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AN 
 
 INAUGURAL DISSERTATION 
 
 ON 
 
 STONE IN THE BLADDER. 
 
 Submitted to the public Examination of the Faculty of Physic under the 
 
 Authority of the Trustees of Columbia College, 
 
 in the State of New -York, 
 
 The Right Rev. BENJAMIN MOORE, D. D. President? 
 
 FOR THE DEGREE OF 
 
 DOCTOR OF PHYSIC, 
 
 On the 13th Day of November, 1810, 
 
 BY HENRY U. ONDERDONK, A. M. 
 
 Member of the Royal College of Surgeons, London. 
 
 " The ancients only laid the foundation, which was doing considerable 
 
 service : they who have come after them, have worked upon their plan, 
 
 and from time to time, the art of Surgery has received improvements." 
 
 Gataker's Translation of Le Droll's Operations, 
 
 I 
 
 $eto*Iorri: 
 
 Printed by T. & J. SWORDS, Printers to the Faculty of Physic 
 of Columbia College, No. 160 Pearl-Street. 
 
 1810, 
 
&OLXJMBXA3XA. 
 
 
 
 v A " tL i' 
 
 '{ 
 
 A- 
 
 "C^^z^C^Z 
 
TO 
 
 DOCTOR JOHN ONDERDONk 
 
 AS A 
 TRIBUTE OF FILIAL DUTY AND GRATITUDE 
 
 TO 
 
 WRIGHT POST, ESQ. 
 
 Professor of Anatomy and Surgery in Columbia College, 
 and Surgeon to the New- York Hospital, 
 
 AS A 
 
 TESTIMONIAL OF RESPECT AS AN INSTRUCTOR 5 
 AND OF ESTEEM AS A FRIEND; 
 
 AND TO 
 
 THOMAS BLIZARD, ESQ. 
 
 Fellow of the Royal Societies of London and Edinburgh, 
 and Surgeon to the London Hospital, 
 
 AS AN 
 
 ACKNOWLEDGMENT OF PROFESSIONAL AND 
 PERSONAL CIVILITIES; 
 
 THIS DISSERTATION 
 15 RESPECTFULLY INSCRIBED 
 
ADVERTISEMENT. 
 
 T. HE author of the following pages was led 
 to select his subject from having witnessed at 
 the Hospitals in London, the frequent use of 
 a bistoury in lithotomy ; and from a convic- 
 tion, that it was an instrument superior in 
 principle to any other he had seen used. But 
 to have merely dwelt upon the merits of the 
 knife, would not have afforded matter suffi- 
 cient for an Inaugural Dissertation of reason- 
 able length. He has therefore given a general 
 history of the disease, for whose removal the 
 instrument is proposed. He is sensible that 
 much of this is mere selection; but he has 
 endeavoured to quote from such authorities 
 as are standard, and to adduce only such facts 
 and observations as are of importance. These, 
 he trusts, will compensate for any deficiency 
 In his own remarks. 
 
 Nassau-Street, Oct. 2, 1810. 
 
on 
 
 STONE IN THE BLADDER. 
 
 CALCULOUS concretions are found in many 
 parts of the body; but their most usual situation is 
 in the urinary organs ; in the kidney, ureter, blad- 
 der, prostate gland, urethra, and around the corona 
 glandis. The nature of those found in the bladder, 
 the symptoms they occasion, and the methods of 
 relief, are the subjects of the present dissertation. 
 
 Calculi in the bladder vary in size, number, and 
 composition. The most usual sizes are between 
 those of a musket ball and a hen's egg. But they 
 are sometimes much larger. At the lectures of the 
 Royal College of Surgeons in London, a stone is 
 exhibited, which weighs 44 oz. and is 16 inches in 
 one circumference, and 14 in the other. An at- 
 tempt was made to extract this b y S i r Jamoo fcafte-, 
 but he, of course, failed, and the patient died from 
 consequent irritation. Calculi are sometimes much 
 smaller than the size above limited. 
 
 Commonly there is but one calculus in the blad- 
 der, Much variety however in this respect is met 
 
8 
 
 with. I have seen two sets, one of 37, and another 
 of 22, each taken from a single bladder. Dessault 
 extracted 200 from one bladder,* which were most 
 probably small. Mr. Home relates an instance of 
 350 from one patient. f When more than one exist, 
 their surfaces are smooth. Cheselden gives a plate 
 of two from one bladder, which had opposing smooth 
 surfaces like a joint: J they had probably been re- 
 tained in the bladder in such a situation that their 
 friction upon one another was confined to these sur- 
 faces. Dr. R. S. Kissam showed me a single cal- 
 culus with a small part of its surface polished, which 
 he attributed to its lying constantly upon an enlarged 
 prostate. 
 
 Mr. Brande, in a paper published in the Philoso- 
 phical Transactions for 1808, § has arranged urinary 
 calculi into three kinds : Those composed chiefly of 
 uric acid ; those made up chiefly of an ammoniaco- 
 magnesian phosphate, or of phosphate of lime, or 
 of both ; and those which contain oxalate of lime^ 
 called also mulberry calculi. 
 
 The first kind are those passed from the kidney 
 out of the body, without remaining in the bladder 
 at all, or only a short time. They consist of uric 
 acid and animal matter, in proportions varying from 
 nearly equal quantities of each, to two thirds of the 
 former. This species are soluble in alkalies, and 
 disappear before the blow-pipe: they have smooth 
 surfaces, and are made up of concentric layers like 
 a section of a tree; their colour is commonly brown s 
 
 * Parisian Journal, vol. ii. p. 386. 
 f Philosophical Transactions, 1808, page 244. 
 - Cheselden's Anatomy, edit. 1.722, plate SO 
 ; ) Page 223. 
 
9 
 
 I have, however, seen them white. Dr. G. Pearson, 
 in a paper of the Philosophical Transactions for 
 1798,* terms the acid which constitutes the base of 
 this kind of calculus, uric oxide: he asserts that it 
 is only found in the human subject, and may be dis- 
 covered in gouty concretions, but not in those of 
 the teeth, stomach, intestines, lungs, brain, &c. 
 He notices some analogies which induce him to be- 
 lieve, that, if man lived on vegetables alone, he 
 would not have this oxide formed in his body.- — The 
 first detection of uric acid by analysis of urinary 
 calculus was by Scheele. 
 
 The next division made by Mr. Brande, compre- 
 hends such calculi as are principally made up of the 
 ammoniaco-magnesian phosphate, or of phosphate 
 of lime, or of both. These substances, he asserts, 
 are met with when the stone has been some time in 
 the bladder, or when a stone is detained longer than 
 usual in the kidneys. These are commonly the 
 most abundant ingredients in a large calculus. They 
 are generally mixed with the uric acid, either in dis- 
 tinct layers, or by mechanical diffusion. Calculi 
 formed of these alone, are found in the bladder only, 
 and have some loosely agglutinated particles of the 
 same matter for a nucleus. The colour of calculi of 
 this species is a whitish grey; their surfaces fre- 
 quently exhibit transparent crystals ; they generally 
 are firm, but not unfrequently so friable as to crum- 
 ble under very slight pressure; they are soluble in 
 muriatic acid. They are thought to be connected 
 with greater disease of the bladder than either of the 
 other species. 
 
 Page lc 
 
 2 
 
10 
 
 The last division of Mr. Brande contains the 
 few specimens which exhibit on analysis oxalate of 
 lime. These are found only in the kidney, or are 
 immediately passed thence. If they have been re- 
 tained in the bladder, they are only nuclei for some 
 other species. When they are passed immediately 
 out, the patient is less liable to a return of the com- 
 plaint. The surface of this species of stone is rough, 
 not unlike the fruit to which it is compared; they 
 are firm in texture, and difficultly soluble in acids. 
 
