LITHOTOMY.
By "W. P. Harris, M.D., Civil Surgeon, Shahjehanpore. (Continued from
Lateral
page
207J
Section VIII.?(Continued.) Operation.?The most important and
difficult
question
in lithotomy is, the extent to which the prostate and neck of the bladder, should be cut. In Coulson's words, the question is?" Should the internal incision be carried freely through the prostate and neck of the
bladder, to be
or
are
prefered
moderate incisious with
"
subsequent
dilatation
incisions, which consist in carrying the knife on bladder, but only just enough to notch the ligamentous band at that part, are preferable. They are sufficient for the extraction of the largest calculi, it is safe to operate upon, if subsequent dilatation be used. Except for the extraction of small stones, the above-mentioned slight notching of the ligamentous band at the neck of the bladder will generally be required both in adults and children, The latter
into the neck of the
as to admit of sufficient dilatation of that part for the extraction of the stone without much violence. It is sufficient to limit the uso of the knife to the prostate for
so
the extraction of small stones in all patients, except in very short children; for in these a small and rcccntly-formed stone does not cause sufficient dilatation of the neck of the bladder to enable the operator to insert his finger into that part, until it has been slightly notched by tho knife. Erichsen says, " Scarpa advises that tho incision into it (the prostate) should not exceed "five lines in adults and two in children." He adds, " It is difficult to measure the extent of the incitsion; it is sufficient to say that it should be as limited us
September 1,
LITHOTOMY.?BY AV. P. HARRIS.
1873.] "
forming but a limited possible; tlio blade" (of the knife) angle with the staff" (this is a point of much importance), and especially in withdrawing it that it be brought carefully hack over the finger, and still in contact with the instrument." This latter recommendation applies to all cases ot stone however large, and is more judicious than Fergusson's dictum : If the stone is supposed to be of considerable magnitude, the blade should, in withdrawing it, be carried a little out of the "
"
so as to increase the incision of the prostate." The best practical course, even though the stone is the largest which can safely be extracted by lateral lithotomy, namely, 3 to
groove,
5 inches in circumference in its smallest direction, is to make such incision into the prostate and neck of the bladder as is the result of pushing forward the knife through those
only
parts,
sufficiently by dilatation with the finger. The internal incision being completed, the knife should then be taken out, remembering the recommendation, as given above, to keep it in careful contact with the staff. The forefinger of the left hand is then slipped slowly into the bladder along the staff, and its point moved about in search of the stone, which being found, the staff should be removed, and the Surgeon should introduce the closed forceps along the finder, (a good pair of forceps being selected, the points of which meet accurately), slipping the former into the neck as the latter and to extend it
is taken out. This manoeuvre of keeping the finger in the neck of the until the forceps has arrived at that part, and then the latter in at the moment the former is taken out, is
bladder, slipping
the safest plan of using the forceps and of referred to by Fergusson as follows :?
avoiding
the accident
"With such a narrow wound some care is required in slipping them towards the bladder, for otherwise their points might get between the prostate and rectum. Indeed, even in using the forefinger there is danger, particularly in children, of passing in this direction." In adults when the bladder is unusually deep, and in boys under 3 feet in height from small size of the neck of the bladder, there may be difficulty in introducing the finger into it. It is in the latter when the operator is groping about the neck of the bladder unable to enter it, that he is liable to pass his finger into the recto-vesical fascia. The readiness with which this is
done,
cannot be too
strongly impressed
upon every young
operator. Professor Humphrey in one of his lectures writes:?"In a little child it is sometimes difficult to enter the bladder. The tissues are soft, and readily give way before the finger; the seems to be at an unexpected distance" (lying more in the pelvis than it does in an adult). He continues?" The young operator should be content to go slowly on, not to be seduced
bladder
into
quitting
the
guidance
of the
staff,
not
on
any account to
withdraw the staff till he is certain that his finger is in the bladder, and till he feels the stone with it, but to work quietly and gradually on with finger and knife till he has brought the finger into contact with the stone."
In some cases, it may be necessary to pass the knife along the staff a second time, to enlarge slightly the opening into the bladder, or what is safer in young boys, and a plan 1 have often
successfully adopted, is to pass the polypus forceps (the kind without a dilated end) along the groove of the staff into the neck of the bladder, and use them to gently dilate that part, enter the bladder, and do not taking care that stop
they fully
short in the prostate.
