large operators show better results-results which improve the more they operate.

Lithotomy is respectable for its longevity; but it is idle in a textbook of the present day to discuss the unfavorable opinion of Hippocrates, who believed that wounds of the bladder were deadly, or the barbarous method of "cutting on the gripe," the "apparatus minor," or the "apparatus major" of musty antiquity. Nor, again, does space allow a detailed description of the many cutting operations which have been proposed and successfully performed for the removal of stone from the bladder-operations bearing the names of many illustrious men, and modifications of these the names of many more, to whom all honor is due. Practically, the surgeon requires but three operations to meet the necessities of all cases, and these three only will be described-they are the lateral, the median, and the high operation for stone. For the statistics I have collected upon lithotomy, I must refer to another place.*

Lateral Lithotomy.-At the present writing it seems that the glory of lateral lithotomy is dying away. The operation is only required for male children, where the operator is unwilling to employ litholapaxy, possibly for a few foreign bodies, and occasionally when bladder drainage is required. The latter, however, may be as well or better attended to by median incision and a tube. Large stones now call for the high operation, and vesical and prostatic tumors may be reached as well through the median as through the lateral incision. Multiple stone is suitable for lithotrity. Encysted stones call for suprapubic cystotomy.

Young children do well by any operation, but the lateral is undoubtedly the best, as the incision is not liable to injure the seminal ducts, and a free outlet is afforded for the extraction of the stone. If the latter is quite small, the median operation is perhaps as good; but, where it is large, the violence done in dilating the vesical neck is objectionable. It is exceedingly rare for children to have infiltration of urine, although the limits of the prostate are undoubtedly often surpassed by the incision in the lateral operation. Peritonitis from violence is what is to be feared in children, and there is little danger of this (even with large stones) from the lateral operation. The median section, however, in children has the advantage of being generally attended by less hæmorrhage, and is useful for small stones; the older the child, the less objectionable the operation.

The lateral operation is ascribed to Pierre Franco, of Provence, about the middle of the sixteenth century, and claims the names of Jacques in the seventeenth century, and Rau, his pupil, in the eighteenth. It was popularized and practiced with great success in Eng

*Consult the section upon this subject in my article, "Urinary Calculus," in the "International Encyclopædia of Surgery," vol. vi.-KEYES.

land, by Cheselden, in the last century, and it is his operation which is still performed.

Instruments employed.-The instruments necessary for this operation are the searcher (Fig. 69), a staff of proper size with a long curve deeply grooved on its convexity (Fig. 86), the groove encroaching on the right lateral aspect of the staff toward the point. The handle of

the staff should be broad, heavy, and marked with deep, crossed lines, so that it may be held firmly with greater ease. The groove should not run off at the beak, but stop abruptly, leaving the last quarter of an inch blunt and round.

TIEM

FIG. 86.

The scalpel should be firm, seven or eight inches long, with a stout shank and solid back, the blade about three inches long (Fig. 87), the cutting edge about one and a quarter inch.

Blizard's probe-pointed knife (Fig. 88-4, English pattern), long, straight, with a stiff back and (Fig. 88-B, American) a ribbed handle. The blunt gorget, possibly useful where the patient is fat and the perinæum deep (Fig. 89). The scoop (Fig. 90), several

forceps of different sizes, with extremities roughened in the inside to hold the stone firmly, one with crossed handles (Fig. 91), so as to be opened sufficiently in a deep perinæum without stretching the wound unduly; another with its blades sharply curved (Fig. 92), so as to catch stones behind the pubes or in the "bas-fond.” The heavy instruments, formerly used to crush stones found to be too large to be extracted through the lateral incision, are no longer called for, such stones being properly dealt with by suprapubic lithotomy. I think

1/18

G. TIEMANN & CO.

O

FIG. 91.

OG. TIEMAN-CO

00

FIG. 92.

G.TIEMANN & CO.

FIG. 93.

G.TIEMANN & CO

FIG. 94.

it a safe rule that, if two of the diameters of a stone are even a little over an inch and a quarter each, the patient will do better by the high operation; and it is quite possible that the future may narrow the limit.

A metallic tube, one-third inch diameter (Fig. 93), with an open end and a large eye-furnished with an obturator for easy introduction-through which to wash out débris. Another tube, one-sixth inch diameter, provided with a globular head, about a half-inch diameter, having large holes in the globular head pointing backward (Fig. 94), and a piece of rubber tubing on its proximal extremity-this to be used with a Davidson's syringe to wash out débris. A shirted cannula

for hæmorrhage (Fig. 95), and a tenaculum which unscrews at the handle (Fig. 96, Keith's tenaculum), and several forcipressure forceps for the same purpose; Pritchard's anklets and wristlets (Fig. 97); some soft rubber and other catheters, brandy, hot and cold water, sponges, towels, ligatures, ether, etc. These make up the necessary list of instruments. At least five assistants are necessary: one for the ether; one to steady each knee of the patient; one-the post of honor-to hold the staff; one to sponge and act as general assistant.

TIEMANN-CO

G.TIEMANN & CO.

The Operation. The patient is prepared beforehand as for any other capital operation, and in addition has the perinæum shaved and receives a full enema about two hours before the operation, to clear the rectum, after which he abstains, if possible, from again passing water. He should be etherized in bed, and then carried to a small, firm table, and comfortably arranged on an old blanket. The anklets and wristlets are adjusted (or the hands and feet bound together with bandage). The pelvis is now drawn to the lower edge of the table, facing the light, a piece of old carpet and a pan with

FIG. 95.

FIG. 96.

sawdust placed be

neath to catch the blood and urine. The operator passes the staff, feels the

stone with it, and then intrusts it to his assistant of

honor, and, taking his seat on a low stool, facing the patient's pelvis, with all his instruments systematically arranged within easy

reach of his right hand, is in readiness to commence. Should the staff fail to strike the stone, it may be withdrawn and the searcher introduced. Should this also fail to detect it, after a careful and prolonged sounding, the operation should be deferred. Some of the best

operators have been deceived in their diagnosis, and have cut patients in whom no stone existed; so that it has become a cardinal rule never to cut a patient in whom the stone can not be felt after he is upon the table. The sound may fail to detect it, if it lies in a deep basfond, but not so the searcher.

The holder of the staff usually satisfies himself that the sound strikes the stone. It is not essential that the end of the staff should rest against the stone. As long as it is certainly in the bladder, nothing more is required. The chief assistant stands at the patient's left, holds the staff vertically, steadily, and firmly hooked up under the symphysis, with its long curve a little bellied out in the median line

of the perinæum, and keeps the integument of the latter taut by pulling the scrotum up around the staff. The assistants steady the knees, while the operator impresses his mind finally with the shape and size of the long outlet of the pelvis by running his fingers down the rami of the ischium, touching their tuberosities, feeling the symphysis pubis and the coccyx. The surgeon should picture to himself a pelvis lying before him, in position, denuded of soft parts (Fig. 98), and recall the general inverted heart-shape of its outlet (Fig. 99).

The operator now introduces the left index-finger into the rectum, assures himself that the sound enters at the apex of the prostate and passes centrally through its canal, and that the rectum is empty and collapsed. Then, withdrawing his finger, he searches, with the thumb or finger of his left hand upon the raphe of the perinæum, for the