 The following is the result of the analysis of 150 
 calculi, made by this chemist. It exhibits the pro- 
 portional frequency of the several species, and may 
 afford some useful hints in considering the means 
 proposed for dissolving a stone. 
 
 16 consisted of uric acid ; 
 
 45 of uric acid as the larger, and the phosphates 
 as the smaller ingredient ; 
 
 66 of the phosphates as the larger, and uric acid 
 as the smaller ingredient ; 
 
 12 of the phosphates alone; 
 
 5 of uric acid and the phosphates, with a nucleus 
 of oxalate of lime; 
 
 6 of oxalate of lime chiefly. 
 
 The analysis of urinary calculi was extended by 
 Mr. Brande to those found in the brute creation, 
 Specimens from the horse, ox, sheep, dog, hog, 
 rabbit, and rhinoceros were examined; and the 
 grand difference between them and the human, 
 was, that they contained no uric acid, but carbonate 
 of lime very generally, an ingredient not discovered 
 in the human specimen? 
 
11 
 
 SYMPTOMS. 
 
 A patient generally first experiences an itching or 
 smarting sensation about the frenum. This induces 
 him to rub the part frequently, and the prepuce is 
 thus sometimes preternaturally elongated. When 
 very violent, the sensation has been compared to 
 cutting with a red-hot knife. A frequency in making 
 water, together with pain, is soon observed; and 
 this pain is particularly great while voiding the last 
 drops, during which the bladder contracts firmly 
 upon the stone, and undergoes excessive irritation. 
 The pain at the glans is most acute, from that part 
 being a centre of sympathy for the bladder and ure- 
 thra; that in the region of the bladder is of a more 
 dull nature. 
 
 A more remarkable and more certain diagnostic of 
 the disease, is an irregularity in passing the urine. 
 It first flows in a full stream, and then is suddenly 
 stopped. This arises from a falling (as it is usually 
 termed) of the stone against the mouth of the ure- 
 thra. But the obstruction is rather caused by the 
 stone being raised to this point, from the lower pos- 
 terior bulging part of the cavity ; into which its own 
 gravity will incline it to subside, and which becomes 
 obliterated while the bladder is contracting to void 
 the urine : when the stone is raised to the point men- 
 tioned, it will be disposed to remain in the funnel- 
 like cavity, until a new distention of the bladder 
 allows it to subside to its first situation. This 
 symptom occurs also in that disease of the prostate, 
 where a part of that gland is made to project into the 
 bladder. 
 
Agitation greatly increases the pain from a stone. 
 Riding in a carriage or on horseback will occasion 
 excruciating torture, and not unfrequently cause the 
 urine to be tinged with blood. If the bladder be 
 particularly irritable, the mere change from a stand- 
 ing to a recumbent posture will give pain. These 
 symptoms do not take place in enlarged prostate, 
 and may serve as distinctive marks between the two 
 diseases. 
 
 When the pain is very violent, there is often a 
 sense of weight in the rectum, with a frequent de- 
 sire to go to stool. Sometimes there are prolapsus 
 ani, and piles. Incontinence of urine is also enu- 
 merated as a symptom. This probably arises from 
 the relaxation of the sphincter of the bladder, in 
 consequence of an irritation in its general muscular 
 coat. It may also arise from the stone being so large, 
 as nearly to fill the whole cavity of the bladder, and 
 thus leave no room for the accumulation of urine, 
 which will necessarily be constantly passing off. I 
 have assisted in the examination of a patient, who 
 died under the latter circumstances. 
 
 The urine is sometimes limpid, commonly it has 
 a wheyey appearance, probably from the quantity of 
 mucus it contains, and which it deposits in the form 
 of sediment. This increased quantity of mucus is 
 secreted, as a defence to the bladder from the irri- 
 tation of the stone. After violent exercise, blood 
 is mixed with the urine. Mucus, speckled with 
 blood, is deemed an unequivocal symptom. A 
 gravelly deposit is also common : it may be either 
 the Uric acid precipitated in the vessel, or a gravel 
 of the phosphates. 
 
 When the complaint has proceeded to a violent 
 
13 
 
 height, and what may be termed the latter stages 
 have set in, the constitution will suffer from the irri- 
 tation, the abdominal muscles take on a spasmodic 
 action, and there will be frequent and violent ri- 
 gors. 
 
 If the stone be small and have an even surface, it 
 may cause the patient little or no uneasiness. And 
 whatever be the size, the pain is not constant. It 
 returns occasionally, making what have been termed 
 fits. These are not regular in their recurrence, and 
 arise most probably from the bladder being more 
 irritable at one time than at another. They have 
 been likewise attributed to the stone resting upon 
 the commencement of the urethra. A stone passing 
 from the kidney will also cause a fit. Exercise will 
 sometimes produce it. The roughness of a calculus 
 will also be the cause of much additional pain. A 
 boy of about 14 years old had symptoms of stone 
 from his infancy, but of the milder kind. A few 
 weeks before the operation, his pain became violent. 
 Dr. Post extracted the stone ; its surface was smooth, 
 except a portion on which some crystals had formed; 
 these were probably of a late date, and gave rise to 
 the increase of pain. 
 
 CAUSES. 
 
 These, at present, are involved in great obscurity. 
 What circumstances give some persons a disposition 
 to these concretions, while others remain exempt, 
 
14 
 
 have not been satisfactorily traced. The complaint 
 seems occasionally to be hereditary; in some cases 
 it has been ascribed to the waters of a particular 
 tract of country. But these explanations are unsatis- 
 factory, in as much as their application is far from 
 general. 
 
 Any solid substance introduced into the bladder, 1 
 will form a nucleus for the concretion of a stone. 
 Cheselden gives a plate of a calculus, formed on a 
 bullet " shot through the upper and back part of the 
 thigh into the bladder of a soldier."* I have seen a 
 similar specimen in the Museum of the Royal Col- 
 lege of Surgeons, London. There is said to be one 
 of a like kind in a Museum at Philadelphia. Mr. 
 Astley Cooper exhibits to his class, a calculus 
 formed in the urethra of a sailor on a piece of wood 
 which he had introduced while at sea, as a substi- 
 tute for a bougie. In the above Museum in Lon- 
 don, besides the specimen of bullet nucleus, Sir 
 Wm. Blizard, in his lectures at the College, exhi- 
 bited stones formed on bougies, on pins, on a bod- 
 kin, a needle, a pea, and a hazel-nut. Le Dran 
 took a calculus from a child, formed on a dossil of 
 lint, which had slipped into the bladder from a former 
 operation.f In the Parisian Journal, mention is 
 made of one whose nucleus was an " ear of corn; "J 
 and of one extracted by Dessault in the Hotel Dieu, 
 whose nucleus was a " small apple." § And in 
 
 * Cheselden's Anatomy, edit. 1722, plate 30. 
 j- Le Dran's Operations, page 250. 
 
 £ The American reader may be apprised that Indian corn is not here 
 meant. 
 
 £ Vol. ii. page 386. 
 
15 
 
 some papers, published by the Massachusetts Medi- 
 cal Society, in 1790, a stone is described to have 
 formed on " two or three inches of the smooth 
 stalk of a plant, broken off in the bladder by acci- 
 dent."* It is also familiar to surgeons, that a sil- 
 ver catheter, left for three or four days in the blad- 
 der, has a calculous crust deposited on its extremity. 
 
