SURGERY. 
calculi at the stricture, the plain indication is of course to 
make an incision down to the extraneous substances, and 
extract them. 
In old cases of fistulas in perinaeo, where the dangers aris¬ 
ing from the diffusion of urine, are past, the surgeon is to en¬ 
deavour to make the natural passage as free as possible by 
the use of bougies and catheters: for the fistulous openings 
in the perineum often heal up spontaneously, as soon as the 
urine finds a ready passage forwards through the urethra. 
The prostate gland is liable to enlargement, which inter¬ 
feres with the passage of urine, and renders it very difficult 
to get any instrument into the bladder. Counter-irritation, 
leeching the perineum, and a long continued course of con¬ 
stitutional remedies, will frequently cause great diminution 
in the enlargements. 
An account of the formation of stone in the bladder is 
contained under the article Pathology, and the futility of 
any means of dissolution pointed out. It remains only, in 
the present plan, to speak of the surgical operations for its 
removal.—There are several operations of this kind, but only 
two that deserve our particular consideration, namely, the 
removal of small stones through the urethra, and that which 
is called the lateral operation. The lateral operation is per¬ 
formed either with a knife or with gorgets of various con¬ 
structions altogether: the former instrument and of a straight 
director appears to us by far the simplest and easiest mode of 
-operation. We shall therefore merely subjoin an account 
of it by Mr. Key, who has lately brought it into notice. 
“ With a view to obviate the evils attending the employ¬ 
ment of the gorget and curved staff, and, at the same time, 
to adhere closely to the operation of Cheselden, I use a 
straight director, which I find to answer all the purposes of 
a common staff, to be entirely free from its objections, and 
to combine advantages which a curved instrument cannot 
possess. 
“ I was first led to try an instrument of this form, on the 
dead subject, by the following accidental occurrence. Being 
called upon to examine a child who had died with stone in 
the bladder, I was desirous of performing the operation, 
before making any examination of the body; and having 
neither staff, gorget, nor knife with me, I was obliged to 
operate with a common director, a scalpel, and dressing 
forceps; and I was forcibly struck with the facility with 
which the director conducted the knife into the bladder. 
“ The introduction of this instrument is not attended with 
difficulty; it enters the bladder of the adult, or infant, with 
as much facility as one of the accustomed form. When 
held in the position for the first incision of the operation, it 
might strike a surgeon, in the habit of using a common 
staff, that the point of the director was not in the bladder, 
an objection that, if correct, would justly condemn it as a 
dangerous instrument. To satisfy my own doubt on the 
subject, when first I used it, I cut open the bladder, while 
an assistant held the director, and in every subject on which 
I tried it, I found the extremity projecting some way into 
the base of the bladder. At first I had the extremity made 
straight, but thinking that in depressing the handle it might 
be caught by a projecting fold in the bladder, which would 
considerably embarrass the operator, I had the point slightly 
curved upwards, and as the knife is never introduced so far 
into the bladder, as to reach the curve, it will cause no 
difficulty in its introduction. The groove is made some¬ 
what deeper than in the common staff; to prevent any risk 
of the knife slipping out. The extremity is not grooved, 
but rounded like a common sound, to prevent abrasion of 
the prostate or mucous lining of the bladder. The handle is 
somewhat larger, to afford a better purchase to the hand of 
the operator. 
“ The advantage of a straight over a curved line, as a 
conductor to a cutting instrument, is too obvious to require 
any comment, but its chief superiority consists in allowing 
the surgeon to turn the groove in any direction he may 
wish. Before carrying the knife into the prostate, the 
groove, which has been held downwards for the first inci¬ 
sion, may be turned in any oblique line towards the patient’s 
Vol. XXIII. No. 1603. 
729 
left side, that the operator may think preferable for the di¬ 
vision of the prostate. Nor does it preclude the use of the 
gorget. This instrument may be propelled along the straight 
groove, with more safety than in the curved staff. To those 
who have been used to the gorget, it may be difficult to lay 
it aside; and its employment is certainly less objectionable 
with the straight director than with the common slaff. 
When the gorget is employed, the corresponding motion of 
the left hand is not required to carry it into the bladder; the 
director should be held perfectly quiet, while the gorget is 
propelled along its groove. The danger of passing it out of 
the groove of the director is diminished, if not entirely re¬ 
moved, from which circumstance alone the surgeon gains 
much additional confidence, and, consequently, the pa¬ 
tient much benefit. 
“ The knife resembles, in form, a common scalpel, but 
is longer in the blade, and is slightly convex in the back 
near the point, to enable it to run with more facility in the 
groove of the director. The scalpel blade has this advan¬ 
tage over the common beaked lithotome, that the external 
incision can be made with the same instrument, as the sec¬ 
tion of the prostate gland, thus rendering a change of in¬ 
strument unnecessary. There is less danger also of any 
membrane getting between the groove and the knife, as the 
point of the cutting edge, being buried in the groove, will 
divide whatever lies before it, which is not done by a beake4 
instrument. The opening made in the prostate, and also in 
the perineal muscles, can, in some measure, be regulated 
by the angle which the knife makes with the director, as it 
enters the bladder. In the majority of cases, it will merely 
be necessary to pass the knife along the director, and hav¬ 
ing cut the prostate, to withdraw it without carrying it out 
of the groove; varying the angle according to the age of 
the patient, the width of the pelvis, and the size of the stone. 
As the direction in which the prostate should be divided (in 
order to adhere to Cheselden’s operation), is obliquely 
downwards and outwards, the increasing the angle at which 
the knife enters the bladder, will incur no risk of wounding 
the pudic artery. When the stone is unusually large, it will 
be necessary to dilate the prostate, in withdrawing the 
knife. 
“ This want of power to regulate the size of the incision, 
is an objection to which the gorget is acknowledged to be 
open. Whether the stone be large or small, the same 
opening, and that a small one, must serve in either case; 
and, if the stone be large, the operator cannot avoid em¬ 
ploying violence in its extraction. 
“ As not more dexterity is required to introduce this knife 
upon the director, than every surgeon, however unused to 
lithotomy, possesses, it is almost needless to caution against 
the employment of undue force in the section of the pros¬ 
tate. The knife may be conducted with deliberate care into 
the bladder; the resistance afforded by the prostate will be 
readily felt, and the hand of the operator should be checked 
as soon as he feels the prostate has given way. It will be 
evident, that the most important part of the operation is 
thus divested of that blind force, which renders it hazardous 
in the hands of the most dexterous, as well as of the most 
unskilful lithotomist. 
“ The mode of conducting the operation is as follows:—- 
“ An assistant holding the director, with the handle 
somewhat inclined towards the operator, the external inci¬ 
sion of the usual extent is made with the knife, until the 
groove is opened, and the point of the knife rests fairly in 
the director, which can be readily ascertained by the sensa¬ 
tion communicated; the point being kept steadily against 
the groove, the operator with his left hand takes the handle 
of the director, and lowers it till he feels a check, keeping 
his right hand fixed; then with an easy simultaneous move¬ 
ment of both hands, the groove of the director and the edge 
of the knife are to be turned obliquely towards the patient’s 
left side ; the knife having the proper bearing, is now ready 
for the section of the prostate; at this time the operator 
should look to the exact line the director takes, in order to 
carry the knife safely and slowly along the groove; which 
8 Z may 
