LITHOTOMU 



prfition to Ill's own principles is fuily proved by the fol- 

 lowing pafTage : " I cannot omit this opportunity of adding 

 a fow words on a lubject, wliich appears to me highly dc- 

 fcrving of fome notice, as its influence may be very cxtciifive, 

 and very prejudicial : it is the falfe idea which the by-ilanders 

 at an operation genera'ly have of chirurgic tlexterily ; to 

 which word thry annex no other idea tlian that of quickncfs. 

 Tiiis has produced a moll abfurd cuilom of mcafuring the 

 motion of a furgeon's hand, as iockeys do that of the feet 

 of a horfe, i);;;. by a llop-watch ; a practice which, though 

 it may have been encouraged by operators themfelves, mull 

 Live been productive of moll mifchievous confequences. 

 7'«// et telsrlier are both very proper charactcriftics of a good 

 chirurgic operatiwi : but lute Hands, as it fliould do, in the 

 fir;l place; as the patient, who fuffers the fmalletl injury 

 from the hurry of liis operator, has no recompence from the 

 reputation which the latter obtains from the by-llanders. 

 In moft of the capital operations, unforcfeen circumlla'.ices 

 w ill fometimes occur, and muft be attended to ; and he who, 

 without giving unnecefTary pain from delay, finilhes v/hat 

 he has to do in the moft perfedl manner, and the moll likely 

 to conduce to his patient's fafety, is the bell operator." 

 (Pref. to Obf. on Fill. Lachrymalis. ) We fhould not have 

 premifcd thefe remarks, had we not often feen furgeons 

 guilty of unwarrantable hurry and roughnefs in the per- 

 formance of lithotomy ; and did we not believe that the in- 

 flammation of the bladder and peritoneum, of which patients 

 urually. die after the operation, may, in numerous inftances, 

 be imputed to fuch a caufe. 



The Hones, which are met with in tlie human bladder, are 

 not all originally formed in this vifcus : many defcend 

 through the ureters from the kidnies ; but yet it is not to 

 be denied, that moll of them are firfl produced in the bladder 

 itfelf, by a fpontaneous concretion of particular falts con- 

 tained in the urine. It may be inquired, Is the exigence 

 ef a centre, round which the calculous materials are de- 

 pclited and arranged, abfolutcly neceflary to the formation 

 of fuch concretions ? It is well known, that whenever an 

 extraneous fubilance lodges in the bladder, it becomes the 

 nucleus of a Hone; but, on the other hand, the centre of 

 many calculi prefents no particular appearance, nor any 

 mark from which we can infer that they had any central 

 fubllance, upon which they increafed to their prefent fize. 

 Puffibly, fays Richerand, a clot of blood, or a piece of 

 thickened mucus, may ferve as their bafe, and yet, after a 

 time, difappear. However this may be, urinary calculi 

 offer numerous differences in refpedt to their fize, (hape, 

 number, denlity. compofition, and the manner of their being 

 contained in the bladder. Nofogr. Chir. torn. iii. 



In fome cafes, the bladder only contains one (lone ; in 

 others, it includes feveral. In this iall circumilance, the 

 calculi are always fmaller ; their diminifhed fize being in 

 proportion to the greatnefs of their number. It has been 

 ellimated that, on the average, about three-fourths of cal- 

 culous patients have only one Hone in their bladder. Our 

 Own individual experience would make the proportion much 

 highe^> perhaps five or fix out of every feven. Sometimes 

 the bladder contains two calculi ; but a larger number may 

 occur from three to fixty, or more. Their fize varies from 

 that of a bean to that of a cocoa nut. The mufeums of the 

 Ecole de Medecine at Paris, arid that of profeflor Fourcroy, 

 exhibit fpecimens of calculi, which filled the whole cavity 

 cf the bladder. In the Philofophical Tranfaftions for 1 809, 

 .fjr James Earle has defcribed an enormous Hone, which 

 could not be extra£ied from the bladder; the attempt 

 having been made in vain by Mr. Cline. Indeed the cal- 

 culus filled almofl the whole of tlie pelvis^ and could not 



be taken : out of the dead fubjcft witliout corrSdcrable diffi. 

 culty. The weight of this immenfe Hone was forty-four 

 ounces ; its form elliptical, with a long axis of fixteen, and 

 a lliorter one of fourteen inches. ' This, however, was an 

 extraordinary cafe ; and the average fize of calculi, met with 

 in the bladder, is from the bulk of a pigeon's to that of a 

 hen's egg. 