 The consideration of these facts would induce a 
 belief that calculi were generally deposited upon a 
 nucleus ; and in the cases where an external one was 
 wanting, a clot of blood, a piece of hardened mu- 
 cus, a small quantity of gravel, and a stone from 
 the kidney, have been assigned ; they are almost al- 
 ways found in the centres of calculi. 
 
 The various ingredients which make up the che- 
 mical composition of calculi, are found in the urine. 
 Uric acid is a permanent ingredient, although " most 
 abundant in sick people ;"t the degree or nature of 
 sickness which may produce it, is not indeed traced, 
 but it may be owing to local diseased action, as well 
 as to general sickness. The acid phosphate of lime, 
 the phosphate of magnesia, and phosphate of am- 
 monia, are also constant ingredients. The oxalate 
 of lime is also found "as it were by accident." 
 Animal matter, that is, gelatin and albumen, are 
 likewise always present; but " very variable in their 
 proportions in different kinds of urine." These 
 " afford the gluten, which holds the particles of cal- 
 culi together." 
 
 Calculi of uric acid, and of oxalate of lime, ap- 
 pear to be the only ones formed in the kidney, with- 
 
 * Page 92. 
 
 f Thompson's notes on Fourerov's Chemistry, vol. jii. p. 321- 
 
16 
 
 out a nucleus. Why this should be the situation of 
 the spontaneous concretion of these alone, cannot 
 be well explained; unless we suppose that uric acid, 
 when abundant, is only mechanically diffused in the 
 urine ; a supposition which derives support from its 
 spontaneous subsidence after urine is discharged. If 
 such a subsidence took place in the bladder, as the 
 particles would be very small, they would easily be 
 washed out in passing the water, and the complaint 
 would remain in the stage of gravel only ; no nu- 
 cleus being retained to give rise to a stone. If this 
 subsidence, and consequent concretion, should take 
 place in the tubular part of the kidney, the stone 
 would be there wedged in, and gradually receive ad- 
 ditional laminae, until it passed to the bladder. 
 
 The urine is secreted in the bladder in a dilute 
 state, — dilute, comparing the proportion of water and 
 salts. This dilution is lessened by retention in the 
 bladder.* The salts, of course, may then be more 
 readily deposited; and the presence of a nucleus, 
 will probably make this deposition invariable. Crys- 
 tallization, perhaps, results from a still farther depri- 
 vation of the aqueous parts of the urine. f 
 
 There are but few data on which to ground an 
 opinion, as to the formation of mulberry calculi. 
 They seem to be deposited in the kidney, but on 
 what principles I cannot offer a conjecture. 
 
 By adapting the above circumstances as may be 
 necessary, and by bearing in mind, that in some 
 
 * Edin. Syst. Anat. vol. ii. p. 412. Haller's Physiol, p. 390. 
 
 f Admitting that uric acid and the phosphates are deposited in the raan- 
 aer noticed, a difference between gravel and stone may be assigned. Gra- 
 vel is the deposition of these materials, previous to their having undergone 
 aggregation or concretion; after this process has begun, the disease is stone 
 
17 
 
 oases the secretion of abundant uric acid may not 
 be constant, we may account for the different species 
 of calculi, whether of uric acid alone ; of that mixed 
 throughout the phosphates, alternating with them in 
 layers, or forming a nucleus for them; or of the 
 phosphates alone. The animal operation which 
 yields the material, will not indeed be accounted 
 for ; but a single step towards an ultimate explana- 
 tion is not without its value . 
 
 CURE. 
 
 The first analysis of urinary calculus led to the 
 discovery of a new acid. On the ground of this dis- 
 covery, alkalies were used, in the expectation, that 
 passing by the kidneys, they might become so far a 
 component part of the urine, as to dissolve the stone. 
 In some instances these proved beneficial; but it 
 was impossible, that in the greater number of cases, 
 they could remove the concretion. By referring to 
 the table before quoted, it will be seen that 128 of 
 150, contained more or less of the phosphates, which, 
 as will presently be noticed, are rather increased 
 than lessened by the exhibition of alkalies. 
 
 Mr. Abernethy, in his lectures, relates a singular 
 fact, much connected with the present subject. 
 Two portions of calculus were put into different 
 vessels. Into one of these, the urine of a person 
 taking alkali was frequently discharged; into the 
 other, urine from a person not using any medicine. 
 
 3 
 
18 
 
 The first portion of calculus in a short time crum- 
 bled, the other remained firm. This experiment 
 proves, that alkalies can enter the circulation, and 
 pass by the kidneys ; or at least, that they can so 
 alter the urine, as to make it capable of dissolving a 
 stone. But in this case, the subjects of experiment 
 were exposed to the air, an agent, which may have 
 materially promoted the dissolution of the first. 
 
 Alkalies, however, are known to have a soothing 
 effect on the bladder. They are useful in irritation 
 of the bladder or kidneys. By this operation, they 
 have probably gained their reputation as cures for the 
 stone. Mr. Home* relates two cases of reputed 
 cure of this disease by alkalies, in one of which 
 were found after death 20, and in the other, 14 cal- 
 culi. The symptoms he supposed to have ceased 
 from the confinement of these stones behind the en- 
 larged "posterior lobe of the prostate," but it is more 
 probable, that the bladder had been rendered insensi- 
 ble to their presence, by the remedies employed. 
 The formation of a cyst may also account for some 
 cases of reputed cure. 
 
 In the opinion of Mr. Brande, alkalies may often 
 be hurtful in this disease, at least they may increase 
 the size of the stone. The phosphates are dis- 
 solved in urine by an excess of phosphoric acid. 
 An alkali, by neutralizing this, may increase the de- 
 position of these substances. 
 
 This opinion every practitioner will balance in 
 his own mind, with the propriety of exhibiting alka- 
 lies under certain circumstances ; for circumstances 
 exist, in which they are proper. The operation is 
 
 * Philos. Trans, loc. cit. 
 
19 
 
 sometimes unadvisable, and the painful situation of 
 the patient may call for some assistance. In such a 
 case, as alkalies have proved at least palliative, they 
 certainly deserve a trial. Caustic alkali, with opium in 
 linseed decoction, is a very useful prescription. Ef- 
 floresced soda in pills, and soda water, are used ; but 
 are not probably so efficacious as the former, as the 
 carbonic acid contained in them, having a stronger 
 affinity to the alkali than the uric acid, will retain it, 
 and prevent the chance of a solution of the stone by 
 its uric acid uniting with the alkali. The dose of 
 alkali is in no case to be large. 
 
 With the alkaline remedies, may be noticed lime- 
 water. Its solvent powers are analogous to those of 
 alkalies : how far it may prove soothing, I have no 
 authority to determine. 
 
 Messrs. Fourcroy and Vauquelin have lately re- 
 vived attempts to dissolve a stone by injecting alka- 
 lies into the bladder. They have found occasional 
 success. But in addition to the objections to alkalies 
 in general, this plan is imperfect, from the dilute 
 state in which the medicine must be introduced, 
 and the indisposition of the bladder to bear artificial 
 distention. It is probable too, that the success has 
 been very limited, or the method would now have 
 more numerous advocates, as their experiments were 
 instituted several years since. 
 
 As the phosphate calculi are soluble in muriatic 
 acid, this has been exhibited as a remedy. It is ad- 
 mitted by Mr. Brande, that it possesses efficacy, so 
 far as the phosphate materials of a calculus are con- 
 cerned. But if the stone be made up in part of uric 
 acid, or if its nucleus be of that substance, we only 
 lose time in the experiment. The patient will de- 
 
20 
 
 rive but limited benefit from a partial cure, and the 
 operation will be as necessary after a course of acid, 
 as before. A reference to the table will show, that 
 uric acid is an ingredient too frequently met with, 
 to warrant an expectation of success. Similar 
 objections exist to the injection of this, as were 
 noticed of alkalies. 
 
