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CHAPTER VI.

GENITO-VESICAL.

EXTERNAL PERINEAL URETHROTOMY.

PLACE the subject on the back, and tie the wrist and ankle of each side together. Draw the buttock to the edge of the table and separate the thighs. Shave the perinæum. Sit facing the perinæum.

Pass a sound having a groove on its convexity into the bladder. An assistant must hold the sound perpendicularly in the median line, drawing slightly toward the pubes, at the same time holding up the scrotum. Make an incision in the median line of the perinæum one inch and a half long, ending one half inch anterior to the anus. Divide the integument and fasciæ. Incise the tissues in the median line until the groove of the instrument can be felt. Guide with the left index-finger the point of a narrow knife into the groove. 1. Run the knife along the groove to the apex

cf the prostate.

2. Cut an opening three quarters of an inch long into the urethra by running the knife along the groove. Pass a ligature through each side of the urethral wound. Withdraw the sound to imitate the case of an impassable obstruction. By drawing on the ligatures the urethral canal is opened. Pass a probe into the bladder as a guide.

3. Dissect in the median line to the apex of the prostate, or upon the end of a bougie passed by posterior catheterization to imitate cases where no external opening can be discovered.

Leave the wound open.

SOUNDING FOR STONE.

Place the subject on the back, with the buttock elevated on a block. Pass into the bladder through the perineal wound a small piece of chalk.

Stand on the left side and introduce a Thompson's searcher. Its passage through the membranous urethra occurring when the searcher is vertical may be aided by pressure over the pubes to relax the suspensory ligament of the penis, or by pressure over the convexity of the curve of the searcher as it bulges the perinæum. Inject through the searcher about five ounces of water.

Stand between the thighs. Make the beak of the instrument follow every part of the walls of the bladder. By

twirling the handle slightly, the beak is made to rap lightly against the walls. To explore behind the prostate, insert the left index-finger into the rectum and push upward toward the inverted beak of the searcher. Aid the exploration of the anterior wall by pressing above the pubes.

In the female, pass the searcher as a catheter. Aid the exploration by the finger in the vagina.

The click made by striking the stone may be increased by attaching a sounding-board, or by fastening one end of a rubber tube to the instrument and

inserting the other end into the ear. If more than one piece of chalk be inserted, a click may be obtained after one piece is held in the forceps.

LITHOTRITY.

Remove the searcher and introduce a lithotrite, allowing it to enter the bladder by its own weight.

Lithotrity may be performed through the urethra or through the opening made by external urethrotomy.

When the lithotrite touches the chalk, turn the beak away and open

its blades. Turn the separated blades toward the chalk, and engage it between them. Close the blades to confine the chalk. Raise the chalk from the mucous membrane and crush it by screwing the lever quickly once or twice. The large fragments fall close to the instrument and can be easily picked up. The chalk may be caught by pressing the convexity of the lithotrite against the base of the bladder and allowing it to fall between the open

blades. The crushing should be done in the center of the cavity of the bladder.

The débris of the chaik may be removed at once by means of an evacuator (“rapid lithotrity” of Bigelow). Remove the lithotrite and introduce an evacuating catheter (Keyes's). Attach the washer filled with water. By pressing the bulb of the washer, it is partially emptied into the bladder. When the pressure is removed, the bulb, resuming its shape, causes a current of water into the washer, which carries with it small particles of the chalk. The particles sink into the receptacle below the washer.

Large fragments cause a “click” when carried against the catheter. The remaining fragments must

be crushed, and the washing continued until all are removed. Hold the lithotrite steady while crushing the chalk, and be sure that the blades are in contact before beginning its removal. Bryant's catheter and crusher combined prevents the change of instruments after the first crushing.

In perineal lithotrity, a large lithotrite and evacuating catheter may be used without lacerating the tissues; also the same applies to lithotrity through the female urethra.

CYSTOTOMY.

1. Median Perineal Cystotomy.Place the subject as for external urethrotomy.

Pass a grooved staff into the bladder which is held as in external urethrotomy. Insert the oiled left index-finger into the rectum to feel the apex of the prostate.

Puncture the perinæum one half inch above the anus in the median line, directing the point of the knife with its edge turned upward nearly to the apex of the prostate. While withdrawing the knife, cut upward in the median line to the extent of one inch.

Remove the finger from the rectum. Guide the knife with its edge directed downward, until its point is in the groove of the staff. a. Push the knife along the groove into the bladder. b. After the urethra has been divided, a grooved director may be passed along the staff, after which the staff may be withdrawn. The neck of the bladder may now be incised upward.

Introduce the finger along the guide into the bladder, and examine the interior.

(Removal of a piece of chalk by means of forceps may be practiced. Introduce the forceps along a guide and grasp the chalk in its long axis. In removing the forceps holding the chalk, draw downward, moving the handle of the forceps from side to side without rotation.)

Introduce through the wound a chemise catheter into the bladder. Pack the catheter by filling the space between the chemise and the catheter, thus exerting pressure on the walls of the wound.

2. Vaginal Cystotomy.Place the subject as in the last operation. Retract the posterior vaginal wall with a Sims's speculum. Inject into the bladder four or five ounces of water through a catheter and then plug the catheter.

Hold the catheter so that it bulges the anterior vaginal wall. Through the vagina divide the tissues in the median line, cutting on the catheter to the ex: tent of an inch. The incision should be made from behind forward, and care must be taken not to incise the cervix posteriorly, nor the urethra anteriorly. The interior of the bladder is readily explored by the finger.

Close the wound by the continuous suture from behind forward. Draw the vaginal wall forward by means of tenacula, to facilitate the closing of the wound by sutures.

3. Lateral Perineal Cystotomy.The subject is placed in the same position as for the median operation.

a. In the Male.Pass a grooved staff into the bladder, which is to be held perpendicularly, the scrotum being raised by the same hand of the assistant.

Begin an incision just to the left of the median

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