674

SURGERY.

means of forceps. The patient was now carried to bed, and theafter treatment left to the attendants. Professor Rau of Holland improved upon this method, by making a groove in the staff, whichenabled him, with greater certainty, to continue his incision intothe bladder: but instead of dividing the urethra and prostate gland,the latter of which he was afraid of wounding, he dissected by theside of the gland, till the convex part of the staff was felt in thebladder, where he made his incision, and extracted the stone ; butthis method was too difficult to perform, and attended with toomany inconveniences and dangers ever to be generally adopted.It suggested, however, to the celebrated Cheselden the lateralmethod of cutting, as it is now with a few alterations very generallypractised. The different steps of this operation, in its present im-proved slate, are as follows; If the patient be plethoric, a fewounces of blood should be taken away, and at proper intervals thebowels ought to be-emptied by any gentle laxative which will notgripe. The diet should consist of light food for some time pre-vious to the operation. If the pain be violent, opium is proper.Sometimes it is relieved by keeping the patient in bed with thepelvis raised, so as to remove the stone from the neck of the blad-der. He ought not to sit up, or take any exercise, in the time ofpreparation. The warm bath ought to be usued two or three times,and the patient should remain in it half an hour at each time. Alaxative ought to be given on the day preceding the operation,and an injection a few hours before it is performed. The patientought to drink plentifully of some dduent liquor, and to retain theurine several hours previous to the operation. If this cannot be readilyeffected, a slight compression, by a ligature, may be made uponthe penis, so as to have the bladder sufficiently distended, that theremay be no danger of the posterior surface being hurt by the endof the gorget. The perin®um and parts about the anus should bewell shaved. A table somewhat more than three feet high, andof sufficient strength, must be firmly placed, and covered withblankets, pillows, &c. Upon this the patient is to he laid and pro-perly secured, by two pieces of broad firm tape, each about livefeet long, which are to be doubled, and a noose formed upon them.A noose is then to be put upon each wrist, and the patient desiredto lay hold of the middle of his foot upon the outside. One endof the ligature is to go round the hand and foot, and the otherround the ankle and hand, and cross again, so as to repeat the turnsin the reverse way. A running knot is then to be tied, by whichthe hand and foot will be properly secured. The buttocks arethen to be made to project an inch or tCvo over the table, and to beraised considerably higher than the shoulder by a couple or morepillows, and one ought to be put under his head. The operatoris now to introduce a grooved staff, fig. 77, of proportionablesize, and open to the very end, through the urethra into the blad-der; and having again fully satisfied himself of the existence of astone, he inclines the staff, il the surgeon be right-handed, obliquelyover the right groin, so that the convex part of the staff may befelt in the perinaeuin on the left side of the raphe, lie then fixesit, and delivers it to his assistant, who is to hold it with his rightband, desiring him to press it genlly, to make the fulcus of the staffproject in the direction in which he received it. With his left-handthe assistant is to raise and support the scrotum. The thighs of thepatient being separated by the assistants, and the surgeon beingseated upon a chair of a proper height, and in a convenient light,lie makes an incision with a common convex edged scalpel throughtlie skin and cellular substance, immediately below the symphysisof the ossa pubis, a little below the scrotum, where the crus penisand bulb of the urethra meet, and on tiie left side of the raphe, andcontinues it in a slanting direction downwards and outwards to thespace between the anus and tuberosity of the ischium, endingsomewhat lower than the basis of that process, by which a cut willbe made of three or four inches in length. This incision ought notto be shorter, otherwise there will not be room for (he rest of theoperation. As soon as the integuments are thus divided, he oughtto introduce two of the fingers of the left hand. With one hekeeps back the lip of the wound next the raphe, and with theother he presses down the rectum. He ought likewise particularlyto guard against cutting the crures of the penis, which lie canreadily feel, and separate at their tinder pait with one of the fin-gers. lie next makes a second incision almost in the same direc-tion with the first, but rather nearer to the raphe and anus, by whichhe preserves the trunk of the arteria pudica. By this incision he