 To the practical surgeon, however, it is needless 
 to multiply proofs of the inefficacy of cures for stone.* 
 An operation becomes in almost every case neces- 
 sary. And if a patient's situation does not forbid, 
 it is improper to defer it, lest the kidneys become so 
 diseased as to render it of no avail. 
 
 Old age does not appear to be an objection to ope- 
 rating. Patients above 80 have been successfully 
 cut, between 60 and 70 frequently, and at 60 very 
 frequently. It is not well to operate on a very young- 
 child, as untoward occurrences during the operation 
 are more seriously felt The youngest child on 
 whom I have heard of its being performed with suc- 
 cess, was a year and nine months old. 
 
 The existence of another disease in the system 
 may forbid an operation. To add a new disturbance 
 to a constitution in such a state, would be a great 
 hazard of life. The other disease should be re- 
 moved, and then the operation may be safely under- 
 taken. 
 
 If there be pain in the loins, and other symptoms 
 of a descending calculus, it is proper to wait until 
 
 * In a preceding note, a distinction was pointed out between gravel and 
 stone. From that it will appear, that the former of these will only be 
 known by observing the gravelly discharge. If the complaint be in this 
 state without symptoms of stone, the exhibition of alkalies or muriatic acid 
 may be useful. 
 
21 
 
 these have subsided, that the additional calculus 
 may be removed by the same operation. 
 
 A discharge of blood on introducing the sound, 
 and other symptoms of highly irritable bladder, may 
 render it prudent to wait, until, by the exhibition of 
 alkalies and other remedies, the excessive irritability 
 be subdued. A slight degree of irritability is no 
 objection to operating. 
 
 SOUNDING. 
 
 No single symptom of stone is sufficiently une- 
 quivocal to warrant an operation. Nay, although 
 the whole united may afford the highest presump- 
 tive proof of the existence of a calculus, no surgeon 
 is justified in operating, unless he receive the more 
 full conviction to be obtained from sounding. 
 
 Previous to introducing the sound, the urine should 
 have been retained a few hours, that the bladder may 
 be sufficiently distended to allow the necessary mo- 
 tion of the instrument. 
 
 The most convenient position is a recumbent one, 
 with the head and chest elevated. The hip and knee 
 joints are to be flexed, the knees are to remain asun- 
 der, and the patient must allow his muscles to be as 
 relaxed as possible. Other positions may be neces- 
 sary, but these must be regulated by circumstances. 
 
 The introduction of a sound, if there be no dis- 
 ease, is effected without much difficulty. The canal 
 of the urethra is to be followed; and if the point of 
 
22 
 
 the instrument be entangled in the folds of its lining 
 membrane, or in the orifices of the lacunas, it must 
 be slightly withdrawn, and the attempt repeated. A 
 large sound, in a healthy urethra, is most easily in- 
 troduced. 
 
 Some have disputed whether a sound should be 
 passed with its convex or concave side to the abdo- 
 men. The former requires a turn when the point 
 reaches the membranous part of the urethra. This 
 turn is supposed to increase very much the pain of 
 introduction — a pain so great in some cases, that I 
 heard a boy, who had been twice before cut, while 
 on the table for a third operation, entreat the surgeon 
 not to introduce the staff, as he feared it more than 
 the incisions themselves. I have inquired of pa- 
 tients, in whom I introduced the catheter both ways, 
 and they found no perceptible difference. From 
 this fact, and from finding surgeons divided in 
 opinion, it is probable that there is no very great dif- 
 ference between the two methods. Introducing it 
 with the convex part to the abdomen, appears rather 
 the easiest to the surgeon. 
 
 Stricture may prevent the passage of a sound. If 
 this be spasmodic, a gentle pressure against the ob- 
 struction will often make it dilate. If the stricture 
 be permanent, its cure is to be first effected. 
 
 Enlargement of the prostate will change the curve 
 pf the urethra, giving it a turn upwards. When the 
 sound is checked at this part, a finger should be in- 
 troduced into the rectum to raise its point. 
 
 The stone is often felt immediately on the enter- 
 ing of the sound. Sometimes it is lodged in the in- 
 ferior posterior part of the bladder, so as to require 
 a finger in the rectum, to elevate it until it strikes 
 
23 
 
 the instrument. The patient's position may be va- 
 ried. Or a catheter may be introduced in place of 
 the sound, which, as it allows the urine to flow, will 
 make the bladder contract so as to bring the stone in 
 contact with it. Mr. J. Bell* is very strenuous in 
 advising* the introduction of a finger or two into the 
 anus, to ascertain the relative situation of parts, and 
 the size of the stone. But I think, that a surgeon 
 should rely with caution on information so indis- 
 tinctly obtained. 
 
 Mr. Abemethy relates in his lectures, that a pa- 
 tient was obliged to introduce a catheter eveiy two 
 hours for several years, to discharge his urine ; but 
 never discovered any stone. Seven were found in 
 his bladder after death. 
 
 Dessaultf records a case, in which the operation 
 was performed after (as the surgeon and his assist- 
 ants thought) having felt and heard the stone by the 
 sound. When the forceps were introduced, they 
 could not be opened to grasp the stone. A scoop 
 was passed in to assist the extraction, and made the 
 noise of two hard bodies in collision ; but no stone 
 was extracted. On examination, " no stone was 
 found to exist ; but the bladder was found compact, 
 cartilaginous in its circumference." — It is reported 
 of Mr. Cheselden, " that in the course of his prac- 
 tice, which indeed was very extensive, three patients 
 were cut by him in whom no stones were discovered, 
 and where a schirrous or hardened state of the blad- 
 der had given rise to the mistake.":!; These cases 
 
 * Smith's Abridgement, page 174. 
 
 f Parisian Journal, vol. ii. p. 125. 
 
 4 R. Bell's Surgery, vol. iii. p. 164. Troy edit. 
 
24 
 
 cannot render the feel of a stone in sounding a less 
 reasonable ground for operating. 
 
 It must be held as an invariable maxim, never to 
 operate unless the stone be felt by the staff, when 
 introduced for the operation. Cases have occurred, 
 in which the stone has slipped between the fasciculi 
 of the muscular coat of the bladder, and carrying 
 with it the internal membrane, has formed a sac, se- 
 parate from the general cavity of that viscus. Mr. 
 Home, in the paper above quoted, states that he has 
 frequently met with them, even two, three, or four 
 in one bladder, and each containing a stone. Dr. 
 Smith, in his notes on J. Bell's Surgery, mentions 
 that he has seen one.* In Mr. Abernethy's collec- 
 tion, I have seen such specimens. When in such a 
 sac, a stone is not painful; and as the sac may be 
 formed between the times of first sounding and of 
 operating, it would be unjustifiable to hazard the pa- 
 tient's life, for the removal of a disease which was 
 to be no longer troublesome. These sacs have 
 sometimes prevented the extraction of a stone after 
 an operation for that purpose. Dr, W. Moore re- 
 lated to me an instance of this, which occurred to 
 the late Dr. J. Jones of this city. The nature of 
 the case, and the existence of the sac, were made 
 evident by examination. An operation similarly un- 
 successful occurred lately in this place. An ex- 
 amination of the patient could not be procured; but 
 as it was a child, the not finding the stone arose more 
 probably from its being in a sac, than from a disease 
 of the bladder resembling that in Dessault's and 
 Cheselden's cases. These are cases which ought 
 
 * Paare 187 
 
25 
 
 not to prevent us from deeming the sound a sufficient 
 test of the propriety of an operation, as the circum- 
 stances, from their nature, are not within the know- 
 ledge or control of the surgeon, and as we know of 
 no test equal in certainty to this instrument. 
 
