Nodes of pe;forming Lithotomy.—To describe at length the various modes of operating for the stone, and the modifications which each method has undergone, would occupy too much space in a publication not strictly surgical ; we shall therefore merely glance cursorily at those formerly in use, while we direct our attention more particularly to the method which is employed at the present day.
Of the Apparatus Minor Cutting on the Gripe, or Celsns's Method.— This is the most ancient kind of lithotomy, and has probably been practised from time immemorial ; but Celsus having first described it, it has been called Lithotomia Celsiana ; and from the stone, previously fixed by the pressure of the fingers in the anus, being cut directly upon, cutting on the gripe, a knife and a hook being the only instru ments used. The appellation of tho lesser apparatus was given to it by Maria:m..1n order to distinguish It from a method which he described. called the apparutas seirjor, from the many instruments employed. The objections to cutting on the gripe are,—Ist, it is only applicable to children under fourteen years of age ; 2nd, it Is uncertain what parts AM divided, this depending on the degree of force employed In making the stone project in the perineum ; 3rd, the injury liable to be inflicted on parts whose integrity is essential to the success of the operation.
Apparatas Major, or iferias Method, was founded on erroneous principles, and in ignorance of the nature of the parts to be operated on. It was supposed that wounds of membranous parts would not heal, while their dilatation might be undertaken with impunity. In conformity with these uotione, the precept of Celine." Ut plaga paulo major quaru calculus sit," was neglected, and the object endeavoured to be attained was, to do as little as possible with the knife, and as much as possible with instruments called dilators; but the parte thus 'object"' to attempts at dilatation are inelastic, and consequently were lacerated. The severe injury thus produced rendered this one of the most fatal operations in surgery ; but notwithstanding thin, it was practised for near 209 years, till Fnre Jacques, in 1697, taught at l'aris the method at present in use.
MA Operation, so named from the incision into the bladder being male above the pubes, was first practised at Paris in 1475, by Colot, as an experiment on • criminal, by permission of Louis Xl.; but the' earliest pnblishal account of this mode of operating was in 1556, by Pierre Franco. This method is most applicable to those cases in which the stone is too large to be extracted from the perineum, or where there is disease of the urethra sod prostate gland ; but there are several objections to it, and it is now entirely abandoned.
Operation throw gh the Iteetam.—This method was first suggested in a work published in the IGth century; hut the proposal never received much attention till the year I8I6, when it was revived by M. Suwon, of Paris, and carried into operation by him and by Dupuytren ; but the unfavourable results which attended the performance of this ope ration prevented its being generally tried or adopted, and no one of the present day ever thinks of performing it.
Lateral Operation.-4o called from the prostate gland and neck of the bladder being cut laterally, in order to avoid wounding the rectum, is that adopted at the present day. It was first practised by Pierre Franco, a surgeon at 'I ourrierea, but he never eatabli.,hed the method as a permanent improvement in surgery ; this was left for Frere Jacques, a priest, who in 1697 carne to Paris in order to make known this method, which he employed with groat success at various places. Although it appears that he was not quite so successful as he had led the world to believe, the superiority of his mode of operating was immediately perceived and recognised, and, with alight modifications, was adopted by most of the surgeons of that period. Hitherto the Marian section had been used : the advantages of an operation by which a free opening was =de into the bladder, over one in which it was so mull he not to admit of the extraction of the stone without laceration of the parts are too obvious to require comment. Surgeons
of the present day differ somewhat as to the extent of the opening to be made into the bladder, and on the choice of instruments to be employed : some make use of a common scalpel, which cuts into the bladder from without inwards; while others prefer the bletoire cach6, or gorget. which divides the prostate gland and neck of the bladder from within outwards. Having premised thus far, we will proceed to describe the operation as usually undertaken with the cutting gorget. The patient having been sounded, to ascertain that the stone is actually within the bladder (for instances have occurred of steno becoming encysted a short period before the operation), and the rectum being emptied by means of a olyster, he is placed on his back upon is table, with his buttocks projecting rather beyond its edge ; he should bo directed to grasp the outside of each foot with the hand of the same side, and the two pair should then be firmly bound together. A which is an instrument shaped very 'much like a catheter, or sound, but somewhat longer, and grooved on Its convex side, is passed through the urethra Into the bladder, where it must be retained firmly by an assistant ; its convexity looking towards the perineum, and the groove slightly inclined to the left ride of the patient. The operator now commences his incision below the hull, of the urethra, about an inch and a quarter in front of the mum, and continuos it Obliquely down ward, to the loft of the lapin' of the perineum for three inches, till it reaches midway between the tuberosity of the ischium and the anus ; this should cut through the integuments and superficial fascia. The next incision, made in the alma direction, divides the transversus permed muscle, and expenses the membranous portion of the urethra, which must be opened, and the groove in the stall felt for with the finger ; Into this groove, which serves as a director for making the con clust.ng section of the operation, is inserted the beak of the gorget (a sort of knife terminated by a beak, that fits into the groove of the owl). The operator now rises from his chair, and, taking the staff in LL left hand. raises its handle from the abdomen till it forms nearly a right angle with the patient's body; the gorget is now pushed mean's, al ing the groove, till it enters the bladder. ply raising the handle of the staff the gorget is made to enter the bladder in a direction corer 1,41ing with its axis, and the danger of wounding the rectum is thereby avoided. As soon as the gorget has been Introduced the staff a withdrawn, and a pair of long forceps, ezpresaly adapted for this operation, is passed along the gorget into the bladder, and this latter instrument withdrawn. The stone is now to be mixed, and gently extracted; but it sometimes happens that a stone is too large to be rumored without using a degree of force that would be perfectly unjustifiable: in this case, if the wound will not admit of further enlargement, nothing remains to be done but crushing it, and thus taking it away piecemeal. A stone shauld always be examined Mune. ilintely after It is extracted, because its appearance conveys some information concerning the existence of others ; and in every instance the cavity of the bladder should be explored with the finger, to ascer tain that there is no other atone present. Eneysted calculi seldom require en operation for their removal, but should this be necessary, the cyst may be opened by a blunt-pointed bietoury, and the stone taken away. When a stone is known to be of ample size, some ope rators perform what is called the bilateral operation, from both sides of the prostate gland being cut ; for this purpose a double-edged knifo has been invented, called the doable lithotonte.