THIS Method was invented by an Ecclesiastic, who called himself Frere Jaques: He came to Paris in the Year 1697, bringing with him an abundance of Certificates of his Dexterity in operating; and making his History known to the Court, and Magistrates of the City, he got an Order to cut at the Hotel Dieu, and the Charité, where he performed this Operation on about fifty Persons. His Success did not answer the Promises he had made and from that Time his Reputation seems to have declined in the World, if we may give Credit to Dionis, who has furnished us with these Particulars.

He was treated by the Surgeons of those Times as ignorant and barbarous; and tho' upon enquiry into the Parts which suffer in this Method, it was once the Opinion of some of the most eminent amongst them, that it might be made a most useful Operation, if a few Imperfections in the Execution of it were removed; yet after having given this Judgment, they suddenly dropt the Pursuit, for no other reason, to all Appearance, but that they would not be obliged to any one but a regular Surgeon for a Discovery of so great Consequence. The principal Defect in his Manner of cutting, was the want of a Groove in his Staff, which made it difficult to carry the Knife exactly into the Bladder; nor did he take any Care of his Patients after the Operation; so that for want of proper Dressings, some of the Wounds proved fistulous, and other ill Consequences ensued: But I am inclined to think he succeeded better, and knew more at last, than is generally imagined; for I remember to have seen, when I was in France, a small Pamphlet, published by him in the Year 1702, in which his Method of Operation appeared so much improved, that it differed in nothing, or but very little, from the present Practice. He had by this time, learnt the Necessity of dressing the Wound after the Operation, and had profited so much from the Criticisms of Messieurs Mery, Fagon, Felix, and Hunauld, that he then used a Staff with a Groove; and what is more extraordinary, had cut thirty-eight Patients successively at Versailles, without losing one, as appeared by a Certificate annexed to the Piece.

Amongst many that saw Frere Jaques operate, was the famous Professor Rau, who carried his Method into Holland, and practised it with amazing Success: He never published any Account of it himself, though he admitted several to his Operations; but since his Death, his Successor Albinus, Professor of Anatomy and Surgery at Leyden, has given the World a very circumstantial Detail of the several Processes of it, and mentions as an Improvement upon Frere Jaques's Manner, that be made his Incision thro' the Bladder beyond the Prostate; but whoever will try the Experiment of making a Wound in that Place, without touching the Prostate, on a Staff, such as Albinus has delineated, which is of an ordinary Length, will find it almost impracticable; for if by inclining the Staff a little towards the Abdomen and right Groin, you endeavour to raise that part of the Bladder towards the Wound, it slips out all but the very End of it into the Urethra, and leaves no Direction for the Knife. Besides, that he cut the Prostate, may be gathered from the Event of some Cases which Mr. Cheselden published, when he first undertook, the Lateral Operation: He considered it as almost impossible to make the Incision in this Place, unless the Bladder were distended, to which purpose, he injected as much Barley-water as the Patient could suffer, which made it protuberate forwards, and lie in the Way of the external Wound; so that leaving the Staff in, he cut very easily upon it. The Operations were exceedingly dextrous; but the Wound of the Bladder retiring back, when it was empty, did not leave a ready Issue for the Urine, which insinuating itself amongst the neighbouring Muscles and Cellular Membranes, destroyed Four of the Ten which he practised this Method upon, and some of the others narrowly escaped.

If therefore, this was the Consequence of a Wound of the Bladder beyond the Prostate, in so may Instances, and we find by experience that it is exceedingly difficult in some Men to carry the Incision even so far as the Prostate, sure it is possible that Abinus may be mistaken in his Description, or even that Rau himself, if he was of that Opinion, might be deceived in the Parts he wounded; since we know it was generally thought, till within these few Years, that the Bladder itself was cut in the old Way.

After this unsuccessful Trial, Mr. Cheselden made use of the following Method, which is now the Practice of most English Operators.