 ANATOMY OF THE PARTS CONCERNED 
 IN THE OPERATION. 
 
 In lithotomy, as in all other operations, an accu- 
 rate acquaintance with the parts through which in- 
 cisions are to be made, is absolutely necessary. A 
 moderate share of anatomical knowledge has indeed 
 sufficed for some operators. Thus Frere Jacques is 
 said to have performed the operation, " without any 
 direction and without any knowledge of the parts he 
 was to cut;" his patients " were found with the blad- 
 der cut through, guts wounded," &c. — The only 
 means of giving a humane operator confidence, is a 
 perfect " knowledge of the parts he is to cut." 
 
 It will be readily seen, that mere description of 
 the anatomy of these parts, will not convey an ade- 
 quate idea of them. Dissection alone can do this. 
 
 A point in the perineum, just below the bulb of 
 the. urethra, is to be considered the centre. From 
 this, the transversi perinei, accelerator urinse, and 
 sphincter ani muscles proceed. The transversi pe- 
 rinei are reckoned two ; they are given off laterally 
 from this point, and are inserted into the tuber ischii. 
 The accelerator urin<e sends its fibres diverging up- 
 
 4 
 
26 
 
 wards; and the sphincter ani goes diverging down- 
 wards. The erector penis arises from the tuber 
 ischii, and runs upwards and slightly inwards upon 
 the crus of the penis. 
 
 The bulb of the urethra is just before a perpen- 
 dicular let fall from the arch of the pubis* Directly 
 behind it is the membranous part of that canal. 
 Mr. Wilson, a teacher of anatomy in London, has 
 described two muscles "of a triangular shape, united 
 below by a common tendon, but having each a sepa- 
 rate tendinous attachment to the symphisis pubis, and 
 which are so placed as to surround the membranous 
 part of the urethra."* After leaving these muscles, 
 the canal enters the prostate gland, being completely 
 surrounded by it. Here it is called neck of the blad- 
 der. While leaving the prostate, it receives an in- 
 distinct sphincter of muscular fibres from the gene- 
 ral coat of the bladder; it then opens into that 
 cavity. 
 
 The rectum lies close behind the bladder, con- 
 nected with it at the inferior part by a loose cellular 
 and ligamentous substance. This, at its lower end, 
 is supported by the levator ani muscle ; which also 
 surrounds the neck of the bladder, prostate gland, 
 &c. and lies at its anterior edge, in contact with Mr» 
 Wilson's muscle. 
 
 The vesiculas seminales lie between the bladder 
 and rectum. They proceed from the posterior part 
 of the prostate, in a diverging manner, backwards. 
 The vasa deferentia lie within them. The cut of 
 lithotomy is made anterior to these, sufficiently s® 
 
 * Medico-Chirurg. Transact, p. 176, 
 
27 
 
 to avoid their ducts, which empty at the lower sur- 
 face of the neck of the bladder. 
 
 Three arteries may be enumerated as concerned 
 in lithotomy, the internal pudendal, the artery of 
 the bulb, and the transverse perineal. The former 
 of these runs along the ramus of the ischium, exte- 
 rior to the levator ani muscle, and rather within the 
 edge of the ramus. It gives off the transverse peri- 
 neal, which follows the transversus perinei muscle. 
 At the root of the penis it gives off the artery of 
 the bulb, and is then lost in the dorsal and central 
 arteries of the penis. 
 
 The parts cut through in the lateral operation, are 
 these: 1. The common integuments and cellular 
 membrane ; 2. The transverse perineal muscles and 
 artery; 3. The membranous part of the urethra, with 
 Mr. Wilson's muscle investing it; 4. The neck of 
 the bladder, and a side of the prostate; 5. The 
 sphincter of the bladder, and a small portion of its 
 parietes. 
 
 This enumeration of parts cut through, is given 
 on the supposition that we direct our incision, first 
 to the fore part of the prostate, and next to the mem- 
 branous urethra. But the more ordinary course is 
 to the bulb of the urethra; in which case, that part, 
 its artery, and perhaps a small portion of the accele- 
 rator urinae, are divided in addition to the parts 
 just mentioned. There is no farther impropriety in 
 this, than that the operation is not so neat, and that 
 an additional artery is divided. 
 
 The internal pudendal artery is not divided unless 
 it vary its situation, lying nearer the centre of the 
 perineum, or the incision reach very far to one side. 
 It is frequently cut by Mr. Cline's gorget. 
 
28 
 
 The operator cannot expect to see all the parts 
 through which he cuts. The blood from the vessels 
 of the integuments will probably conceal them : 
 when the transverse perineal artery is divided, they 
 will certainly be hid. An accurate anatomy will 
 now be especially useful. The finger must be the 
 guide; "it is only by feeling opposition and stric- 
 ture that we recognize the transverse muscle;" and 
 the chief direction for finding the membranous part 
 of the urethra, is the groove of the staff. 
 
 The axis of the pelvis is a line drawn from the 
 extremity of the os coccygis to the umbilicus. The 
 axis of the bladder is a parallel line, which, for prac- 
 tical purposes, is to be considered as beginning at 
 the commencement of the urethra. This imaginary 
 line, it is of the highest importance to remember, as 
 it is the direction in which the instrument is entered 
 for making the second incision. Either from igno- 
 rance of this anatomical point, or from neglecting it 
 in practice, have arisen most of the accidents of the 
 operation. 
 
 OPERATION. 
 
 It would swell this thesis uselessly to recapitulate 
 the different methods which have been proposed for 
 extracting a calculus from the bladder. Nay, it 
 would require a search of no small extent, to dis- 
 cover the whole. Some have become obsolete from 
 not bearing the test of experiment, and some have 
 
29 
 
 rested in the undisturbed narratives of their inven- 
 tors. The only method now used is the lateral ope- 
 ration. This in the first incision is the same in all 
 cases — the second incision varies, as it is made by a 
 gorget or bistoury.* 
 
 The patient is to be prepared for the operation by 
 reducing his habit, if it be plethoric, by low diet 
 and an occasional purge. If he be already debili- 
 tated, he is to be restored by generous diet. The 
 occasional introduction of the sound, to accustom 
 the urethra and bladder to its irritation, is re- 
 commended by Mr. Astley Cooper in his lectures. 
 Previous to operating, the rectum is to be emptied 
 by an enema or gentle cathartic, to allow it to be as 
 little distended, and consequently as distant from in- 
 jury as possible. The urine should, as in sounding, 
 be retained for a few hours. 
 
 The hands are to grasp the soles of the feet, and 
 the patient is to be bound in that position. Some 
 use an additional bandage, passing from the neck 
 
 * I ought, perhaps, to apologize for omitting the variety of the lateral ope- 
 ration invented by Mr. Cheseklen, and sanctioned by Mr. J. Bell. It con- 
 sists in continuing the external incision, until the scalpel divides the " sides 
 cf the bladder, immediately above the prostate," and in drawing it " firmly 
 and steadily towards him (the surgeon), pressing the knife into the groove 
 of the staff," till " the gland and cervix vesica? are divided." This operation 
 one would be led to imagine the best, as it has received the approbation of 
 such eminent surgeons; but those less renowned do not seem to favour it, 
 and Cheselden himself abandoned it for the gorget in his third manner of 
 operating. It certainly is more complicated, and leaves a more ragged 
 wound; and if the bistoury proposed should not be liable to the objections to 
 the gorget, none, I trust, will question that the incision from the centre of 
 the perineum, is preferable to that towards it. For accounts of this opera- 
 tion, the reader is referred to the papers relative to Mr. Cheselden's me- 
 thods, collected and republished by Dr. Thompson of Edinburgh; to Coo- 
 per's First Lines of Surgery; and Smith's Abridgement of J. Bell's Surgery, 
 page 181. 
 