If the index finger be too large to pas3, the little finger may be introduced, though, whichever is used, it must not be forced into the neck in a rough manner, otherwise the inferior connections of the bladder may be ruptured. It is often useful, in cases of difficulty, to have the hypo-
gastric region pressed down by an assistant, the bladder while inserting the finger into it.
so as
to
steady
93;
Sometimes the manoeuvre of twisting the side of the staff while the latter is enables the operator to introduce his finger.
right
finger round to the pressed to the left,
It is not always advisable to insert the finger fully into the neck of the bladder of these little boys ; but it is sometimes sufficient to dilate the part enough to admit of the introduc-
tion of
a
small
forceps,
tracted. If the neck be found of the forceps, ing been more
with which the stone can then be exso
contracted as to resist the entrance
they should be withdrawn, and the parts havfully dilated with the finger, they may then
be re-inserted. After the entrance of the forceps, there may be so much spasm of the neck as to prevent, for a short time, the expansion of the blades to a sufficient degree to admit of the stone being grasped by them. The gentle and continued pressure of tht> on the inside of the neck generally overthe spasm ; but if not, they may be taken out, and thte again dilated with the finger, or, if necessary, more chlo-
expanded forceps comes
part
roform may be given so as to relax the spasm. Before resorting to the above means for causing dilatation of the neck, it is well, in order to avoid bruising of that part, to try whether extraction cannot be performed with a smaller of forceps. It is often possible to accomplish this with much smaller ones than it is generally the custom to make use
pair of.
caught immediately on the entrance of the given a slight shake and opened, when the calculus will generally drop between the blades; but in some cases difficulty is experienced in seizing it either from its being of a flat or else of a perfectly round shape, especially if the latter be also quite smooth or much tuberculated. A curved forceps or a scoop is often successfully used after the straight forceps has failed. In seizing the stone after all water and urine have escaped, great care should be used, as the If the stone is not
forceps, these
should be
bladder sometimes contracts around the stone, and then the mucous membrane if rugous or relaxed may be injured. Lest the membrane may have been caught, it is well to relax the grasp of the forceps during a moment when the forcing efforts of the
patient are suspended, so and only when certain
to allow the membrane to escape; from the feel that the blades are in
as
contact with the stone should extraction be commenced. After the stone is grasped, if the handles of the forceps should remain
widely separated indicating that the stone, if a moderate sized one, has been grasped in its long diameter, the finger should be introduced along the blades or into the rectum, in order to push the stone into a more favorable position: or if this should fail, it should be allowed to fall away from the forceps, and then be caught again in its short diameter. When commencing extraction, let the expanded blades of the forceps holding the stone correspond with the line of the incision in the left side of the neck of the bladder.
Let the movements during extraction be slow, and the hand carried up and down and from side to side with such a degree of pulling and gentle twisting, if necessary, as to cJause the textures to yield gradually, being careful that the neck of the
bladder and the prostate are kept as much as possible in their natural positions, by making traction towards the middle line of the perineum and towards the floor of the incision. If the stone is large, these parts should be pushed back gently while the extracting force is kept up. In one upon the stone, case in which the neck of the bladder was drawn down almost to the external surface of the wound without allowing the 'exit of the stone, I incised it slightly, and was immediately after-' 11 wards able to extract the stone. ?
Bringing forward the knees operator relaxes the wound, and the stone.
patient towards the facilitates the extraction of
of the so
THE INDIAN MEDICAL G-AZETTE.
234
In one case in which resistance to extraction
was
found after
the stone, but in which an extra twist brought it away, I found that the nucleus of the calculus was a straw, which had contracted adhesions to the mucous coat of the bladder.
seizing
This
man made a good recovery. In another case, a pedunculated tumour attached to the inside of the neck of the bladder was pushed down in front of the stone during extraction, and might have been torn off if rude
force had been used, but by altering the position of the stone and pushing aside the tumour, extraction was effected. Care should be taken not to fracture the stone during extracunless it be too large to pass safely through the internal
tion,
incision, in which
case
it is advisible to crush it.
If this should be
required, the bladder should be washed out by inserting the nozzle of a common enema syringe of a size proportioned to the age of the patient along the finger into the bladder, care being taken not to inject the water so forcibly as to injure that viscus. After extraction, introduce the finger into the bladder, so as to ascertain the presence or not of another stone. The finger is generally long enough to explore every
part
of
[September 1,
187?..
the inside of the bladder, if pressure downwards be made at the time on the hypogustrium ; though if the perineum should be very deep, a searcher may be used. same
)(To
be
concluded.)