divides the transversalis penis, and as much of the levator ani andcellular substance within these as will make the prostate gland per-ceptible to the finger. If any considerable vessel be cut,it is immediately to be secured, though this is seldom necessary.After this he will have a view of the membranous part of theurethra, which is distinguished from that covered by the bulb by-being very thin. He is now to search fur the groove of the staffwith the fore-finger of his left hand, the point of which he pressesalong from the bulb of the urethra to the prostate gland whichsurrounds the neck of the bladder, lie keeps it there ; and turn-ing the edge of the knife upwards, he cuts upon the groove of thestaff, and freely divides the membranous part of the urethra, fromthe prostate gland to the bulb of the urethra, till the staff can befelt perfectly bare, and that I here is room to admit the point of thefinger; and 'as the finger assists in keeping the parts stretched, andeffectually prevents tire rectum from being hurt, the incision intothe urethra may be made with perfect ease and safety. The nextpart of the operation, viz. dividing the prostate gland and neck ofthe bladder, might, by a dexterous operator, be safely performedwith a common scalpel, with the edge turned the opposite way.But to guard against accidents, a more convienent instrument,called the cutting gorget, fig. 78, is now in general use. It wasoriginally invented by Mr. Hawkins of London , and since histime lias undergone various alterations. Fig. 7f), is a double gor-get invented by Dr. Monro . The inner plate, which is blunt, ismade to slip forwards to protect the back part of the bladder. Themembranous part of the urethra being now divid-d, and the fore-finger still retained in its place, the point of the gorget, previouslyfitted 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; and asthis is one of the nicest parts of the operation, the most particularattention is here required, that the point of the gorget be distinctlyheard lo rub in the bare groove, and that nothing is interposed. Inthe introduction of the gorget into the bladder, if the assistantcould be depended upon, the staff might be allowed to remain inhis hand ; the operator, however, generally chooses to manage ithimself. lie now rises from his seat, takes the staff from the as-sistant, raises it to near a right angle, and presses the concave partagainst the sympljysis of the ossa ptibis; satisfies himself againthat the point or beak is in the groove, and then pushes on thegorget, following the direction of the groove till the beak slip fromthe point of the staff into the bladder. The gorget is not to bepushed farther than this, otherwise it may wound the opposite sideof the bladder, &c. The gorget having now entered the bladder,which is readily known by the discharge of urine from the wound,the staff is to be withdrawn, and the finger introduced along thegorget to search for the stone, which, when felt, will point out thedirection to be given to the forceps: at any rate, the introductionof llie finger serves to dilate the wound in the bladder; and thisbeing done, a pair of forceps, fig. 80, of a proper size, and withtheir blades as nearly together as their form will allow, are to beintroduced, and the gorget withdrawn slowly, and in the same di-rection in which it entered, so as to prevent it from injuring theparts in its return. After the forceps are introduced, and passedtill they meet with a gentle resistance, but no farther, the handlesought to be depressed till they are somewhat in an horizontal di-rection, as this will most correspond with the fundus of the bladder.One blade of the forceps is to be (timed towards the symphysis ofthe pubes to defend the soft parts there, the other of consequencewill guard the return. After they have distinctly touched the stone,by moving them a little in various directions, they are then to beopened, and the stone laid hold of, which may generally be donewith considerable ease. It often happens, however, that whenthe stone is small, it is not readily felt with the forceps; and in-stances may happen where the under and back part of the bladdermay be so depressed as to conceal the stone. In sucli a situation*nothing will more readily bring it in the way of the forceps than tointroduce the finger into the rectum, and elevate this pail of thebladder. Straight forceps are generally used: crooked ones, insome very rare cases, however, may be necessary, and thereforethe surgeon ought to be provided with them. After the forcepshave laid hold of stone, if it be small and properly placed, 1may readily be extracted: but if the handles of the forceps are ob*served to be greatly expanded, it is certain the stone is improperlyfixed, or tliat it is remarkably large: in either case it should not