MEDIAN LITHOTOMY.

THE median operation of lithotomy is that procedure by which a stone is extracted from the bladder through an incision in the raphé of the perineum extending into the membranous portion of the urethra, with dilatation of the neck of the bladder and prostate gland.

This operation was formerly known as the Marian operation, so called from an old surgeon named Sanctus Marianus, who published a treatise in 1535, describing this method as the "operation of the apparatus major" from the number of instruments used.

Although Marianus was the first to publish a description, his preceptor, an Italian physician of Cremona, Franciscus de Romano, was the real inventor, and was led to perform this operation by "considering the Shortness and great Dilatability of the Urethra in Woman, giving easy Passage to a Stone either spontaneously or with the Help of Instruments, imagined that if an Opening was made into the Urethra of Men near the Bladder, so as to leave the intermediate Part of it short as in Woman, that then it might be dilated and the Stone extracted with equal Ease, for to cut into the Bladder was at that Time esteemed mortal, and therefore criminal from the authority of Hippocrates and Celcus."

The operation of Marianus is thus described by John Bell: "A grooved staff was introduced into the bladder and the patient tied up in the usual way; the lithotomist, then kneeling or sitting before him, made an incision in the perineum, not exactly in the raphé, which was thought to be dangerous, but very slightly to the left side, and terminating just above the anus. The knife was then carried on to the membranous part of the urethra, which was opened on the groove of the staff; and, the knife being kept firmly pressed against the staff, a long probe was introduced into the bladder by its side. The knife and the staff were now withdrawn, nothing

'A General System of Surgery by Dr. Laurence Heister, London, 1768.

but the probe being left in the bladder to serve as a guide into this cavity; along this probe two iron rods, called "conductors," were now passed, and with these the operator dilated the prostate and neck of the bladder by separating the handles. These couductors being held aside, "dilators" were introduced so as to enlarge the opening, the forceps were then pushed into the bladder and the stone extracted."

This operation continued to be practised up to the middle of the last century, when it fell into disuse, being superseded by the lateral operation of Cheselden. It has, however, been occasionally resorted to in a modified form, and recommended by such surgeons as Sir Astley Cooper, Manzoni, and Borsa, of Verona.

In 1855 Mr. Allerton, of South Molton, England, revived the median operation in a modified form, and, in the year 1863, published a work on this subject, in which he gives a full history of his method, with statistics of all the cases that he was able to collect, and claims that the mortality is much less than that of lateral lithotomy.

His method of operating differs from the old Marian operation in 1st. The neck of the bladder and prostate gland are dilated by the finger, and not forcibly expanded or torn open by dilating instruments.

2d. If the stone is too large to be removed with safety, it is crushed by means of the improved instruments which we now possess.

The fatality of the old Marian operation was without doubt due to the severe laceration the bladder was compelled to undergo by the dilating force. Le Dran, a French surgeon, about the year 1700, was the first to observe from post-mortem examinations of those who died after this operation, that the "whole neck of the bladder was almost constantly slit or lacerated as well as expanded by the method of dilating in the apparatus major," to avoid which danger he dilated with the finger as subsequently recommended by Mr. Allerton.

We will now describe in detail Allerton's "operation" as it is now called.

The patient being put under the influence of ether or chloroform and placed in the usual position for lithotomy, a grooved staff is introduced into the bladder and held by an assistant. The forefinger

Erichsen's Surgery.

Heister's Surgery.

of the left hand of the operator is introduced into the rectum and the prostate gland distinctly made out; the finger should rest against the apex of the prostate, to act as a guide for the knife and prevent the rectum from being wounded. The groove of the staff should be distinctly felt. A straight, narrow, sharp-pointed bistoury is then introduced in the raphé of the perineum, from half to three-quarters of an inch above the anus, with the cutting

edge directed upwards; until the point strikes the staff at the membranous portion of the urethra just anterior to the prostate, where the forefinger of the left hand is resting. (Fig. 1.)

An incision is then made upwards in the groove of the staff, cutting the membranous portion of the urethra for a few lines, and as the knife is withdrawn the incision in the skin is also extended upwards about an inch.

The knife is then laid aside, and a director or large probe introduced through the wound along the groove of the staff into the bladder. The staff being removed, and the director or probe held with the left hand, the index finger of the right is guided to the neck of the bladder, which, with the prostate, is carefully dilated so as to admit the finger. (Fig. 2.) The director is then

withdrawn and the stone can generally be readily detected with the finger; the forceps are now introduced and the calculus seized and extracted.

If the stone be of moderate size, it may be withdrawn by steadily moving the forceps from side to side, causing them to dilate the opening. In rare cases, where the calculus is of very large size, a lithotrite or a pair of strong long-handled forceps may be introduced, the stone crushed, and the fragments removed. The

bladder should then be carefully searched with the fore-finger of the right hand for fragments. This can be easily done, every part of the bladder being accessible to the finger, except in some adult cases where the perineum is deep. In these cases, if strong pressure be made with the left hand placed above the pubes, the bladder will be pushed down within easy reach of the finger. The bladder should, of course, be thoroughly washed out after the operation. In this operation there is no necessity for the bladder being previously distended with urine, or the injection of warm water.

The staff used may be the same kind as for lateral lithotomy, but as there is sometimes difficulty in striking the groove of the staff with certainty, Dr. Thomas M. Markoe, of New York, has had a staff constructed by Messrs. Tiemann & Co., in which the groove is flattened so as to make it wide and shallow (Fig. 3), thus

Fig. 3.

One-third size.

presenting a larger surface for the point of the knife. The groove in this staff is continuous to the end of the instrument to allow the probe or director to pass into the bladder without any obstruction. The director now generally used in New York is represented in Fig. 4, and was constructed at my suggestion about four years ago.

Fig. 4.

One-half size.

It is about six inches long, with a flat tapering groove terminating with a probe point. The handle is set at an angle of about fortyfive degrees, so that the hand holding it is out of the way, while the finger of the other hand is dilating the opening. This instrument is passed along the groove of the staff after the knife is withdrawn, and serves as a guide for the finger or forceps on entering the bladder.