Having devoted a few minutes to the very interesting and instructive task above referred to, we now proceed to dilate the urethra and neck of the bladder. It is a great consolation, when confronted with a large stone, to know that this portion of the urinary passage is capable of considerable relaxation and dilation. Sudden and spasmodic attempts at dilation is bad practice, and should on no account be resorted to. For effecting the opening out of the .urinary channel the three-bladed dilator (fig. 154), constructed on the plan of a human anal dilator, but with longer blades and with a correspondingly large range of action, will be found effective.
Fig. 154. - Dilator.
This is introduced into the opening made in the perineum and pushed onward towards the bladder. The handles of the instrument are now compressed and the blades caused to diverge steadily until the necessary dilation has been accomplished.
The patient is now allowed to rest on the right side. The operator finds it most convenient to occupy the recumbent posture, and places himself on his left side.
The form of the forceps to be employed in removing the stone will, of course, depend upon the consistence of the calculus to be removed. Where the superficial portion of the stone is found to be loose in texture, and consequently liable to crumble, the spike-faced forceps (fig. 155) should be employed. This is armed with three spikes on the opposing surface of each blade, which, on meeting the stone, penetrates its outer weak crust, and gains a firm hold of the more dense parts beneath. Escape from the grip of the instrument during extraction is thus rendered difficult, and disintegration is at the same time avoided. The forceps, held in the left hand, is introduced into the bladder, and the right hand is passed into the rectum to steady and direct the stone, which will now be distinctly felt and heard grating against the instrument. Here the blades must be opened and closed again and again, with a catching movement, being also turned about first in one direction and then in another, until seizure of the calculus is effected. Should any difficulty in securing the stone be experienced in the procedure, the forceps is to be withdrawn, and the calculus brought forward by the hand acting through the rectum and held firmly against the neck of the bladder, while the blades of the instrument are slid carefully over it. A firm hold having been secured, the operator must then assure himself that no part of the mucous membrane is grasped and included with the stone. This may be done by rotating the forceps on its axis, and moving it backwards and forwards, first in one direction and then in the other. If no impediment is experienced it is to be inferred that the bladder has not been laid hold of, and that in this respect all is right; on the other hand, should the movement of the instrument meet with interruption, the blades must be slightly relaxed and the imprisoned membrane liberated. The position of the stone, as it rests in the forceps, is next to be considered.
Here we may remark that vesical calculi are almost invariably ovoid in shape, and are frequently seized across the short diameter, in which position it is at all times difficult, and in most instances impossible, to extract them. For this reason it is of the first importance that the long diameter of the stone should be made to correspond with the long axis of the forceps. To accomplish this the calculus is drawn well up to the neck of the bladder, when, with the index finger acting between the released blades of the instrument, it is carefully turned and brought into the desired position. This having been done, extraction of the stone is then proceeded with. The extracting force required to effect removal will, of course, depend upon the size of the stone in relation to the urethral orifice. Large calculi, and particularly such as are rough and catchy, require a considerable amount of traction and careful manoeuvring to bring them away. Before attempting removal, the stone must be firmly gripped and a good hold secured by bringing both hands to bear on the handles of the forceps, whose blades should be so placed that their surfaces are directed right and left, and their edges upward and downward. A steady and continuous pull, gradually increasing in force, is now begun and continued, with a wriggling movement of the hand and an occasional slight alteration in the direction of the traction, at one time pulling slightly to the right, at another to the left, now upward, then downward, and so on. If the wound be not sufficiently large, a touch with the scalpel here and there at the points of resistance may be resorted to as a means of facilitating extraction, or an assistant may be called upon to open the wound by inserting his fingers well within its edges and pulling in opposite directions. Should the stone prove to he too large for extraction by reasonable force, crushing must be at once had recourse to. Where the calculus is loose in texture, and friable, the resistance of the edges of the wound to the extracting force may give rise to disintegration of the outer crust, which, breaking away, remains in the blades of the forceps, while the main body of the stone escapes into the bladder. In such an event the offending body must be again secured. Having undergone a reduction of size, less resistance will be experienced in the next attempt at removal. An additional advantage will also be gained in the firmer hold the more compact remains of the calculus allows to the forceps.
Fig. 155. - Spike-faced Forceps.
PLATE XXIX. OPERATION FOR STONE.
Fig. A. I. Catheter. 2. Stone. 3. Rectum. 4. Knife cutting into the Urethra.
Fig. B. I. Lithotrite. 2. Stone in the jaws of the Lithotrite. 3. Hand in the Rectum assisting in bringing the Stone into the jaws of the instrument ready for crushing.
Having removed the stone, the bladder will now require to be well washed out with warm carbolized water in order to cleanse it of the blood, mucus, and earthy debris, some or all of which it is sure to contain in greater or less amount. This operation is best accomplished by introducing the three-bladed dilator (fig. 154) into the neck of the bladder, and, after moderately enlarging the orifice, forcing into the cavity a fairly strong stream of warm carbolized water out of a small enema syringe.
Whether the perineal wound should be closed at once must depend upon the nature and extent of disease existing in the bladder. If there is reason to think that the lining membrane is seriously ulcerated, or covered with false membrane, a distinct advantage will be gained by introducing a lithotomy tube (fig. 156) into the bladder and allowing the wound to remain open until the vesical irritation has been subdued by frequent injections of warm carbolized water. On the other hand, if no such complications exist there, the edges of the superficial wound may be brought together at once by three interrupted sutures of flexible wire, and the patient removed to his box.
The irritation resulting from the operation naturally leads to much whisking of the tail, during which hairs become entangled with the wire, and the parts about the wound suffer considerable contusion; this must be provided against by tying the tail on one side to a roller or some other convenient arrangement. Under ordinary circumstances but little is needed in the shape of after-treatment. The skin below the perineum is smeared with lard or vaseline to prevent excoriation by the urinary and other discharges, and the wound is carefully cleansed and carbolized as often as may be required. An enema of warm water occasionally thrown into the rectum affords a good deal of comfort by freeing the gut from feculent matter, and removing all pressure from the sore and sensitive urethra and bladder beneath.