LITHOTOMY. 



LITHOTRITY. 



Mariano*, hi order to .Ustinguish it from method which he described- 

 oalled the uppmrttui major, from the many instrument* employed. 

 The objection* to cutting on the gripe m,-!*. it i* only applicable 

 to children under fourteen year* of age ; 2nd, it U uncertain what 

 ntru ar* divided, thi* depending on the degree of force employed in 

 making the .tone project in the perineum ; 3rd, the injury liable to be 

 innirted on part* whose integrity if CMontial to the SUCCCM of the 



Appamtm Major, or tlaria* Ittlkod, wa* founded on erroneous 

 principle*, and in ignorance of the nature of tho part* to be operated 

 oo. It wa* supposed that wound* of membranous part* would not 

 heal, while their dilatation might be undertaken with impunity. In 

 conformity with those notion*, the precept of C'eUus, " Ut pUga paulo 

 major quam calculus it," wa* neglected, and the object endeavoured 

 to b* attained wa*, to do u little a* possible with the knife, and a* 

 much M possible with instrument* called dilator* ; but the part* thu* 

 subjected to attempts at dilatation are inelastic, and consequently were 

 Unrated. The sever* injury thu* produced rendered thi* one of the 

 moat fatal operation* in surgery; but notwithstanding this, it was 

 practised for near SOU yean, till Frere Jacques, in 1697, taught at 

 Paris the method at present in use. 



ll>-jlt Operetta*, to named from the incision into tho bladder being 

 made above the pube*. waa first practised at ParU in 1 475, by Colot, as 

 an experiment on a criminal, by permission of Louis XI.; but the' 

 earliest published account of this mode of operating was in 1556, by 

 Pierre Franco. Thi* method is most applicable to those cases in which 

 the stone is too Urge to be extracted from the perineum, or where 

 there is diiisian of the urethra and prostate gland; but there are 

 Mveral objection* to it, and it is now entirely abandoned. 



Operation tkrowjk Oa Bectum. Thi* method wa* first uggested in a 

 work published in the 16th century ; but the proposal never received 

 much attention till the year 1816, when it was revived by M. Sanson, 

 of Paris, and carried into operation by him and by Dupuytren ; but 

 the unfavourable result* which attended the performance of thi* ope- 

 ration prevented its being generally tried or adopted, and no one of 

 the present day ever think* of performing it 



Lateral Operation, *o called from the prostate gland and neck of the 

 bladder being cut laterally, in order to avoid wounding the rectum, U 

 that adopted at the present day. It was first practised by Pierre 

 Franco, a surgeon at Tourriores, but he never established the method 

 as a permanent improvement in surgery ; thu wa* left for Frore 

 Jacques, a priest, who in 1697 came to Paris in order to make known 

 thu method, which he employed with great success at various place*. 

 Although it appears that he wa* not quite so successful as he had led 

 the world to believe, the superiority of hi* mode of operating was 

 immediately perceived and recognised, and, with slight modifications, 

 was adopted by moat of the surgeon* of that period. Hitherto the 

 Marian section had been used : the advantages of an operation by 

 which a free opening wa* made into the bladder, over one in which it 

 waa so small as not to admit of the extraction of the stone without 

 laceration of the part* are too obvious to require comment Surgeons 

 of the present day differ somewhat as to the extent of the opening to 

 b* made into the bladder, and on the choice of instrument* to be 

 employed : some make use of a common scalpel, which cuts into the 

 bladder from without inwards ; while others prefer the bistoire cachiS, 

 or gorget which divide* the prostate gland aud neck of the bladder 

 from within outward*. Having premised thus for, we will proceed to 

 describe the operation a* usually undertaken with the cutting gorget 

 The patient having been sounded, to ascertain that the (tone is actually 

 within the bladder (for instance* have occurred of atone becoming 

 encysted a short period before the operation), ami tho rectum l>eing 

 emptied by mean* of a clyster, he U placed on his back upon a table, 

 with bis buttocks projecting rather beyond it* edge ; be should ba 

 directed to grasp the outside of each foot with the hand of the same 

 aide, and the two pair should then be firmly bound together. A ilaff, 

 which is an instrument shaped very much like a catheter, or sound, 

 but somewhat longer, and grooved on it* convex side, is passed through 

 the urethra into the bladder, where it must be retained firmly by on 

 Mutant ; it* convexity looking towards the perineum, and the groove 

 lightly inclined to the left side of the patient. The operator now 

 commence* hU incision below the bulb of the urethra, about an Inch 

 and a quarter in front of the oinu, ami continue* it obliquely down- 

 ward* to the Uft of the rapbe' of the perineum for three inches, till it 

 reaches midway between the tubenoeity of the ischiuin and the anus ; 

 thi* ahould cut through the integuments and superficial fascia. The 

 next incision, made in the some direction, divide* tho transversus 

 perinei muscle, and expose* the mcnibranou* portion of thu urethra, 

 which miut be opened, and the groove in the stall' f. It for with the 

 ngar ; into thu groove, which serve* M director for making the con- 

 cluding Motion of the operation, is inserted the beak of the // 

 ort of knife terminated by a beak, that fit* into the groove of the 

 staff). The operator now rise* from hU chair, and, Uking the staff in 

 hi* left hand, raise* it* handle from tho aUlomeii till it forms nearly a 

 right angle with the paticnf* l>ody ; the gorgtt ia now pushed onwan i. 