The Patient being laid on a Table, with his Hands and Feet tied, and the Staff passed as in the old Way, let your Assistant hold it a little slanting on one Side, so that the Direction of it may run exactly thro' the Middle of the left Erector Penis and Accelerator Urinæ Muscles; then make your Incision through the Skin and Fat, very large, beginning on one Side of the Seam in Perinæo, a little above the Place wounded in the old Way, and finishing a little below the Anus, between it and the Tuberosity of the Ischium: This Wound must be carried on deeper between the Muscles, 'till the Prostate can be felt, when searching for the Staff, and fixing it properly, if it has slipt, you must turn the Edge of the Knife upwards, and cut the whole Length of that Gland from within outwards, at the same time pushing down the Rectum with a Finger or two of the left Hand; by which Precautions, the Gut will always escape wounding; after which, the Operation finishes nearly in the same manner, as with the greater Apparatus.

If upon introducing the Forceps, you do not perceive the Stone readily, you must lift up their Handle, and feel almost perpendicularly for it, since for the most part, when it is hard to come at, it lies in one of the Sinuses sometimes formed on each Side of the Neck of the Bladder, which project forward in such a manner, that if the Stone lie there, the Forceps pass beyond it the moment they are through the Wound; so that it would be impossible to lay hold of it, or even to feel it, if not aware of this Circumstance.

When the Stone breaks, it is much safer to take away the Fragments with the Forceps, than to leave them to be discharged with the Urine; and if the Pieces are very small, like Sand, a Scoop is the best Instrument; though some prefer the injecting Barley-water into the Bladder, which suddenly returning, brings away the broken Particles of the Stone.

As there are hardly any Instances of more Stones than one, when the Stone taken away is rough; so when it is smooth and polished in any part of it, 'tis almost a certain sign of others behind; on which account, an Operator should be careful, in that Cafe, to examine not only with his Fingers, but some convenient Instrument, for the remaining ones; tho' indeed, in all Cases, it may be proper to examine the Bladder after the Extraction of a Stone because it is possible there may be a second Stone, notwithstanding the first Lie rough.

The great Inconvenience of the lateral Operation is the Hæmorrhage which sometimes ensues in Men; for in Children the Danger of it is not worth mentioning; this however is the principal Objection which has prevented it being universally practised; but in all likelihood it will be more general, When the Merits of the Method are better known, and it is once discovered that the ill Consequence of most of these Hæmorrhages is owing more to an Error in operating, than to the nature of the Operation; for I think I can positively say, that all those Branches of the Hypogastrick Artery which lie on this Side of the Prostate, may be taken up with the Needle, if the Wound be made large enough, to turn it about freely at the Bottom; yet this is a circumstance, that many Surgeons have been deficient in, and instead of making it three or four Inches long in a Man, they have sometimes made it not above an Inch; in which case, it is not only impossible to tie the Vessels between the Skin and Bladder, but it also prevents the proper Application of Lint, or Stypticks to the Artery creeping on the Prostate: so that it is not surprising the Operation should be discountenanced, when the Practice of it is attended with this Difficulty.

I have here mentioned Lint or Stypticks, as a proper Application to stop the Hæmorrhage from the Artery of the Prostate but if they should not prove effectual, I would advise the Introduction of a silver Canula through the Wound into the Bladder, which should be three or four Inches long, according to the Depth of the Wound; and almost as thick as a Man's little Finger. It must be covered with Rag or Lint (that it may lie soft) and continue in the Bladder two or three Days, before it is taken away,

If in the Operation any very large Vessel of the external Wound should be divided, it is adviseable to tie it before the Extraction of the Stone; but the Necessity of doing this, does not occur once in twenty times: It rarely happens that the Vessels of the Prostate burst open any considerable time after the Operation, if they did not bleed during the Performance of it; but as it is the nature of the Symptomatick Fever, to dilate the Vessels, and quicken the Motion of the Blood, 'tis proper to be upon our Guard, especially in plethorick People, and endeavour to obviate the Accident, by taking away ten or twelve Ounces of Blood from the Arm, and giving an Opiate immediately.

