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Lithotomt

stone, bladder, staff, instrument, gorget, urine, groove and operation

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LITHOTOMT.

The existence of a stone in the blad der causes various symptoms in the blad der itself; and others in neighbouring parts. The former are frequent incli nation to void the urine, which some times stops suddenly from the stone me chanically obstructing its passage ; pain in making water, and particularly after the discharge, from the bladder contract ing on the foreign body ; mucus, and sometimes blood in the urine, and pain on exercise. The latter are an uneasiness and itching at the end of the penis, lead ing the person to draw and elongate the prepuce; sense of weight in the perineum; tenesmus ; numbness of the thighs, &c. These symptoms come on in fits. In order to ascertain the fact, a solid steel instru ment, shaped like a catheter, and called a sound, is introduced into the bladder, where its point, meeting the stone, gives decided information to the surgeon. It must be moved in various directions after its introduction, as it may not immediate ly or easily come in contact with the stone. The operation should never be performed, unless the stone can be plainly felt before the operation : the rectum should be pre viously emptied, but it is more advanta geous for the bladder to be full. The patient is to be placed with his pelvis at the edge of a table, and the staff intro duced into the bladder. The thighs and legs are then bent so as to enable him to grasp the soles of the feet with his hands, and the limbs are retained in this position by broad garters, doubled and placed by means of a noose round the wrists, carri ed over the back of the hand, and inside of the foot; then brought up again, and continued round the wrist and ankle, and firmly tied. The staff is shaped like a sound or catheter, and has a groove fbt conducting a cutting instrument into the bladder. An assistant standing on the patient's right side holds the handle of the staff with one hand, making its con vexity project in the perineum, and draws aside the scrotum with the other. An in cision should be made through the integu ments, commencing on the left side of the raphe of the perineum, just opposite to the membranous part of the urethra, and continued obliquely downwards and outwards for about three inches between the anus and ischium. The transversalis perinei should then be cut through, and the membranous part of the urethra free ly opened, so as to expose the groove of the staff. The beak of the gorget is now introduced into the groove, and the ope rator takes the handle of the staff into his left hand, holding the gorget in his right.

He then thrusts the gorget into the blad der, keeping its beak in close contact with the groove of the staff; and bringing the handle of the latter instrument downwards and forwards, in order to raise its point, and make its direction coincide with the axis of the bladder. The cutting edge of the gorget, by this mode of introduc tion, divides the prostate gland and neck of the bladder. This instrument is used of various figures by different surgeons. The best perhaps is that in which the cut ting edge of the instrument extends hori zontally from its beak, from which it may be carried to the length of three quarters of an inch. A good anatomist may perform the operation with a scalpel, which Instru ment will enable him to divide the parts with more exactness. The escape of the urine shows that the bladder is opened. The staff should now be withdrawn, and a proper pair of forceps passed along the concave surface of the gorget into the bladder, for the purpose of seizing and extracting the stone. This instrument is first employed as a probe to ascertain the position of the stone, which being accom plished, the blades are to be expanded, and moved in such a direction as to grasp it ; and the instrument, very firmly held, may then be slowly withdrawn, being moved from side to side, in order to bring the foreign body through the wound. If the stone be very large, it may be expedi ent to dilate the wound with a curved knife, or to break the stone in the blad der, by means of forceps constructed for that purpose. In the latter case, and in instances where the stone is broken in the operation of extracting it, the bladder should be washed out with lukewarm wa ter, to remove any small fragments. Careful examination with the finger is ne cessary, to ascertain that nothing is left behind. A compress of lint, pledget, and T bandage, may be put on, but they are of little service, as the urine escapes through the wound. Since peritoneal in flammation is the occurrence most to be feared after lithotomy, great attention to the state of the abdomen is required, and on the least indication of such a conse quence, venesection, leeches, warm bath, warm fomentations, blisters, emollient clysters, and purgatives, should be resort ed to, according to the symptoms.

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