The varieties of fhape are innumerable : moft of the 

 (lones, however, v.hich are found in the bladder, are oval, 

 and more or lefs flattened. Their furface is fometimes fmooth 

 and rounded ; very often it is irregular and rough. Stones, 

 fludded «'ith afpcrities, are frequently termed mulberry cal- 

 culi, and that thefe mull produce confiderable irritation of 

 the bladder, and a vail deal of pain, is a fact which re- 

 quires no comment. We faw a (lone extradled a few weeks 

 ago, the outer furface cf which was quite fir^ooth and of a- 

 light colour ; but on breaking a portion of it away, the 

 inner part of the calculus prefented a granulated and dark 

 brown appearance. The generahty of flcncs taken from 

 the human bladder are hard and refiPdng ; but fome are 

 exceedingly friable, giving way to the flighteft prefTure, and 

 breaking into fmall pieces, or even into a fort of gritty 

 matter. 



The chemical compofition of urinary calcuU is far from 

 being always the fame. The lea'-ned invefligations of 

 WoUallon, Pearfon, Fourcroy, and Vauquehn, have difco- 

 vered, that the materials may confill of uric acid, urate of 

 ammonia, phofphate of lime, ammor.iaco-magnefian phof- 

 phate, oxalate of hme, filex, and a peculiar modification of 

 animal matter. The bafis of thefe concretions was afcer- 

 tained by Scheele to be the uric acid. Other fpecies were 

 afterwards detefted. Dr. Wollafton, whofe difiertation wrs 

 pubhfhed in the Philofophical TranfaCtions two years be- 

 fore the memoir cf Fourcroy and Vauquelin was read to 

 the French National Iiillitute, anticipated nearly everr 

 thing which the French chemills announced as their own 

 difcoveries ; and it is very remarkable (as profeflor ^furra7 

 has noticed), that although the experiments of Pearfon, 

 publilhed in the Philofophical Tranfaclions the year after 

 Wollafton's, are referred to in that memoir, not the 

 llightell mention is made of the difcoveries of this latter 

 gentleman ! As our department is furgical, and not chemi- 

 cal, we fliall quit this fubjeCl with briefly flating, that 

 Dr. Wollafton has arranged urinary calcuh into four fpecies. 

 I ft. The uric acid concretion, zdlv. The fufible calculus, 

 or phofphate of ammonia and magnefia. 3dly. The mul- 

 berry calculus, or oxalate and phofphate of lime. 4tlily. The 

 bone earth calculus, or that compofed of the phofphate of 

 lime. 



It will be with regret, that we fhall prefently have to 

 ftate^tlie little pr^-dlical advantage hitherto derived from the, 

 knowledge of the chemical compofition of urinarv calculi. 



Thefe concretions are ufually quite free and unconneclcd, 

 fo that the particular lltuation, which they occupy in the 

 cavity of the bladder, is fubjcft to change, being deter- 

 mined entirely by their own weight, or the contractions of 

 the organ containing them. In fome inllanccs, however, 

 they are adherent to the parietes of the bladder, and con- 

 tinue fixed in one place. Such adhefion may happen in 

 three manners, i. The ftone may have been formed in a 

 cul-de-lac appendage, confilling of aprotrufion of the lining 

 of the bladder between the fibres 01 its mufcular coal ; 

 or, after being originally lodged in the common cavitv of 

 the bladder, it may have been torced into a pouch of this 

 kind by fubfequeut contractions of this vifcus. 2. The 

 ftone mav be lodged in that portion of the ureter wliich 

 runs obliquely between the coats of the bladder. 3. Laftly, 



the 



