236 HOOTON. 



surgeons, have also employed Keith's method in the same hospital with most 

 encouraging results, and Colonel Henderson has published a series of a hundred 

 and ten cases with three deaths. 



Keith's original operation in its turn has in recent years undergone further 

 modification at the hands of various operators. Surgeon-General Stevenson, it 

 would appear, makes a slightly larger opening so as to allow of one instrument 

 being introduced alongside another, the prineiisle being- to retain a guide all the 

 time; while Major S. Evans prefers to make his incision somewhat further back, 

 and thus strike the wider prostatic portion of the urethra. Both these modifica- 

 tions would tend theoretically to minimize what I am convinced is the reason 

 of the comparatively slow adoption of the operation by surgeons who have not 

 had opportimities of seeing it actually performed, namely, the risk of missing 

 the opening in the urethra in working without a guide. However, this risk is 

 not a great one, for Keith's original incision strikes the tirethra at a point 

 where it is easily accessible, and where the wall, surrounded by the constrictor 

 fibers, is more likely to grasp the instrument and so prevent leakage. In my 

 experience it is not easy to work through a small opening using say the lithotrite 

 as a gviide for the canula to follow it; and, finally, the figures quoted above speak 

 for themselves. 



In the account given below, I have adhered closely to what 1 under- 

 stand was Keith's original procedure, for any knowledge of which 

 I wish to express my indebtedness to Colonel Henderson. I may remark 

 that my own experience is limited to thirteen cases, all of which re- 

 covered. Those only which call for comment were three children with 

 large stones, necessitating prolonged manipulation and the repeated 

 passing of instruments, and in whom the small incision did not heal, 

 as it ordinarily does, by first intention. 



ADVANTAGES OF KEITH's OPERATION. 



A comparison may perhaps best be made with suprapublic lithot- 

 omy in adults, and lateral lithotomy in children and in both, perineal 

 litholapaxy is usually, I would urge, very much preferable. Supra- 

 pubic lithotomy has, I think, a larger mortality, it necessitates prolonged 

 confinement to bed, and the patient is a nuisance to himself and his 

 attendants. Lateral" lithotomy, although very successful in children, 

 has all the disadvantages of involuntary micturition, and there is reason 

 to believe that in some cases the sexual powers are interfered with. 



In Keith's operation there is usually no shock, micturition is vohm-' 

 tary, the sexual apparatus is not injured, and the period of convales- 

 cence is usually not much longer than that of ordinary litholapaxy. I 

 personally make a practice of keeping cases in for five to seven days, 

 but often, after twenty-four hours, healing is so far advanced as to 

 prevent any further escape of ixrine from the wound, and instances have 

 frequently been noticed in which all urine escaped via the meatus from 

 the first. 



