LITHOTOMY. 



ihe irregular furface of a calculus may be, as it were, im- 

 planted in the fun;^ous granulatiaus, which occnfionally' 

 avife from the infidc of the bladder, and, in this circum- 

 ftance, the ftoiie can only be exirafted by tearing its con- 

 nedlion. 



The calculi, which lie in a fort of cul-de-fac protrufion 

 of the lining of the bladder, are often named enc^ed. We 

 believe that a Hone, thus ciicumllanced, is not hkely to 

 caufe fevere pain ; the containing pouch becomes habituated 

 to its prefence ; and the fenfible inlide of the bladder is not 

 expofed to any irritation or inj"ry from it. We conceive 

 it poffible for fome of the alleged diffolutions of Hones 

 to have^bcen cafes, in which the extraneous body became 

 thus. protruded, between the fafciculi of niufcular fibres, 

 into a cyrt; formed of the inner membrane of the bladder. 

 A ftone encyled in this manner would, in all probability, 

 neither require extraftion, nor admit of it. 



Blundering and baffled operators are generally eager to 

 lay hold of any excule for their mifconduct, or ill fucccfs. 

 The adhcfion of the ftone has been frequently employed 

 as a defence againft ccnfure, when the attempts to extrai^t: 

 the foreign body have failed. Encyfted calculi, generally, 

 ■cannot be touched with a found, and both on this account, 

 and becaufe the fymptoms are far more lenient than thofe 

 ■of a ftone in the bladder, fuch cafes do not demand the 

 performance of lithotomy. A ftene in the lower part of 

 the ureter could not be touched with the found, and would 

 be attended wi'h efTefts different from thofe of a calculus 

 in the cavity of the bladder. Now, thefe are the only ex- 

 amples where the extraftion of the Hone would be imprac- 

 ticable on the ground of adhcfion, and they are certainly 

 inllances in which an inteUigent furgeon would never be- 

 gin the attempt. But we alTert with confidence, that when 

 a calculus is fairly lodged iu the cavity of the bladder, 

 no adhefion can be a juft excufe, or reafon, for its not being 

 extraded. We inuft be convinced, with that eminent fur- 

 geon Le Dran, that an animated body, which fubfills by a 

 circuLition of fluids, and another body, which owes its 

 bulk en'irely to an appofition of matter, can never become 

 one and the lame by any kind of adherence, let it be ever 

 fo ftrong. Le Diaa made no doubt, that there were fuch 

 things as adherent ilones, becaufe he had feen inllances of 

 them, but thefe adhefions ought not to have hindered 

 the (lone from b'-ing extracted, provided it could be laid 

 hold of with the forceps. In 1730, this furgeon cut a 

 •lady, ar.d extratted a (tone, that weighed feven ounces and 

 a hall. One fide of it was uneven, and in a manner en- 

 tirely ii'.crulted upon that part of the bladder which is con- 

 nedled with the reilum, Tliis incruftation was occafioned 

 ty the inequalities of the Cone, which had produced an 

 excoriation ot that part of the ■ bladder upon which they 

 prefied.arid, in conlequence thereof, a num.ber of flefhy 

 or fungous excrefcentes arofe from the excoriated furface, 

 and had lodged therafelves in the cavities of the ftone. The 

 adhefion was broken with hardly any pain. Le Dran, at 

 fubfequent periods, extradled from three patients ftoncs, 

 which adhered in the fame manner. In 171 5, he was 

 prefent at an operation, performed by M. Marechal, when 

 a ftone was extrafted, which was (liaped like a cilaballi, or 

 gourd, ai:d brought out with it a fungus, that encircled 

 the ftone at its naiTOweft part. As this fungous excref- 

 cence paffed round, and covered the middle of the ftone, 

 no new ftrata could be formed in that part, but were made 

 zt the two extremities, which was the reafon of its boi: g fo 

 fliaped ; and the fungus fixed it fo completely in the blad- 

 der, that it could riOt poRibly change its fituation. Tiaite 

 (des Operations de Chii-uigie. 



