are now to be introduced 
with their blades shut close, and tire gorget 
is then to be drawn slowly away in the same 
direction in which it entered. The handles 
of the forceps are now to be depressed till 
they are nearly horizontal; one blade is to 
be directed towards the symphisis pubis, 
when the stone is touched, the blades of the 
forceps are to be opened and moved in vari- 
ous directions, so as to lay hold of the stone ; 
if the operator find a difficulty in doing- this, 
the linger may be introduced into the rectum, 
and that part of the bladder which may lodge 
the stone, elevated. If the forceps happen 
to grasp the stone, in a direction inconveni- 
ent for its extraction, it should be permitted 
again to slip out of the blades. The stone 
should be extracted slowly. When it has 
broken in the bladder, or is in detached 
pieces,. the scoop (iig. 53), or finger may be 
introduced to retnove«the smaller fragments. 
Sometimes it is necessary, to- inject the wound 
with warm water, and raise the patient’s body, 
in order to wash out some of. the remaining 
concretions. 
When any considerable artery bleeds, 
it is, if possible, to be taken up with a' liga- 
ture ; if this cannot be done, pressure is to be 
made on the 'wound with a firm roller. 
When the operation is over, the pelvis of 
the patient should be placed lower than the 
body, in order to preserve the wound in a 
depending posture, to facilitate the discharge 
of blood. When the bleeding has subsided, 
the bandages are to be untied, a piece of dry 
lint put between the lips of the wound, which 
is to be often renewed, and the thighs are to 
be brought together. The patient is then to 
be laid in a bed, with the pelvis low, a large 
dose of laudanum given ; and when much 
pain is afterwards complained of in the ab- 
domen, anodynes' are to be given by the 
mouth and by enema, and fomentations, with 
bladders of warm water, are to be applied 
to the pubes. Sometimes after the ope- 
ration of lithotomy, the wound will be healed 
in a month ; at other times, even if the ope- 
ration be successful, the patient will be con- 
fined for three or four months. 
Incontinence of urine. This may arise 
from various causes ; loss of power in the 
sphincter of the bladder, irritation about the 
neck of this organ, laceration of its coats, 
or pressure from the uterus in advanced stages 
of pregnancy, are circumstances which may 
be conceived fully adequate to produce an 
incontinence or suppression of urine. 
When a suppression of urine arises from 
deficient power in the bladder to expel its 
contents, the catheter (figs. 75 and 76) is to 
be introduced in the same manner as the 
sound, in order to draw off the water ; in 
cases likewise of suppression from the pres- 
sure of the gravid uterus, the catheter is often 
employed with much advantage. 
When the urine is retained in consequence 
of irritation and inflammation in the neck of 
the bladder, the disorder is violent and 
alarming; it is characterised by the ordinary 
symptoms of inflammation, attended with an 
extreme pain and much swelling of the -affect- 
ed parts, so that the catheter cannot be intro- 
duced. Treatment: Topical and general 
blood-letting, anodyne fomentation, opiates 
in large dose ; injections into the rectum of 
warm water, warm bath. 
If the disorder, notwithstanding these 
means, continues, and every attempt has 
failed of introducing the catheter, a puncture 
must be made into the bladder; this ope] 
ration is by. some recommended to be per- 
formed above the pubis, by introducing a 
a laucet.poiiited trocar of two inches long, 
11 