There is but one Objection more of any consequence, which is the danger of wounding the Rectum; and this I confess is a very troublesome Accident: But if the Operator observes the Rule I have laid down with regard to that Article, I should hope it might always be avoided.

In this Description, I believe I have been so far from disguising the Inconveniencies of the Lateral Operation, that before I speak of its Advantages I should once again repeat, that these Effusions of Blood are but very rare, and seldom or never mortal, when properly managed; of which the World needs no better Proof than the late extraordinary Success we have cut with in our Hospitals, which I believe has never been equalled in any Time, or Country. In this Method the remarkable Parts wounded by the Knife are the Musculus Transversalis Penis, Levator Ani, and Prostate Gland: In the old Way, the Urethra only is wounded, about two Inches on this side the Prostate, and the Instruments are forced thro' the rest of the Passage, which is composed of the bulbous Part of the Urethra, the membranous Part of the Urethra, the Neck of the Bladder, and Prostate Gland. This Channel is so very narrow, that 'til it be torn to pieces, the Management of the Forceps is exceedingly difficult, and It happens frequently, that from the tender Texture of the membranous Parts, the Forceps are unwarily pushed thro' it between the Os Pubis and Bladder; besides that in introducing the Gorget upon the Staff, it is apt to slip downwards, between the Rectum and Bladder, both which Inconveniencies are avoided in the Lateral Operation. It is true, the Wound made in the Lateral Method, will not admit of the Extraction of a large Stone without Laceration, as well as in the old Way; but, in the one Case, the Laceration is small, and made after a Preparation for it by an Incision, and in the other, all the Parts I have mentioned are torn without any previous Opening, and which are so very tight, that the Pain of the Distension must necessarily be excessive. It is pity, the Operators do not in the old Way always slide the Knife along the Groove of the Staff, till they have quite wounded through the length of the Prostate, since they are convinced, that by the Extraction of the Stone, it is opened in a ruder and more dangerous Manner than by Incision, and without any Advantages from it; because this Opening is made by the finishing of the Operation; whereas for want of it before the Extraction, we can hardly widen the Forceps enough to receive a large Stone; and when we do, the Resistance is so very great, as often to break it, notwithstanding all our Care. However, in both these Operations, the Surgeon must not grasp the Stone with Violence, and even in extracting, must with both Hands to the Branches of his Forceps, resist their shutting so tight, as the Compression from the Lips of such a narrow Wound would otherwise make them: Here I speak of the Difficulty of laying hold of a Stone in any Part of the Bladder; but if it happen to lie in one of the Sinuses before-mentioned, the Forceps are so confined that it becomes still harder. The Extraction of very large Stones is much more impracticable with the greater Apparatus than by this Method, because of the smallness of the Angle of the Bones in that Part where the Wound is made; so that indeed it is necessary in almost all Extractions to pull the Stone downward towards the Rectum, which cannot be done without great Violence to the membranous Parts, and even the Separation of one from another; whence follow Abscesses and Sloughs about the Wound, which is a Circumstance not known in the Lateral Operation. Ecchymoses followed by Suppuration and Gangrene, sometimes spread themselves upon the Scrotum, and in short, all the Inconveniences and ill Symptoms which attend upon the Lateral Operation, except the Hæmorrhage, are in a more violent Degree, incident to the old Way.

An Incontinence of Urine is not common after the Lateral Operation, and a Fistula seldom or never the Consequence of it; but the Prevention of a Fistula seems to depend very much upon the Skill of dressing the Wound afterwards; and perhaps it would not so often happen, if, the Dressing were rightly managed in the old Way, though certainly this Method is much more liable to them, as the Wound is made among Membranes, is more contused, and in many, from an Incontinence of Urine, is continually kept open. I have seen some Instances indeed in the Lateral Operation, where through Neglect, the Bladder has remained fistulous, but the Wound being in a fleshy Part, I have, without great Difficulty, got little Granulations to shoot up, and healed it externally; so that at present I think a Fistula can hardly be accounted one of the Inconveniencies of cutting for the Stone in the Lateral Way.

