(1) The ordinary median operation for stone may be extended in the following manner: On the finger being introduced into the blad der as for digital exploration by perineal urethrotomy, the membra nous urethra may be opened up by passing a curved probe-pointed bistoury into it, with the edge directed toward the operator, from the wound; in this incision may be included more or less of the entire thickness of the perineum. A further extension is made by passing the curved probe-pointed bistoury by the side of the finger well into the bladder. The edge is turned toward the rectum, and the floor of the prostate is divided from within outwards, commencing in the de pression which more or less exists at the entrance to the urethra. The incision thus made may be extended downward to the capsule by the firm pressure of the finger. In this way as free an opening into the bladder may be made in the median line of the as by a lateral lithotomy, and with no risk of causing hemorrhage. I believe this will be found a simple and safe way of opening the bladder for the removal of stones, which, without these modifications, could only be effected by either lateral or supra-pubic cystotomy. Further, it provides for an incontinent flow of urine from the bladder, which usually continues for some days.
(2) The second method of utilizing median urethrotomy for the removal of stone from the bladder consists in breaking the stones into such fragments as will permit of their withdrawal without any exten sion of the ordinary incision. Perineal lithotrity, as this operation may be called, has been referred to by Dr. Gouley," of New York, in the following words " The name of perineal lithotrity was given in 1862 by Professor Dolbeau," of Paris, to an operation completed in one sitting, by which the membranous portion of the urethra is opened, the prostate and neck of the bladder dilated instead of being cut, and a large stone crushed, and the fragments immediately extracted." The pulverization of the stone is here effected by crushing forceps, straight and curved (Figs. 61 and 62) which can be passed into the bladder through a perineal urethrotomy admitting the index finger as for digital exploration. These forceps are provided with a cutting rib within the blades. The more powerful instruments are fitted with a movable screw on the handle. The fragments may subsequently ho withdrawn by aspirator catheters passed through the wound, or even by the forceps. If care is taken to make the perineal wound correpsond in sizewith evacuating catheters there is no difficulty in keeping the bladder distended with fluid during the necessary manip ulations.
One of the severest tests to which I have seen these crushing for ceps put to was in the case of a large cystine calculus removed by Mr.
Heycock at St. Peter's Hospital in May, 1894, by perineal lithotrity. It weighed over two ounces. The tough, waxy nature of the stone would have resisted the most powerful lithotrite and it was with some difficulty that the forceps reduced it to such pieces as were remova ble by this route. The patient made a good recovery.
I have selected this method in twelve instances out of over 400 stone cases requiring operation, and have so far had no deaths follow ing it. The chief points in its favor are these : (1) It enables the operator to crush and evacuate large stones in a short space of time. (2) It is attended with a very small risk to. life as compared with other operations where any cutting is done, such as lateral or suprapubic lithotomy, and is well adapted to old and feeble subjects. In a re cent address, Mr. Swinford Edwards'°° shows that the latter operation for large stones has a mortality somewhere about fifty per cent. (3) It permits the operator to wash out the bladder and any pouches connected with it more effectually than by the urethra, as the route is shorter and the evacuating catheters employed are of much larger calibre. (4) The surgeon can usually ascertain, either by exploration with the finger or by the introduction of forceps into the bladder, that the vis cus is cleared of all debris. (5) It enables the surgeon to deal with certain forms of prostatic outgrowth and obstruction complicated with Molly of the bladder in such a way as to secure not only the removal of the stone, but the restoration of the function of micturition. (6) By the subsequent introduction and temporary retention of a soft rubber drainage-tube, states of cystitis clue to the retention of urine in pouches and depressions in the bladder wall are either entirely cured or are permanently improved. To lock up unhealthy am moniacal urine in a bladder that cannot properly empty itself after a lithotrity, is to court the formation or recur rence of a phosphatic stone. Hence the operation is well
suited to some cases of recurrent calculus. I have never known the wound to remain unhealed, except in those in stances where, for some reason or other, it has been desired to construct a low-level urethra.
It is well adapted for some cases of stone in the blad der complicated with stricture in the deep urethra, as it enables the surgeon to deal with both at the same time. Nor does it expose the patient to the risk which may be attendant where lithotrity is performed with a weakened or permanently damaged urethra, as illustrated in a pre ceding case. Dr. Bangs"' records .a case of recurrent cal culus of much interest, where dilatation of the prostatic urethra through a perineal opening was effected, for the purpose of crushing and extracting the stone, by means of Dolbeau's dilator (Fig. 63). The instrument is expanded by a screw arrangement at the handle. Commenting upon this patient, Dr. Bangs observes : "He is able to urinate spontaneously standing, and in a full stream, and when the catheter is passed once a clay for the purpose of washing there is only one, and rarely two, ounces of residual urine. This improvement in his power of urination is the result to which I wish to call special attention. During the first operation (supra-pubic cystotomy) the apparent obstacles to urination, namely, the prostatic outgrowths and the calculus, had been re moved; and after the operation the bladder had been drained as long and kept as clean as after the second. But there was very little spontaneous urination, and the act was accomplished with a hesitating, dribbling stream, leaving a notable quantity of residual urine to decompose and fret an already irritable bladder. After the perineal operation, however, he was able to stand up, and almost entirely empty his bladder in a strong, full stream, with every sense of comfort. An explanation of the difference in the result must be sought for, and I think is to be found in the enormous dilatation to which the prostatic urethra was subjected in the perineal operation. This fact has, I believe, an important bearing upon the many failures to obtain spon taneous urination after prostatectomy." Stone in female adults and children is comparatively rare, which is probably due to the short urethra favoring the escape of a calculus at the earliest period of its formation. Concretions on foreign bodies, such as hair-pins, are not unfrequently met with, and the possibility of a stony mass having a nucleus of this kind must not be lost sight of in connection with their removal. Instances are recorded where the jaws of the lithotrite became entangled in wires and hair-pins, upon which a phosphatic deposit had taken place, during attempts made to remove the foreign body in this manner.
Where the stone is not large, removal may be undertaken by rapid dilatation of the urethra and extraction of the calculus with forceps. If dilatation is extreme more or less permanent incontinence of urine may result, a condition which is most distressing to the patient, as it is not easily remedied. As indicating the extent to which the fe male urethra may with safety be dilated for the purpose either of ex ploration or of extracting a stone, the following passage on Dr. Ogston's authority may be quoted: "Simon's statements have now been verified by general experience. Hence, since the average diame ter of a man's right index finger at its thickest part is about inch (1.8 cm.), and of his little finger 1 inch, it may be stated that we can safely dilate the adult urethra so as to admit the index finger, and the child's so as to admit the little finger." These limits should not be exceeded, otherwise a risk of permanent incontinence is incurred.
In the case of large stones, which cannot be included within the grip of the lithotrite, removal has been effected by supra-pubic or vaginal lithotomy. The latter operation consists in opening the va ginal wall of the bladder by a median incision, and, after extracting the stone by forceps, reuniting the edges of the wound by sutures, as is done for vesico-vaginal fistula, as described by Dr. J. C. Warren.'" Dr. Galabin has recorded a case where by this operation he removed twelve large calculi and about fifty small ones from the bladder of a woman aged sixty-one. The wound was closed by su tures, and at the end of ten days union was complete.'" Vaginal lith otomy has been almost entirely supplanted by lithotrity and the high operation.