30 
 
 under the knees, to limit still farther the struggling. 
 The patient's buttocks are to be brought just over 
 the edge of the table, the knees kept asunder, and 
 the body supported by assistants; the perineum is 
 to be exposed to a good light, and shaved if neces- 
 sary. The staff is to be introduced by the surgeon, 
 and given to an assistant, who holds it firmly with 
 the curve of it pressing gently outwards the left side 
 of the raphe, just below the scrotum. With his 
 other hand the assistant supports the scrotum. 
 
 As the operation is usually performed, the inci- 
 sions are made by two instruments. This makes a 
 natural division of the operation into two incisions, 
 the first or external, and the second or internal inci- 
 sion. 
 
 The operation is begun, by entering a scalpel near 
 an inch behind the scrotum, on the left side of the 
 raphe, over the part where the staff is felt; this inci- 
 sion is to be carried in a direct line till it be an inch 
 past the anus, midway between that and the tuber 
 ischii. The cellular and ligamentous substance, 
 with the transverse muscles, are to be divided by a 
 continuance of the incision, directed towards the 
 prostate, with the rectum kept out of the way by 
 such of the surgeon's fingers as are not otherwise 
 employed. The bulb of the urethra is to be avoided, 
 and when the finger can distinguish the groove of 
 the staff so plainly as to be certain that the mem- 
 branous urethra only is between them, this is to be 
 divided upon the staff: it is to be divided by one 
 bold stroke; a repetition of cuts will endanger a 
 loss of substance, and according to Mr. J. Bell,* 
 
 * Smith's Abi-idgement, page 1&6. 
 
31 
 
 may contribute to the forcing " off the neck of the 
 bladder and prostate from the urethra" by the gor- 
 get. The cut into the membranous part of the ure- 
 thra terminates the first or external incision. 
 
 The second incision is done in two ways. 1. An 
 instrument is thrust in, which makes its incision in 
 entering. 2. A bistoury is introduced, in withdraw- 
 ing which, an incision is made, regulated in size by 
 the judgment of the operator. 
 
 The most used instrument of the former class 
 is the gorget. This is to be fitted into the groove 
 of the staff, and thrust along it to the bladder, 
 in the direction of its axis, until the flow of urine 
 assures us that it has entered that viscus. The staff 
 is then usually withdrawn, the forceps introduced on 
 the gorget as a director, and the latter instrument 
 also removed. The stone is then felt for, and ex- 
 tracted. The gorget is of various forms. As in- 
 struments on the same principle, may be reckoned, 
 the scalpel as spoken of by Sharpe,* and used by 
 Mr. C. Bell, and the beaked scalpel as formerly 
 used by Mr. A. Cooper. When either of the latter 
 instruments is used, the staff is to remain in, the 
 scalpel to be immediately withdrawn, and the finger 
 introduced upon the staff, both to ascertain the place 
 and size of the stone, and to serve as a director for 
 the forceps. This practice indeed is preferable in 
 using the gorget; it lessens the risk of cutting- 
 through the sides of the bladder. It was introduced 
 formerly in the London Hospital by Mr. Thomas 
 Blizard; and as the gorget was no longer to serve as 
 director to the forceps, he had' it made with its han- 
 
 * Operat. Surg. p. 96, edit 1782.. 
 
32 
 
 die continued in a line with the blade. This direc- 
 tion gave the instrument obvious advantages. 
 
 Of the second description of instruments, those 
 of Mr. Astley Cooper, and Mr. Thomas Blizard, 
 appear the most perfect in principle. That of the 
 former is a curved bistoury, with a beak projecting 
 from its point. That of the latter is a straight bis- 
 toury, rounded for three fourths of an inch from its 
 point, with a beak slightly turned up to be more 
 readily fitted into the groove of the staff.* The in- 
 cision by these instruments is made, as was stated, 
 in withdrawing them. The finger is then to be in- 
 troduced upon the staff, and that instrument with- 
 drawn ; the situation, and, if possible, the size of the 
 stone are to be ascertained by the finger; the for- 
 ceps is to be introduced under its guidance, and the 
 stone grasped. A minute point, but one of some 
 importance, should next be attended to; the forceps 
 is to be turned, that the surgeon may be certain that 
 no fold of the bladder is entangled in its grasp. 
 This ascertained, the stone is to be extracted by a 
 continued force, united with a motion of the han- 
 dles of the forceps upwards and downwards, consi- 
 dering that instrument as " two levers." When the 
 stone is taken away, a finger is to search the blad- 
 der lest there be more. 
 
 If the wound in the bladder be not large enough 
 to extract the stone, it must be dilated by a probe- 
 pointed bistoury. If an extensive incision be re- 
 quired, the opposite side of the bladder is to be cut 
 
 * The plate at the title page represents this instrument. One view 
 shows the form of the Made and the rounding of it towards the point. The 
 other shows the elevation of the beak. The handle should be made rough 
 for a more secure grasp. The figure is of the exact size of the instrument. 
 
33 
 
 with the same instrument. If the stone be too large 
 to extract whole, it should be broken. To this 
 practice we are led by a comparison of chances of 
 the patient's recovery, rather than by a grounded 
 hope of such an event. 
 
 Calculi sometimes adhere to the bladder, i. e. 
 a fungus shoots from the internal surface of that 
 viscus, which fixes upon the stone. It may ab- 
 sorb portions of it, and enter the crevices thus 
 made. There can be no hesitation as to the pro- 
 priety of removing the stone, if possible. Death is 
 certain if it be left; at least it will be so if an un- 
 successful effort has been made with the forceps. 
 Vigilance to prevent abdominal and vesical inflamma- 
 tion, after such a calculus is taken away, may afford 
 the patient a chance of recovery. 
 
 After extracting the stone, the surgeon is to attend 
 to the haemorrhage. If this be trifling, we may con- 
 clude that no vessel likely to cause danger has been 
 cut. If bleeding arteries be at all conspicuous, they 
 ought, if possible, to be tied. If this cannot be done, 
 and the haemorrhage be troublesome, pressure should 
 be made. This would be best done by the finger of 
 an assistant; but as it must be continued some days, 
 and as a change of assistants will endanger a renewal 
 of haemorrhage, the use of a canula will be found an 
 eligible substitute. This is much dwelt upon by Le 
 Dran, and I have seen it used successfully by Dr. 
 Post. 
 
 The dressing of the wound is a matter of minor 
 importance. Little difference in the cure takes 
 place whether it be dressed or not. The scrotum 
 should be supported, particularly if a canula is 
 used. The patient's stomach is liable to be out of 
 
 5 
 
34 
 
 order by his complicated sufferings. Mr. Abemethy 
 is particular in directing the attention of his class to 
 this. He recommends the occasional exhibition of 
 a few grains of the pil. hydrarg. and of a gentle purge. 
 The latter will be particularly serviceable, if lying 
 in bed render the patient costive. 
 