The Manner of treating the Patient after the Operation, is pretty nearly this: If it happens, that the Vessels of the Prostate bleed, dry Lint, or Lint dipped in some styptick Water, such as Aqua Vitrioli, must be applied to the Part, and held there with a considerable degree of Pressure for a few hours, or as I have before mentioned, a silver Canula of three or four Inches long, covered with fine Rag, may be introduced into the Bladder and left there two or three Days, which seldom fails to stop the Hæmorrhage. The Patient may also take an Opiate. If the Wound does not bleed, a little dry Lint, or a Pledgit of Digestive, laid gently in it, is best. The Place where the Patient lies should be moderately cool, as Heat not only disposes the Vessels to bleed afresh, but generally makes him low and faint. If soon after the Operation, he complains of a Sickness at the Stomach, or even a Pain in that Part of the Abdomen near the Bladder, 'tis not always a sign of a dangerous Inflammation, but frequently goes off in half an Hour: To assist however in Its removal, a Fomentation put into an Hog's Bladder, and applied pretty warm to the Part in pain, will be of great service: If the Pain increases, after two or three Hours, the Consequence is much to be feared; and in this Case, Bleeding and emollient Clysters by way of Fomentation to the Bowels, are immediately necessary.

The first good Symptom after the Operation, is the Urine coming freely away, as we then know the Lips of the Bladder and prostate Gland are not much inflamed; for they often grow turgid, and shut up the Orifice in such a manner, as not only to prevent the Issue of the Water, but even the Introduction of the Finger or female Catheter, so that sometimes we are forced to pass a Catheter by the Penis. From this Symptom too we learn, that the Kidneys are not so affected by the Operation as to cease doing their Office, which, tho' a very rare Circumstance, may possibly occur. If the Patient should become languid, and continue without any Appetite, Blisters prove beneficial, which may be applied with great Safety, and little Pain; as there is, seldom or never any Strangury. About the third or fourth Day a Stool must be procured by a Clyster, for it seldom comes naturally the first time, and this Method must be continued as every Man's Discretion shall guide him. As soon as the Patient comes to an Appetite, he should be indulged in eating light Food, with this Caution, that he do not eat too much at a time: It sometimes happens that a Fortnight or three Weeks after the Operation, one or both Testicles indurate and inflame; which Disorder may generally be removed by Fomentations and discutient Applications; or if a Suppuration ensue, which however is very seldom the Case, the Abscess is not very difficult of Cure.

If during the Cure the Buttocks should be excoriated by the Urine, let them be anointed with Nutritum: The Dressing from first to last, is seldom any other than a soft Digestive, or dry Lint; for the whole Art of healing the Wound, consists in the Force with which the Dossil is applied; if it be crammed in hard, it becomes a Tent, and prevents the Growth of the little tender Shoots of Flesh, 'till in process of time, from the continual Distension, and long Drain of the Urine, the whole Cavity becomes callous and forms itself into a Fistula: On the other hand, if the Wound be dressed quite superficially, the external Parts of it being more prone to heal and contract than the internal, the Consequence will be a degree of Obstruction to the Urine and Matter, which lying about the Wound of the Bladder, for want of a Discharge, will indurate that Part, and likewise occasion a Fistula. This Method of Dressing is not peculiar to Wounds after cutting for the Stone, but is as applicable to Fistulas in Ano, and almost all Abscesses whatsoever; so that the Branch of Surgery, which regards the Treatment of hollow Wounds, depends much more on the proper Observance of this Rule, than the Application of particular Medicines.

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