MEASURES EMPLOYED FOR THE REMOVAL OF STONE FROM THE BLADDER OTHER THAN BY CRUSHING ALONE.
In exceptional cases, operations other than lithotrity may be ne cessary, and I shall consider those varieties of lithotomy which at the present time are more usually selected. They include those where the bladder is approached (1) from the perineum, and (2) from above the pubes.
Lateral lithotomy is an operation which has been extensively practised in the male at all periods of life. Recently its application has been restricted, partly by reason of the more general adoption, in some form or other, of lithotrity, and partly in consequence of cer tain advantages which the supra-pubic method undoubtedly possesses. In the pre-anEesthetic days, when the sufferings of the patients under going such proceedings required first consideration, and when speed in the performance of an operation was an important element, there was much to be said in favor of a method by which, under advantageous circumstances, the operation has been ended within a minute by the watch. This is now all changed, and other considerations have our first claim. Lateral lithotomy has much to recommend it, on the ground that it provides a ready and sufficient access to the bladder for the removal of stones of a considerable size, and at the „same time enables the surgeon to satisfy himself, almost beyond question, that the whole of the stone therein contained has been removed. In addi tion, it secures a means for the continuous and incontinent drainage of the bladder in a convenient and dependent position for as long as it may be necessary. Mainly for these reasons, coupled with the small mortality that attends it, at all events in early life, it has ob tained in the past, as well as at the present, the confidence of many surgeons of large experience in connection with this class of disor ders. These are grounds for its selection which, when combined with personal dexterity and accuracy in its performance, are beyond gainsay.
The patient being placed under an anmsthetic, and retained in the lithotomy position by the crutch or anklets, a full-sized staff with a lateral groove is passed into the bladder, and held there by an assis tant. In young males, in whom the bladder is an abdominal rather than a pelvic organ, it must be held more obliquely downward than in the adult ; otherwise, as the curve is a short one, the extremity of the instrument may hardly be within the viscus. The bladder should contain, in the adult, at least three or four ounces of fluid, in order that the walls of the viscus may be kept somewhat apart. Pre vious to the operation an empty and contracted rectum should be se cured. Lithotomy is one of the few operations in which from first to last there need be no change in the way the knife is held, as shown in Fig. 59. No other position permits that freedom of movement
which is necessary for its dexterous performance. Commencing about an inch in front of the anus, the point of the knife should be steadily directed toward the staff, with the view of touching it in the mem branous urethra, below the line of the bulb, the incision being larged downward and outward as the knife is withdrawn, to the extent of about two inches, or even more, so far as the superficial structures are concerned, should the size of the stone require it. It is as sumed that the surgeon has been able to form a tolerably accurate notion of the size of the stone to be removed. If the incision is fully made, both in depth and direction, the staff will at once be felt by the finger of the other hand, or be so nearly bared as only to require a touch or so with the point of the knife. The bladder is then opened by cautiously pushing on the knife in the groove of the staff, the edge being directed obliquely outward, so as to incise the prostate in a direction corresponding with its greater radius.
Curved and straight pairs of lithotomy forceps should be at hand, and, in ing the stone, only gentle traction forward and slightly downward is to be exercised. Angular stones, or those with spike-like cesses, are sometimes more or less embedded in the walls of the bladder. When this is the case, the position of the calculus must be altered before it can be withdrawn by the ceps, otherwise the floor or neck of the der may be torn. I have known stones dered stationary in this manner spoken of as being adherent to the walls of the bladder, such a connection being, of course, only a mechanical one. It is well to have one or two different-shaped forceps in readiness so as to secure a fairly accurate adaptation to the stone. Fig. 60 shows unnecessary amount of room may be taken up where the forceps and stone are not well fitted to each other. A scoop and a Higginson's syringe for washing out the bladder through the wound are sometimes required when the stone breaks on being seized with the forceps. Sir George Humphry seems to have a preference for the scoop." When the stone is large, too large to come away without the exercise of such force in extraction as might tear—not stretch—the neck of the bladder, a corresponding incision on the opposite side of the prostate may be made with a straight probe-pointed knife on the operator's left index finger passed fairly within the bladder, should an extension of the existing incision be insufficient. On some occasions I have thus made a bilateral incision with success. In one instance where it was employed, it permitted me to remove, without hemorrhage, a prostatic tumor (an adenoma) in addition to an oxalate stone weighing nearly three ounces.