The lateral operation is found to succeed best between sixty and sixty-five years of age, next from four to twenty, and most seldom between twenty and sixty. A patient who is to undergo this opera tion should be free from any flakes of purulent mat ter in his urine, from diseased prostate gland, from spasmodic action of the abdominal muscles, or any affection of the thorax; he should take a cathartic the day before, have a laxative glyster on the morn ing of the operation, and the hair of the perineum shaved off. He is then to be secured with tapes on a firm table, with the nates projecting over the mar gin, and again sounded with a staff delineated in Fig. 3 of Plate DXVI. In ordinary cases of sound ing, the patient is not tied up, but is laid horizon tally, and if no calculus be found, he should be sounded with a catheter while standing, and when the bladder is full of urine, by which means the stone will strike the point of the instrument; and to facilitate this, the flow of urine may be stopped from time to time. When using the sound, the fore and middle fingers of the left hand of the ope rator should be inserted in the rectum. A calculus being ascertained to be in the bladder, the staff is to be held firm by an assistant at right angles to the pelvis close under the symphysis pubis, who at the same time supports the scrotum, while two as sistants hold the feet and knees of the patient. The operator then makes nearly a perpendicular in cision with a scalpel two or three inches longer in its handle (see Fig. 14 of Plate DXVI.) on the left side of the raphe of the perineum, from the root of the scrotum to the fibres of the gluteus maximus muscle which cross the bottom of this wound, and some of which ought to be divided if the operator calculates the stone to be large; this incision is to run midway between the anus and tuber ischii, and should divide the integuments and cellular sub stance. The operator next deepens this incision opposite the membranous portion of the urethra, carefully avoiding the bulb and the accelerator urine and erector penis muscles, but cutting freely the transversus perintei and levator ani muscles. Having reached the staff, by dividing the mem branous portion, he enters the point of the scalpel into its groove, and with his fore and middle fingers depressing the rectum, he runs the scalpel along the groove of the staff through the prostate gland into the bladder (when the urine flows, satisfying him that he has entered the viscus) and cuts obliquely downwards and outwards between the termination of the ulcer and vesicula seminalis, proportioning the incision in the bladder and that of the levator ani muscle to the size of the calculus. The moment he has finished the wound of the bladder and the le vator ani muscle, he should insert the fore and middle fingers of his left hand into the bladder over the stone, to prevent its being grasped by the mus cular contractility of the viscus; and then pass be low his fingers a scoop represented in Fig. 4 of Plate DXVI., and if he cannot easily remove it with this instrument, he should seize it with a pair of forceps, Fig. 5 of Plate DXVI., below the scoop which is to remain in order to prevent the calculus from being removed from its situation, and extract it. If either the bladder, the levator ani muscle, or the external wound is the barrier to its extraction, it should • he more freely incised.
Whenever a calculus is extracted, its surface should be examined, and if any part be depressed, it is to be presumed that another calculus is pre sent, which is to be extracted in the same way, but if grasped by the muscular contractility of the bladder, and it cannot be with facility removed, the patient should be unbound and put to bed, for, when suppuration is fully established, which is commonly the third day, it may be done without giving the patient the least pain, by simply insert ing the fore and middle fingers of the left hand into the wound. But if not, the scoop may be again used, or the forceps, if the operator prefer them, and even a sound may be inserted along the urethra without exciting pain. This mode is termed
operation en deux terns, and may even be employed with advantage, if any difficulty exists in extracting the first, or even when only one calculus is present. If a calculus is soft, and breaks in extraction, the bladder should be carefully washed out with warm water injected by means of a syringe.
When the operation is finished, the patient should be unbound, and put to bed, with a piece of oiled lint applied to the wound, and a bottle of hot water to his feet; and, whenever reaction has taken place, he ought to be bled, if he has not lost much blood during the operation, and in both cases, if there be the slightest appearance of peritoneal in flammation, which, if it follows, must be most promptly treated with antiphlogistic remedies. If hemorrhage supervenes, it is to be checked with a piece of dry sponge inserted in the wound, having a female catheter pushed through its centre to allow the urine to flow. If the blood flows into the blad der, it excites spasms, and must be washed out with tepid water. Low diet, with gentle laxatives for eight or ten clays, ought to be prescribed. In general the urine begins to flow along the urethra about the twentieth clay, and the patient is well in four or five weeks.
When calculi are encysted in the bladder, unless at its neck, they produce no irritation; and when situated there, they require to be removed by the same operation. Occasionally, calculi have been found in the bladder at death, in those who have never complained of them during life; and indivi duals have passed the greater portion of their lives with a calculus in their bladder, until a certain ex ertion has called into action all the horrible suffer ings attendant on this complaint. In this lateral operation, there have been a great many deviations, and a great number of instruments invented, from the time of Ammonius of Alexandria to the present day; indeed, it may be said, " that every surgeon performs this operation after his own fashion, the sante manner as he signs his name." Cutting on the gripe, invented by Fabricius Hildanus, and practised in the present clay on boys, consists in inserting a staff or sound into the bladder, then the fore and middle fingers of the left hand in the rectum, and bringing forwards the calculus to the perineum, when an incision is made on the left side of the raphe in the perineum as in the lateral operation, at once upon the stone, which is extracted with the fingers of the right hand or a hook.
When calculus occurs in the female, it may be removed by dilating the urethra with Weiss's for ceps; but unless the stone is small, this is a cruel method, and often causes the patient to be tor mented with incontinence of urine for life. An operation is, therefore, to be preferred, and that per vaginum, as done by Fabricius Hildanus, Ruysch, Tolet, Klein, and Vacca, appears superior to those of Messrs. Louis, Dubois, and Lisfranc.
When small calculi are arrested in the male urethra, they are stopt either at the perineum, op posite the scrotum, or opposite the frenum. When at the perineum, a large sound is cautiously in serted into the urethra, until it touches the calculus, the penis and sound are then tied with a piece of tape, and the patient desired to drink freely of di luents; and when the urine has accumulated in the bladder, the tape and sound should be removed, that he may make water forcibly. If this does not succeed, an incision should be made over the stone and extracted. When opposite the scrotum it is highly dangerous, and an attempt must be made to push the calculus gently backwards to the perineum, and treated as just recommended; but if this is im possible, a free incision must be made through the scrotum over the calculus and extracted. When opposite the frenum, it may be removed by inserting a common silver probe, with its eyed-end bent for a short distance; but if' this does not succeed, it must be extracted by an incision.