Of all animals, man is faid to be the moll fubjefl to uri- 

 nary calculi. The human urine contains a particular acid, 

 fo little foluble, and fo difpofed to produce concretions, 

 that, frequent as the diforder is, it is rather a matter of fur- 

 prife, that it is not even more common. In warm countries, 

 like Spain and Africa, as well as in nations much to the 

 north, fuch as Sweden, the difeafe is exceedingly rare. In 

 temperate climates, it prevails the moil in cold damp coun- 

 tries, like England and Holland ; and, accordii;^ to Ri- 

 cherand, it occurs in fome of the provinces of France 

 much more than in others, patients with the ftone being 

 more numerous in the northern, than the fouthern depart- 

 ments of that empire. 



Children and old people arc more frequently afHidled 

 than adults, and women are lefs expofed to the diforder than 

 men. 



Symptoms of a Jlone h the bhiihler. — A ftone in the blad- 

 der occafions pain, and derangement of the excretion of the 

 urine ; and when a futpicion of the difeafe is excited by 

 thefe ambiguous fymptoms, it can only be confirmed by 

 introducing an inftrument, called a found, into the bladder. 

 The pain produced by the prefence of a calculus in l!'C 

 bladder, has the particularity of always affefling, in a very 

 remarkable manner, the extremity of the penis. The glans 

 becomes the feat of an itching fenfation, which daily in- 

 crcafes in violence ; and patients, efpecially children, often 

 get i;to the habit of pulling forwards the prepuce, in or- 

 der to obtain relief. Hence, this part is frequently elon- 

 gated in an extraordinary degree. This fympathetic fort 

 of pain is more acute the larger the ftone is, and the greater 

 the irregularity of its furface. When the bladder is full of 

 urine, the pain is not infupportable ; but juft at the period 

 when the difcharge of that fluid is finiflied, the fuffering 

 becomes intolerable, becaufe, at this inftant, the bladder 

 contrafts, and embraces the foreign body with confiderable 

 force. All rough exercifes augment the pain ; but walk- 

 ing over an uneven country, riding on horfeback, and the 

 jolting df a carriage particularly, have fuch an effeft. When 

 the patient is fubjefted to thefe exercifes, he not unfre- 

 quently difcharges a few drops of blood from the urethra. 



The defire to make water comes on very often, and the 

 urine, as it flows, is attended with a fenfation of heat, 

 which changes into a burning kind of pain at the extremity 

 of the penis. The ftreaci of water is fometimes inter, 

 rupted all on a fudden. The patient vainly endeavours to 

 continue the evacuation ; he applies his hand to the peri- 

 neum ; he moves about, lies down, or, in fome way 01' 

 another, alters his p'ofture, and the urine then begins to 

 run again. The moveablcnefs of the ftone makes it every 

 now and then fall againft the orifice of the neck of the 

 bladder, and thus prevent, for a time, the exit of the urine. 



The inceflant irritation, produced by the prefence of the 

 calculus, extends to the reftum ; the patient is continually 

 tcazed with an inclination to go to ftool, and the efforts, 

 which his imaginary want caufes hrlh to make, bring on, ii-- 

 many inflances, hemorrhoidal csmplaints, or even a prolapfus 

 ani. 



In the courfe of time, the pain becomes more acute and 

 unremitting. The ftone increafes in fize, and, by continu- 

 ally preffing upon the inferior part of the bladder, makes 

 the patient experience a moft painful fenfe of weight about- 

 the reftum. The evacuation of the urine is attended with 

 more and more difficulty. The parietes of the bladder 

 inflame, and are rendered thicker; its inner furface u!ce» 

 rates ; the urine becomes blended with matter and blood ; 

 a How fort of fever occurs ; and the patient, after lingering 

 a great while in roifery and pain, fall-s a vi£lim to the 

 A diforder. 