By "W. P. Harris, M.D., Civil Surgeon, Shahjehanpore. (Continued from
Lateral
page
207J
Section VIII.?(Continued.) Operation.?The most important and
difficult
question
in lithotomy is, the extent to which the prostate and neck of the bladder, should be cut. In Coulson's words, the question is?" Should the internal incision be carried freely through the prostate and neck of the
bladder, to be
or
are
prefered
moderate incisious with
"
subsequent
dilatation
incisions, which consist in carrying the knife on bladder, but only just enough to notch the ligamentous band at that part, are preferable. They are sufficient for the extraction of the largest calculi, it is safe to operate upon, if subsequent dilatation be used. Except for the extraction of small stones, the above-mentioned slight notching of the ligamentous band at the neck of the bladder will generally be required both in adults and children, The latter
into the neck of the
as to admit of sufficient dilatation of that part for the extraction of the stone without much violence. It is sufficient to limit the uso of the knife to the prostate for
so
the extraction of small stones in all patients, except in very short children; for in these a small and rcccntly-formed stone does not cause sufficient dilatation of the neck of the bladder to enable the operator to insert his finger into that part, until it has been slightly notched by tho knife. Erichsen says, " Scarpa advises that tho incision into it (the prostate) should not exceed "five lines in adults and two in children." He adds, " It is difficult to measure the extent of the incitsion; it is sufficient to say that it should be as limited us
September 1,
LITHOTOMY.?BY AV. P. HARRIS.
1873.] "
forming but a limited possible; tlio blade" (of the knife) angle with the staff" (this is a point of much importance), and especially in withdrawing it that it be brought carefully hack over the finger, and still in contact with the instrument." This latter recommendation applies to all cases ot stone however large, and is more judicious than Fergusson's dictum : If the stone is supposed to be of considerable magnitude, the blade should, in withdrawing it, be carried a little out of the "
"
so as to increase the incision of the prostate." The best practical course, even though the stone is the largest which can safely be extracted by lateral lithotomy, namely, 3 to
groove,
5 inches in circumference in its smallest direction, is to make such incision into the prostate and neck of the bladder as is the result of pushing forward the knife through those
only
parts,
sufficiently by dilatation with the finger. The internal incision being completed, the knife should then be taken out, remembering the recommendation, as given above, to keep it in careful contact with the staff. The forefinger of the left hand is then slipped slowly into the bladder along the staff, and its point moved about in search of the stone, which being found, the staff should be removed, and the Surgeon should introduce the closed forceps along the finder, (a good pair of forceps being selected, the points of which meet accurately), slipping the former into the neck as the latter and to extend it
is taken out. This manoeuvre of keeping the finger in the neck of the until the forceps has arrived at that part, and then the latter in at the moment the former is taken out, is
bladder, slipping
the safest plan of using the forceps and of referred to by Fergusson as follows :?
avoiding
the accident
"With such a narrow wound some care is required in slipping them towards the bladder, for otherwise their points might get between the prostate and rectum. Indeed, even in using the forefinger there is danger, particularly in children, of passing in this direction." In adults when the bladder is unusually deep, and in boys under 3 feet in height from small size of the neck of the bladder, there may be difficulty in introducing the finger into it. It is in the latter when the operator is groping about the neck of the bladder unable to enter it, that he is liable to pass his finger into the recto-vesical fascia. The readiness with which this is
done,
cannot be too
strongly impressed
upon every young
operator. Professor Humphrey in one of his lectures writes:?"In a little child it is sometimes difficult to enter the bladder. The tissues are soft, and readily give way before the finger; the seems to be at an unexpected distance" (lying more in the pelvis than it does in an adult). He continues?" The young operator should be content to go slowly on, not to be seduced
bladder
into
quitting
the
guidance
of the
staff,
not
on
any account to
withdraw the staff till he is certain that his finger is in the bladder, and till he feels the stone with it, but to work quietly and gradually on with finger and knife till he has brought the finger into contact with the stone."
In some cases, it may be necessary to pass the knife along the staff a second time, to enlarge slightly the opening into the bladder, or what is safer in young boys, and a plan 1 have often
successfully adopted, is to pass the polypus forceps (the kind without a dilated end) along the groove of the staff into the neck of the bladder, and use them to gently dilate that part, enter the bladder, and do not taking care that stop
they fully
short in the prostate.