 " The first good symptom after the operation, 
 is the urine coming freely away, as we then know 
 the lips of the bladder and prostate are not much 
 inflamed, for they often grow turgid, and shut 
 up the orifice in such a manner, as not only to 
 prevent the issue of the water, but even the in- 
 troduction of the finger or female catheter, so that 
 sometimes we are forced to pass a catheter by 
 the penis. From this symptom too, we learn 
 that the kidneys are not so affected by the opera- 
 tion as to cease doing their office; which, though 
 a very rare circumstance, may possibly occur."* 
 The urine coming freely away, is also a proof that 
 clots have not formed in the bladder* This cavity 
 is sometimes a reservoir for the haemorrhage, and 
 the blood will entangle a considerable quantity of 
 urine with it in coagulating. It is this entangling of 
 the urine which makes the clots so large, rather than 
 blood " collected in great quantities in the cavity of 
 the bladder." The existence of these clots is 
 known by a want of a " free discharge of urine," 
 and when large, they occasion pain and swelling of 
 the abdomen, and fever. As soon as their existence 
 is suspected, the surgeon should introduce his fin- 
 ger, break them down, and procure a complete 
 evacuation of them. As a preventive, the patient 
 
 * Sharpe's Opex'atioas, page 99. 
 
35 
 
 should lie with the wound rather depending, that aii 
 effused blood may pass outwardly. 
 
 Peritoneal inflammation is a very frequent cause 
 of a fatal event after lithotomy. This is known by 
 the frequent and rapid pulse, and the tenderness over 
 the abdomen. As soon as these symptoms appear, 
 both local and general blood-letting are to be largely 
 employed. The warm bath is an essential ; fomen- 
 tations are to be made externally, and internally by 
 clysters. The bowels are to be kept open by full 
 doses of the ol. riciru com. 
 
 A violent and fatal constitutional irritation some- 
 times takes place after lithotomy. Mr. T. Blizard 
 related to me several cases of this kind: he recom- 
 mends a large opiate to be invariably given, as the 
 irritation is more certainly fatal than that occurring 
 after any other operation. The opiate is indeed the 
 usual prescription immediately after every capital 
 operation, but the considerations noticed should 
 make it a constant one after lithotomy. 
 
 The bladder is frequently more or less irritable 
 previous to operating. If this should continue or 
 increase afterwards, opiate clysters are to be resorted 
 to. This occurrence is chiefly in old patients, and 
 is not easily subdued by any remedies. 
 
 When there is no untoward occurrence, the urine 
 commonly passes through the wound for a fortnight, 
 three weeks, or a month. At the expiration of this 
 time, it is in most cases healed. Sometimes the 
 separating of sloughs will protract the cure; and 
 occasionally the passage continues fistulous. 
 
 Calculi seldom form after an operation ; the nu- 
 cleus is taken away, and the patient may escape a 
 second. All, however, are not so fortunate. A case 
 
36 
 
 was before mentioned of a boy operated on the third 
 time. At this last operation, two stones were taken 
 from the perineum, and one from the commence- 
 ment of the urethra. The latter had taken on the 
 form of that canal. Those in the perineum got 
 there probably from the bladder, or may have been 
 deposited from the urine, as it passed that situation 
 through sinuses consequent to the former operations. 
 This was performed by Mr. Astley Cooper. In 
 cases like this, it may sometimes be proper to cut 
 on the right side of the perineum. 
 
 CIRCUMSTANCES OF PECULIARITY IN 
 THE FEMALE. 
 
 The operation of lithotomy is less frequently ne- 
 cessary in the female than in the male. The ure- 
 thra is shorter, larger, and more dilatable. Con- 
 sequently stones of considerable magnitude will 
 occasionally pass. 
 
 In the Medico- Chirurgical Transactions,* a very 
 instructive case of artificial distention of the female 
 urethra is related by Mr. Thomas. His patient 
 had laboured under retention of urine, and as no 
 regular assistance was at hand, had " an ivory ear- 
 picker" introduced. This let off a part of the wa- 
 ter, but unfortunately slipt in. From an unwilling- 
 ness to have an incision made, Mr. T. was induced 
 
 * Page 123. 
 
37 
 
 to use the sponge tent to dilate the passage. This 
 he in the end effected ; he introduced his fore-finger, 
 and extracted the ear-picker. He adds, " I believe, 
 had the case required it, both thumb and finger 
 would have passed into the bladder without the 
 smallest difficulty." 
 
 Mr. Thomas quotes other similar cases — one in 
 particular, from the Philosophical Transactions, of 
 a stone voided by a woman, " the circumference of 
 which measured the longest way 7-^ inches, and 
 round about where it was thickest 5f inches, its 
 weight near 2i ounces troy." 
 
 These facts sufficiently explain why females less 
 frequently become subjects of this operation. 
 
 In addition to the symptoms enumerated as occur- 
 ring in the male, there will be a bearing down of the 
 uterus, and excessive pain at the meatus urinarius. 
 But in the female, as in the male, the surgeon is to 
 trust only to the actual feeling of the stone. He 
 should also be particular that he introduce the sound 
 himself. Cases have occurred where, from regard 
 to false delicacy, a surgeon has permitted his patient 
 to introduce it, and he has been deceived when feel- 
 ing the grating sensation, by the sound rubbing upon 
 a pebble, or other extraneous substance, introduced 
 into the vagina. 
 
 The operation in the female is particularly simple ; 
 the whole of what was termed the external incision 
 is here unnecessary. The staff is straight, a com- 
 mon probe-pointed bistoury is to be introduced in 
 its groove, and a slight lateral incision made; the 
 finger is to be passed in, the forceps along this, and 
 the stone extracted, as in the male. There will not 
 probably be any artery requiring ligature. 
 
38 
 
 It is a disputed point, whethef lithotomy should 
 ever be performed on a female. The dilatability of 
 the urethra, it is alleged, will make an incision unne- 
 cessary " in a young and healthy female subject, where 
 the bladder is free from disease."* One obstacle 
 will present equally to both methods ; incontinence of 
 urine very frequently occurs after both. In Mr. 
 Thomas' case " the involuntary discharge of urine 
 continued only six hours," but in some cases it has 
 undoubtedly been far more obstinate. The sur- 
 geonVdecision between the two methods must be 
 guided by the state of the bladder, and the probable 
 size of the stone. If the former be diseased, and 
 the latter very large, it would be improper to hazard 
 a destruction of the muscular power of the urethra, 
 by over-distention, and an incision would be pre- 
 ferable. If the bladder be sound, and the stone rea- 
 sonably supposed to be small, the trial of dilatation 
 would appear to be the most eligible practice. This 
 at least is the opinion of Le Dran.f I need offer no 
 apology to modern surgeons, for not dwelling upon 
 his means of dilatation, the blunt gorget and several 
 forceps increasing in size. This author adds,J 
 " Women are more subject to this complaint (in- 
 continence of urine) than men, as in them the neck 
 of the bladder is not invested with the prostate gland, 
 which strengthens that part. It is impossible to 
 avoid either dilating or dividing the orifice of the 
 bladder in order to extract the stone ; and when the 
 stone is large, it must necessarily make a dilatation 
 and laceration proportionable to its bulk, or it could 
 
 * Mr. Thomas' paper, loc. cit. 
 
 t Page 255, edit. 1781. * Page 265. 
 
39 
 
 not pass. This is indeed a great misfortune to the 
 sex, but the only method to prevent it is to have re- 
 course to the operation in time, before the stone is 
 arrived to any considerable size." 
 
 INSTRUMENTS. 
 
 Certain accidents not unfrequently occur during 
 the operation, which should make the surgeon very 
 careful in his choice of instruments. Some of these 
 untoward occurrences may be the effect of a want of 
 anatomical knowledge, or of proper caution. But 
 it is evident, that some must be occasioned by using a 
 faulty instrument. My remarks on this head shall 
 be entirely confined to a comparison between the 
 gorget and bistoury. These are the instruments 
 which chiefly divide the opinions of surgeons at pre- 
 sent. 
 
