To any one practically unacquainted with lateral lithotomy it may appear that attention to the many details it includes must necessitate some time being taken up in its performance. Such however, is not the case; and though care is to be commended rather than speed, there is nothing, in cases free from complication, to prevent the oper ation being safely accomplished in a few seconds. Rapidity in ma nipulation must, however, come naturally rather than be aimed at. The object of the operator is to extract the stone from the bladder without exposing the patient to unnecessary risk, and so long as the surgeon accomplishes this, he may regard the time occupied, what ever it may be, as well spent.
After a stone has been extracted, the bladder should be carefully searched to ascertain that it is clear. The index finger is the most trustworthy explorer, aided by downward pressure with the other hand above the pubes. If these means be found insufficient, an ordinary sound may be introduced through the wound. I usually introduce a drainage-tube through the wound into the bladder to prevent any clots obstructing the free discharge of urine. If there is considerable oozing of blood from vessels that cannot be tied, I make the tube fit accurately by the introduction of one or two sutures either above or below it. When an artery has been divided, and is evidently spout ing, it must be tied; this can generally be done without much diffi culty with the aid of retractors ; to plug a severed vessel, if it is possi ble to avoid it, is to court the recurrence of bleeding. More usually I have noticed in section of the prostate and the adjacent parts that the bleeding is of an oozing nature, as if from spongy textures, but in this way many ounces of blood may be lost. For restraining hemorrhage Mr. Buckston Browne's dilatable tampon may be found serviceable.
Hemorrhage from the deep portion of the urethra, as occasionally happens after lithotomy, may also be arrested by distending the rec turn either by a plug or an air bag as is sometimes used with supra pubic cystotomy. Where this expedient is adopted the precaution should be taken of passing a gum-elastic drainage-tube through the wound into the bladder so as to provide an escape for the urine. This device tends to close rather than distend the wound that has been made.
As to the after-treatment of lateral lithotomy there is little to be said beyond what applies to all operations in surgery, in regard to cleanliness, drainage, ventilation, and proper feeding. The old sur
geons, on visiting a patient after lithotomy, were in the habit of asking, Does lie wet well? To-day we should say, How does he drain? The drainage of the wound is favored by slightly elevating the head of the bed, and the patient is to be kept dry by a good supply of ordinary or wood-wool draw-sheets. The food should be of such a character as not to require an action of the bowels for some days, the first movement, if not spontaneous, being promoted by a warm-water enema.
The chief objections urged against lateral lithotomy, apart from the fact that the operation is one entailing considerable skill in its performance, are based on some isolated cases when a fistulous tract, incontinence of urine, or sterility have followed it. When this has been the case such consequences are usually traceable, not to any fault in the original design of the operation, but to unanticipated cir cumstances which have arisen in individual cases entailing a greater section or distention of the parts, either with the knife or in the with drawal of the stone. Where care is taken to provide against such contingencies by keeping the incision within the defined bounds, and the stone within the dimensions thus made for its removal, as will be referred to later in connection with perineal lithotomy, such conse quences need not be apprehended. This operation was frequently re ferred to by the late Sir William Fergusson as "the master-handiwork in surgery." The median operation for stone may be regarded as the simplest proceeding where the use of the knife is required. It is conducted in accordance with the direction given previously for drainage punctures, the incision being made somewhat larger so as to permit of the intro duction of the lithotomy forceps and the withdrawal of the stone. After this has been done a drainage-tube should be passed into the bladder, otherwise retention of urine or a rigor is not unlikely to fol low. As thus practised it is limited to small stones only, which might, as a rule, be easily disposed of with the lithotrite. It is, how ever, capable of being adapted to much larger calculi in two different ways : (1) by the extension of the incision so as to give more room for whatever has to be withdrawn from the bladder; and (2) by com bining it with means for crushing and evacuating the stone by this shorter route.