Occasionally when the artery of the bulb has been divided, the haemorrhage will be so free as to demand a ligature or the application of which may be allowed to remain one or two days. The internal pudic artery has been wounded by carrying the incision too far outward toward the tuberosity of the ischium. Bleeding from this source may be arrested in the same manner. The rectum has also been wounded by carrying the incision too far inward and by failing to keep the blade of the knife sufficiently lateralized; usually the wound in the rectum heals spontane ously.
Median lithotomy is performed by means of an incision directly in the middle line of the perineum. The pa tient is placed in the same position as for lateral lithotomy, the staff intro duced and held vertically and drawn well up under the pubes. The left in dex finger of the surgeon is introduced into the rectum and the groove of the staff located at the apex of the prostate. A knife with a double cutting edge at the point and a cutting edge of about three inches on one side is introduced with the long cutting surface upward an inch in front of the anus and directed to the groove in the staff at the point lo cated by the finger. When the point of the knife has reached the groove of the staff, it is pushed onward toward the bladder so as to incise the apex of the prostate and then withdrawn, cutting upward for from three-quarters of an inch to an inch. A probe-pointed grooved director may then be passed into the bladder on the groove of the staff, to be used as a guide for the intro duction of the finger or of the lithotomy forceps. As this operation is made in
the middle line, there is comparatively little hmmorrhage; still, on the other hand, it provides but very limited space in which to work, and is therefore suit able for removing calculi of the smallest size only. The incision also approaches very closely to the bulb anteriorly and to the rectum posteriorly, either of which may be injured if the knife is carried slightly beyond the limits mentioned.
In a series of 200 operations clone in India for stone, lithotrity was used in 153 males and lithotomy in 30. The stone was never found too hard to crush. Forty-eight of the cases were in boys under 10 years of age, and 15 were in boys under 3 years of age. One death occurred in a boy 3 years of age. Great advantage was derived from the introduction of a drachm of oil into the urethra prior to the passage of the in strument and in young boys the crev ices of the crushing instrument were filled with soap before introduction to avoid scratching the mucous membrane. When the instrument cannot be readily and easily passed, lithotomy had better be resorted to. Three deaths occurred out of 36 cases of lithotomy and three out of 161 cases of crushing, 2 of which could hardly be attributed to the operation. W. F. Adams (Brit. Med. Jour., May 25, 1901).