 The accident most generally feared, is the thrust- 
 ing the gorget between the bladder and rectum, in 
 making the second incision. This, it may be said, 
 cannot take place if the instrument be passed in the 
 direction of the axis of the bladder. As I have not 
 witnessed the occurrence, I cannot say whether this 
 point has been attended to. But it has happened in 
 the hands of surgeons who had a large share of pub- 
 lic confidence, and whom we cannot reasonably sus- 
 pect of deficiency. The accident is not so unfre- 
 quent as has been imagined. Mr. C. Bell relates that 
 
40 
 
 he has known it in two cases;* Mr. A. Cooper, in 
 his lectures, states, that " near a dozen" instances 
 have come within his knowledge ; and I have myself 
 been informed of others. 
 
 This occurrence has been explained by Mr. C. 
 Bell from some appearances observed on the dead 
 body. " The gorget had not gone off the groove : 
 it had only not cut the neck of the bladder, it had 
 pushed the prostate gland onwards upon the staff, 
 and had not pierced the neck of the bladder nor the 
 prostate gland. "f Mr. J. Bell probably has this ex- 
 planation in view, when he speaks of forcing " off 
 the neck of the bladder and prostate from the ure- 
 thra;" but he also thinks it " unquestionable that 
 the gorget is often plunged among the viscera. "J 
 The probability is, that all these varieties of the ac- 
 cident may occur. 
 
 The explanation of the Bells would place the fault 
 of such an accident rather in the instrument than in 
 the operator. And indeed, whatever explanation 
 we adopt, it must be evident, that the gorget is very 
 liable to cause such an occurrence; not to say, that 
 it appears calculated for it. A kind of curve is de- 
 scribed in thrusting it in, which must make it act 
 with obvious disadvantage; its edge striking ob- 
 liquely, will probably lacerate as many fibres as it 
 cuts. In the use of the bistoury however, no such 
 occurrence takes place. It is so small that it passes 
 with the readiness of a sound, and as the incision is 
 made in withdrawing the instrument, it is impossi- 
 
 * Operat. Surg. vol. i. page 344. 
 f Ibid. 
 
 t Smith's Abridgement, pages 186, 187. 
 
41 
 
 ble that the prostate can yield before its edge. Not 
 to mention that the edge of a knife can be made and 
 kept keen with far greater ease than that of a gorget, 
 and will of course be better calculated to make a 
 real incision. We cannot suppose it possible, but 
 by the grossest ignorance or inattention, that the 
 bistoury can be literally pushed between the bladder 
 and rectu im 
 
 Cases have occurred, in which the staff has been 
 bent by an over-attention to keep the beak of the 
 gorget in its groove. In the use of the bistoury, 
 this is scarcely possible; it enters with such facility, 
 that no force is requisite to keep its beak in contact 
 with the staff. 
 
 The gorget being an instrument of no inconsider* 
 able bulk, must be wedged with some firmness in 
 the wound it makes. This will prevent the ope- 
 rator from feeling with accuracy when it has entered 
 the bladder; or rather, (as the flow of urine will as- 
 certain this) he will not be able to command the 
 force with which he thrusts it onward. This acci- 
 dent is admitted by " those who prefer the gorget, 
 and regard it as the ultimate improvement of this 
 operation." It has occurred to surgeons whose cau- 
 tion or knowledge we have no reason to doubt, and 
 it must therefore be, at least in part, attributed to the 
 instrument. I need hardly add, that the bistoury is 
 free from such an imperfection; it passes like a 
 probe, and is as easily regulated by the surgeon ; and 
 even were it thrust in, it would be scarcely more 
 liable to pierce the bladder than a sound. 
 
 The above accident may perhaps be attributed to 
 the bladder's contracting upon the edge of the gor- 
 get. This edge, in every form of that instrument 
 
 6 
 
42 
 
 and those analogous to it, projects; which projec 
 tion, if the stone be not between it and the coats of 
 the bladder, may very readily cut through the latter. 
 It is evident, that the bistoury is not liable to this 
 accident, as its edge does not project. 
 
 It may perhaps be objected to the bistoury, that 
 it gives no limit to the incision. It truly does 
 not; and to a surgeon even moderately expert, 
 this would be a recommendation rather than an ob- 
 jection. I am not indeed certain that any will cavil; 
 if they should, they must be referred to the dead 
 subject, till they can acquire steadiness sufficient to 
 handle a knife. 
 
 The gorget, it will be urged, unites a director 
 with a cutting instrument. It was before stated, 
 that the advantage of such a director was very 
 questionable. If the wound be sufficiently free, 
 and the patient's struggles not unusually violent, the 
 finger upon the staff, and the forceps upon the finger, 
 will fully suffice. If the patient be very fat, his 
 bladder may be too far from the external perineum, 
 to be reached by the finger. Or the surgeon, how- 
 ever expert, may possibly lose the direction of the 
 incision. In this case, a blunt gorget will be an use- 
 ful instrument. But the occasion for a director will 
 be very rare, and the bistoury in all other cases will 
 amply suffice, 
 
 I am sensible, that although the knife is preferred 
 by surgeons of great eminence, the gorget has ad- 
 vocates equally great. With so even a defence on 
 both sides, it might be deemed presumption to offer 
 an unreserved decision. So far however as I am ac- 
 quainted with the opinions of each, I am disposed 
 tp think that the bistoury is ljable to fewer objections 
 
4<3 
 
 than any other instrument with whose use I am ac- 
 quainted. 
 
 Thus far the knives both of Mr. Blizard and Mr, 
 Cooper have been equally advocated ; and from the 
 similarity of principle, it would be difficult to choose 
 between them. There are however some minutice in 
 that of the former, which will make it, on the whole, 
 preferable; or perhaps I may think so, from being 
 accustomed to its use on the dead body. As its 
 beak projects a little from the upper part of its point, 
 it may be introduced more nearly parallel with the 
 staff. As it is rounded for near an inch from the 
 beak, it will follow with greater certainty the canal 
 of the urethra, and will " make assurance doubly 
 sure," that the parietes of the bladder will not be cut. 
 As also it is straight, it is better calculated to make 
 a ready incision. 
 
 These instruments have both been repeatedly used 
 with success; so that no circumstance, either in 
 theory or in experiment, is wanting to embolden 
 a surgeon in adopting them. Of operators, how- 
 ever, who have long used the gorget, and who are 
 satisfied with their practice, it would be unreason- 
 able to ask a change. A younger surgeon will ba- 
 lance in his own mind the comparative merits of the 
 two; and as he has " proved" neither, will adopt 
 that in which he places the greatest confidence. The 
 first duty of every practitioner is to render operations 
 unnecessary. When these efforts are unavailing, he 
 is to free them from danger as much as possible. 
 Anatomical knowledge, and well-established theory, 
 are undoubtedly the most important means of effect- 
 ing the latter; but it must be evident that there is a 
 preference among instruments, — in what operation 
 
44 
 
 more than in lithotomy? It has been advanced, that 
 the gorget is a knife ; if so, it is a very clumsy one. 
 The use of such an argument is a tacit consent to the 
 superiority of the latter instrument. And I know 
 not what higher praise could be bestowed upon the 
 bistoury, than retorting, that it is not a gorget* 
 
 THE END, 
 

 
 
 
 
 i,K Hv.Lt, 
 
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 00 m 
 
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 JUL 21942