C H A P. XVI.
Of the Operation of Lithotomy.
This Operation is undertaken when it is certainly known that there is a Stone in the Bladder; to be assur'd of which, it may not be improper to introduce a Finger into the Anus near the Os Pubis, by which means the Stone is sometimes felt, if there be any: The Finger is likewise usually put into the Anus of young Virgins, and into the Vagina Uteri of Women, for the same purpose. But it is more expedient to make use of the Probe, anointed with Grease, after this manner: The Patient being laid on his Back, the Operator holds the Yard streight upward, the Glans lying open between his Thumb and Fore-finger; then holding the Probe with his Right-hand on the side of the Rings, he guides it into the Yard, and when it is enter'd, turns the Handle toward the Pubes, drawing out the Yard a little, to the end that the Canal of the Ureter may lie streight. If it be perceiv'd that the Probe hath not as yet pass'd into the Bladder, a Finger is to be put into the Anus, to conduct it thither. Afterward in order to know whether a Stone be lodg'd in the Bladder, the Probe ought to be shaken a little therein, first on the Right-side, and then on the Left; and if a small Noise be heard, it may be concluded for certain that there is a Stone: But if it be judg'd that the
Stone swims in the Bladder, so that it cannot be felt, the Patient must be oblig'd to make Water with a hollow Probe.
Another manner of searching may be practis'd thus: Let the Yard be rais'd upward, inclining a little to the side of the Belly; let the Rings of the Probe be turn'd upon the Belly, and the end on the side of the Anus; and then let this Instrument be introduc'd, shaking it a little on both sides, to discover the Stone.
In order to perform the Operation of Lithotomy, the Patient must be laid along upon a Table of a convenient height, so as that the Surgeon may go about his Work standing; the Patient's Back must also lean upon the Back of a Chair laid down, and trimm'd with Linnen-Cloth, lest it shou'd hurt his Body; his Legs must be kept asunder, and the Soles of his Feet on the sides of the Table, whilst a Man gets up behind him to hold his Shoulders: His Arms and Legs must be also bound with Straps or Bands. Then a channell'd Probe being put up into the Bladder, a Servant standing upon the Table on the side of the Chair, holds the Back of the Instrument between his two Fore-fingers on that Part of the Perinæum where the Incision ought to be begun, which is to be made between his Fingers with a sharp Knife that cuts on both sides: The Incision may be three or four Fingers breadth on the left side of the Raphe or Suture: But in Children its length must not exceed two Fingers breadth. If the Incision were too little to give Passage to the Stone, it wou'd be more expedient to enlarge it than to stretch the Wound
with the Dilatators. When the Convex Part where the channelling of the Probe lies, shall be well laid open, the Conductors may be slipt into the same Channelling, between which the Forceps is to be put, having before taken away the Probe. Some Operators make use of a Gorgeret or Introductor to that purpose, conveying the end of it into the Chanelling of the Probe; which is remov'd to introduce the Forceps into the Bladder: And as soon as they are fixt therein, the Conductors or Gorgeret must be likewise taken out. Afterward search being made for the Stone, it must be held fast, and drawn out of the Bladder: But if the Stone be long, and the Operator hath got hold thereof by the two Ends, he must endeavour to lay hold on it again by the Middle, to avoid the great scattering which wou'd happen in the Passage. The Stones are also sometimes so large, that there is an absolute necessity of leaving 'em in the Bladder. Again, if the Stone sticks very close to the Bladder, the Extraction ought to be deferr'd for some time; and perhaps it may be loosen'd in the Suppuration. Lastly, when the Stone hath been taken out, an Extractor is usually introduc'd into the Bladder, to remove the Gravel, Fragments, and Clots of Blood.
After the Operation, the Patient is carry'd to his Bed, having before cover'd the Wound with a good Bolster; and if an Hæmorrhage happens, it is to be stopt with Astringents. A Tent must also be put into the Wound, when it is suspected that some Stone or Gravel may as yet remain therein: But if it evidently appears that
there is none, the Wound may be dress'd with Pledgets, a Plaister, and a Bolster, of a Figure convenient for the Part. The Dressing may be staid with a Sling supported by a Scapulary; or else the Bandage of the double T. may be us'd, the manner of the Application of which we have shewn elsewhere. The Patient's Thighs must be drawn close to one another, and ty'd with a small Band, lest they shou'd be set asunder again.