 long the groove, till it enters the bladder, liy raining the handle of 

 the staff U>* gorget ] nude to enter the bladder in a direction corre- 

 pooding with it* axis, and the danger of wounding the rectum i* 

 thereby avoided. A* soon a* the gorget ha* been introduced the itaff 



i withdrawn, and a pair of long forceps, expressly adapted for this 

 operation, U passed along the gorget into the bladder, and thi* Utter 

 instrument withdrawn. The stone i* now to be seised, and gently 

 extracted ; but it sometimes happen* that a atone i* too Urge to be 

 removed without using a degree of force that would be perfectly 

 unjustifiable : in thu case, if the wound will not admit of further 

 enlargement, nothing remain* to be done but crushing it, and thu* 

 taking it away piecemeal. A atone should always bo examined imme- 

 diately after it i* extracted, because it* appearance conveys some 

 information concerning the existence of other* ; and in every instance 

 the cavity of the bladder should be explored with the finger, to ascer- 

 tain that there i* no other stone present. Encysted calculi *eldom 

 require an operation for their removal, but should thi* be necessary, 

 the cyst may be opened by a blunt-pointed bistoury, aud the stone 

 taken away. When a stone U known to be of ample size, some ope- 

 rators perform what is called the bilateral operation, from both aide* 

 of the prostate gland being cut ; for thi* purpose a double-edged knifo 

 ha* been invented, called the dauUc IMotomc. 



Lilk'itamii I'M ll'i'inr". From tho shortness, largeness, and very 

 dilatable nature of the female urethra, the surgeon i* seldom called 

 upon to perform the operation in women. The formation of calculi in 

 perhaps not less common in women than in men; but from tho 

 anatomical circumstances just alluded to, stones of considerable i 

 tude have been voided spontaneously. This fact has suggested the 

 plan of mechanically dilating the urethra, and thus extracting 

 without the employment of any cutting instruments ; but where the 

 stone is very large, the degree of dilatation necessary for its extraction 

 is liable to produce paralysis of the part, an- 1 incontinence of urine ever 

 after. To avoid these evils, an artificial opening should be made. into 

 the bladder. The operation is simple : a straight staff, or director, is 

 introduced through the meatua urinarius ; the groove is turned 

 obliquely downwards and outwards, in a direction parallel to the 

 ramus of the left os pubis ; and the knife is thus conducted into the 

 bladder, and mokes the necessary inciaion through the whole extent of 

 the passage and neck of the bladder. 



Treatment after the Oftcmtion. 'Fhe dangers to be guarded against 

 after an operation of lithotomy are, inflammation of the bladd 

 peritoneum ; infiltration of urine into the cellular texture of the peri- 

 neum and parts adjacent ; and hfemorrhage. To prevent the dangers 

 that would arise from inflammation, the patient should be kept perfectly 

 quiet, and on a low regimen ; but supposing it to have set in, tho most 

 prompt and energetic measures must be hod recourse to ; vene.- 

 the use of the worm bath and fomentations, with the admimV 

 of such medicines u are known to be moat efficacious in such case*, 

 afford the only chance of preserving the patient Infiltration U to be 

 avoided by placing the patient in such a position that the urine can 

 flow readily from the wound, which should be left un \, r.d. .>r this 

 end is attained more effectually by introducing an elastic gum catheter 

 into the bladder, and suffering it to remain there for the first two or 

 three days. Hemorrhage is fortunately a rare occurrence, but should 

 this take place, pressure, made by means of sponge or lint compresses, 

 may be tried ; and if this fail, the bleeding vessel must be sought for 

 aud tied. 



LITHOTIUTY (from Mflot, a stone, and the. root rpi, to pierce) j 

 Litkolripty (from \l8ot, and rpifiu, to break), "the reduction of a 

 calculus in the bladder into small pieces, by means of instruments 

 passed into that organ through the urethra, so that the fragments may 

 be discharged through tho latter tube, and no necessity remain for the 

 performance of lithotomy." This operation, which must be ranked 

 among the most brilliant achievements of modern surgery, was first 

 seriously proposed in 1812, and Uruithuisen, a Uavoriau surgeon, con- 

 structed an apparatus for performing it But the originality of the 

 idea was probably derived from ancient writers, several of whom speak 

 of the practicability of breaking stones within the bladder, although 

 they make no mention of the mode of performing it. At the com- 

 mencement of the 19th century, Rodriquez, a physician of Malaga, 

 is said to have broken a atone in the bladder by striking it with a 

 catheter ; but the first suggestion we meet with of an apparatus con- 

 structed expressly for this purpose U by Oruithuisen. It consisted of 

 a wide straight tube, which wo* introduced through the urethra into 

 the bladder. Through the tube was passed a noose of copj T wiro 

 (by which the (tone was caught hold of and fixed) and a rod ter- 

 minating in a circle of teeth or a apear-point ; a drilling motion wan 

 now given to the Litter instrument by means of a bow, am) il. 

 wa* thu* perforated or broken. Since thi* period, the operation ha* 

 undergone successive improvement* in the hands of Leroy, ( 

 and Heurtelimp. The following is tho mode of proceeding adopted by 

 thislast gentleman. The patient is placed on an o|,,.r,,tmi; bed, 

 stntcted a* to admit of any inclination being given to it that tho operator 

 may think proper. At its foot ia an apparatus for affording a fulcrum 

 to tho instrument which i* to be passed into the bladder; ami two 

 xli|i|>iTH, securely fixed at a short distance on each side of t! 

 ai,uii.-<l to, serve for securing the feet of the patient, who i., pU, ed in a 

 u nearly resembling that choaen for the operation of lithotomy. 

 The bladder is now moderately dinU-n.li 1 with warm wa 

 through a catheter. Ai ng sliding forceps, the opposite sur- 



face* of which ore furnished with teeth, are then introduced ; ainl (In- 

 calculus having been seised, the lower piece of tho forceps is fixed to a 



