Clinical Lecture ON LITHOTOMY

Eben. Watson
1872 The Lancet  
of this city, and therefore it forms the most natural subject for our consideration this morning. I wish especially to direct your attention to this operation because it is very slightly, if at all, noticed ir text-books on surgery, and, in my opinion, it is not by any means sufficiently valued by the profession. I believe, in' deed, it is easier, both for surgeon and patient, than an3 other method of extracting stone from the bladder, and thai its results will compare favourably with those of
more » ... ny otheJ operation of the kind. The two cases which are the occa. sion of this lecture ended, as you know, quite successfully, though in one of them the man was fifty years old. They make up the number of times I have performed this operation to forty-seven, and of these only two have died, or 1 in 23a; and I may briefly state here that in neither of the two cases in which the patient died could it be said that death was the direct result of the operation. In one it was caused by pyæmia; and, on inspection of the body, I discovered an abscess at the fundus of the bladder, which I thought of older date than the operation. In the other case erysipelas attacked the neighbourhood of the wound, and extensive suppuration and sloughing in the pelvis ensued before death. This patient was about fifty years of age; the former was a child. But even if we count both as deaths from lithotomy, the result is still favourable, even when compared with the apparently less formidable operation of lithotrity. Thus, if we look at the somewhat contradictory statistics of the latter operation, we find that, while Civiale states that he only lost 1 in 42 cases, Malgaigne and other Parisian hospital surgeons give their mortality at 1 in 4 to 1 in 8; Sir Benjamin Brodie lost 9 in 113 cases, or about 1 in 122; Crichton, 1 in 5; Sir Henry Thompson, in 142 ; while the mortality in my cases of lithotomy has been only 1 in 232. Then if the ease of the patient after lithotomy be compared with the anxiety which he must endure after lithotrity and during its frequent repetitions, as well as his distress from the fragments sticking in the urethra and often causing retention of urine, one cannot but regard the cutting operation with greater favour than the one by crushing. When the patient is under chloroform during the performance of lithotomy his sufferings are in the great majority of cases ended by the operation almost as completely as the pain of toothache is terminated by a skilful extraction ; and I have known a patient after lithotomy sleep for several days and nights with but short intermissions, just from his entire freedom from an agony which had disturbed his rest for months before. Yet I confess that this preference which I have for lithotomy in the majority of cases is founded on my conviction of the safety of Dr. Andrew Buchanan's operation when rightly performed, and I shall therefore mention to you somewhat minutely the steps of that operation, with some of the lessons regarding them which experience has taught me. The patient having been laid on a convenient operating table and brought under the influence of chloroform, the rectangular staff should be introduced into the bladder and the stone felt with it. The staff to be selected for use in any case is the largest that can be readily introduced into the urethra. It is of consequence that the rectangular part of the staff should be quite passed into the bladder, and the handle brought down between the patient's thighs, to be held there for the time by an assistant. The limbs are then to be tied up as usual, but I prefer passing the bandages round the thighs to the practice of tying the feet and hands together, both because under chloroform it is needless to fasten the hands, as the patient cannot move them, and because if they are left free there is no interference with the movements of the chest in respiration. The operator now sits down before the perineum, and he should take care that the hips are projected over the end of the table, and that the body of the patient is 3ying quite straight before him. He now places the staff as he wishes it to be held during the operation, and of course on this depend the parts cut and the success of the whole procedure. The index finger of the left hand should be introduced into the rectum and the prostate should be felt, while at the same time the operator should take the handle of the staff in his right hand. He should then raise the long limb of the staff at right angles to the table and to the axis of the patient's body, and should place the angle of the staff just anterior to the prostate gland, and therefore in the membranous part of the urethra. Keeping the long limb of the staff in this position, he should now depress the instrument towards the rectum, until, in fact, the angle is nearly on a level with the junction of the skin and mucous membrane of the anus. One other little manoauvre is still requiredviz., to turn the handle of the staff a little to the right, for by this means the short limb of the staff is inclined to the left side of the perineum. The good of this is, that when the point of the knife enters the groove the operator feels more sensibly the fact of its being there by the opposition which the inclination of the staff occasions to its passage to the bladder. This will be perceived at once-on-trial. If the staff is held right before one, he hardly feels the sliding of the knife along its groove; but if it be held at a slight angle to him, he feels it all the way as he pushes it along t to the stop at the end of the short limb. The staff is now s committed to the charge of the assistant, who is to hold it exactly as it is given to him during the whole procedure. [ It will be observed that in this position the long limb of the staff is nearly parallel with the triangular ligament, and , that its angle is not made to project in the perineum, though 3this was at first supposed to be necessary. In truth, it is f not at all desirable to make it project, because the doing so disturbs the parts and inclines the point of the staff dangerously upon the rectum. It ought also to be remarked . that the angle of the staff is fairly below the central point . of the perineum, and that, as the incision is altogether , below it, the deep perineal fascia and the transverse muscle . and artery of the perineum are uninjured in this operation, ' while they are all divided in the operation of Cheselden. I think this the essential feature of Dr. Andrew Buchanan's . operation and the one on which its success depends. The operator retains the index finger of his left hand in the rectum, and puts the thumb of the same hand on the long limb of the staff a little above its angle, of course having the soft parts between them, and thus he makes sure of where the angle of the staff is, for it must correspond to the angle made by the thumb and finger thus placed. The depth at which it lies is very various in different perineums, but it is seldom very great. I know that it has been stated at two lines, but it is often much more, as in fat children and in tall and corpulent adults. However, it is never so great but that one who is practised in the operation can easily plunge his knife directly into the groove of the staff. To do so one must hold the knife above the hand, and raise it so that its blade shall be parallel with the short limb of the staff. Most of the difficulties which I have known to be encountered at this part of the operation have arisen from the operator holding the knife as if dissecting, with his hand above its handle, and also from his introducing it at an angle to, or not quite parallel with, the short limb of the staff. I insist that the knife must be held above the hand, and boldly raised to a level with the groove along which it is to be passed. It may then be made to pierce the perineum and to enter the groove. There is usually no need of a preliminary incision. A little practice will enable anyone who is accustomed to use the knife to perform this step of the operation at once; but he must be sure that the knife is really in the groove and not above°or below it, or, as sometimes happens, across the staff, for then he is almost certain to do serious mischief. When the knife is fairly in the groove the operator feels a degree of resistance to its passage into the bladder, owing to the slanting manner in which, as I have already said, the staff should be held; and this gives him confidence in running it on till ' s 2
doi:10.1016/s0140-6736(02)64062-0 fatcat:apnmlsbdu5bzdchhgh5ppz46e4