If the index finger be too large to pas3, the little finger may be introduced, though, whichever is used, it must not be forced into the neck in a rough manner, otherwise the inferior connections of the bladder may be ruptured. It is often useful, in cases of difficulty, to have the hypo-
gastric region pressed down by an assistant, the bladder while inserting the finger into it.
so as
to
steady
93;
Sometimes the manoeuvre of twisting the side of the staff while the latter is enables the operator to introduce his finger.
right
finger round to the pressed to the left,
It is not always advisable to insert the finger fully into the neck of the bladder of these little boys ; but it is sometimes sufficient to dilate the part enough to admit of the introduc-
tion of
a
small
forceps,
tracted. If the neck be found of the forceps, ing been more
with which the stone can then be exso
contracted as to resist the entrance
they should be withdrawn, and the parts havfully dilated with the finger, they may then
be re-inserted. After the entrance of the forceps, there may be so much spasm of the neck as to prevent, for a short time, the expansion of the blades to a sufficient degree to admit of the stone being grasped by them. The gentle and continued pressure of tht> on the inside of the neck generally overthe spasm ; but if not, they may be taken out, and thte again dilated with the finger, or, if necessary, more chlo-
expanded forceps comes
part
roform may be given so as to relax the spasm. Before resorting to the above means for causing dilatation of the neck, it is well, in order to avoid bruising of that part, to try whether extraction cannot be performed with a smaller of forceps. It is often possible to accomplish this with much smaller ones than it is generally the custom to make use
pair of.
caught immediately on the entrance of the given a slight shake and opened, when the calculus will generally drop between the blades; but in some cases difficulty is experienced in seizing it either from its being of a flat or else of a perfectly round shape, especially if the latter be also quite smooth or much tuberculated. A curved forceps or a scoop is often successfully used after the straight forceps has failed. In seizing the stone after all water and urine have escaped, great care should be used, as the If the stone is not
forceps, these
should be
bladder sometimes contracts around the stone, and then the mucous membrane if rugous or relaxed may be injured. Lest the membrane may have been caught, it is well to relax the grasp of the forceps during a moment when the forcing efforts of the
patient are suspended, so and only when certain
to allow the membrane to escape; from the feel that the blades are in
as
contact with the stone should extraction be commenced. After the stone is grasped, if the handles of the forceps should remain
widely separated indicating that the stone, if a moderate sized one, has been grasped in its long diameter, the finger should be introduced along the blades or into the rectum, in order to push the stone into a more favorable position: or if this should fail, it should be allowed to fall away from the forceps, and then be caught again in its short diameter. When commencing extraction, let the expanded blades of the forceps holding the stone correspond with the line of the incision in the left side of the neck of the bladder.
Let the movements during extraction be slow, and the hand carried up and down and from side to side with such a degree of pulling and gentle twisting, if necessary, as to cJause the textures to yield gradually, being careful that the neck of the
bladder and the prostate are kept as much as possible in their natural positions, by making traction towards the middle line of the perineum and towards the floor of the incision. If the stone is large, these parts should be pushed back gently while the extracting force is kept up. In one upon the stone, case in which the neck of the bladder was drawn down almost to the external surface of the wound without allowing the 'exit of the stone, I incised it slightly, and was immediately after-' 11 wards able to extract the stone. ?
Bringing forward the knees operator relaxes the wound, and the stone.
patient towards the facilitates the extraction of
of the so
THE INDIAN MEDICAL G-AZETTE.
234
In one case in which resistance to extraction
was
found after
the stone, but in which an extra twist brought it away, I found that the nucleus of the calculus was a straw, which had contracted adhesions to the mucous coat of the bladder.
seizing
This
man made a good recovery. In another case, a pedunculated tumour attached to the inside of the neck of the bladder was pushed down in front of the stone during extraction, and might have been torn off if rude
force had been used, but by altering the position of the stone and pushing aside the tumour, extraction was effected. Care should be taken not to fracture the stone during extracunless it be too large to pass safely through the internal
tion,
incision, in which
case
it is advisible to crush it.
If this should be
required, the bladder should be washed out by inserting the nozzle of a common enema syringe of a size proportioned to the age of the patient along the finger into the bladder, care being taken not to inject the water so forcibly as to injure that viscus. After extraction, introduce the finger into the bladder, so as to ascertain the presence or not of another stone. The finger is generally long enough to explore every
part
of
[September 1,
187?..
the inside of the bladder, if pressure downwards be made at the time on the hypogustrium ; though if the perineum should be very deep, a searcher may be used. same
)(To
be
concluded.)
