LITHOTOMY. 



diforJcr. Ofl opening the body after death, the bladder is 

 found contracted, and its coats tliickened, indurated, and 

 more injefted with blood, than in the healthy (late. 



The fatal termination, to which thcfe cafes tend, when 

 unreheved, is fubjeft to confiderable variety. Some pa- 

 tients have been known to live with a Itone in their bladder 

 ten, twenty, and even thirty years, without the pain being 

 fo fevere as to incline them to fubmit to litliotomy. Iliche- 

 rand moreover affuies us, that calculi, of very large fize, and 

 irregular furfaces, have fometimes given rife to no fymp- 

 toms, by which their prefence could be fufpedled. This 

 author tells us, that, as he was once pracUfmg operations 

 on the dead fubjecl in the HApital de la Charite, he extradled 

 an enormous mulberry calculus from the bladder of a pa- 

 tient who had died of fome other difeafe, and who, while 

 living, had betrayed no complaints, indicating that he was 

 afflifted with the ftone. This calculus, which was compofed 

 of the oxalate of lime, was exceedingly heavy, and by its 

 weight, darknefs of colour, and the manner in which its 

 furface was ftudded with obtufe points, bore a great re- 

 femblance to a fcoria of iron. It is preferved in Four- 

 croy's mufeum, where it was depofited by Bbyer. 



The fymptoms of a ftone in the bladder are fo fallacious 

 and equivocal, that every prudent furgeon avoids deliver- 

 ing a pofitive opinion, before he has founded the patient. 

 Certain complaints mjy make him fufpeCl the nature of the 

 cafe; but he muft never prefume to be certain, uijtil he 

 has aftu:Jly touched and felt the ftone, by means of a me- 

 tallic inftrument, paiTed through the urethra into the bladder. 

 I The general fymptoms of a Hone in the bladder are liot 

 peculiar to this diforder ; they belong to feveral other af- 

 fections, for which the praftiiioner may be confulted. An 

 enlarged proftate gland produces many effedls, like thofe of 

 a ftone in the bladder. There is this difference, however, 

 riding in a carriage, or on horleback, does not increafe the 

 grievances when the proftate is afteCted ; but it does fo, in 

 an intolerable degree, in cafes of ftone. It alfo generally 

 happens, that the fits of ftone come on at intervals, whereas 

 the pain from a difeafed proftate is neither lo unequal, nor 

 fo acute. 



At this prefent time, (September iSli,) there is a man 

 in St. Bartholomew's hofpital whofuffers many of the com- 

 plaints 'ufually attending a ftone in the bladder ; he has been 

 founded, but no calculus can be difcovered : and it is now 

 afcertained that his fymptoms are dependent upon a contrac- 

 tion iituated fome diftance up the reclum. The ftrifture is 

 fo confiderable, that the feces can only pafsin a liquid form, 

 and the introduiSlion of bougies above a fmall fize is quite 

 obftnicled. 



Who would fuppofe that fymptoms, exaftly fimilar to 

 thofe of a ftone in the bladder, could proceed trom the ve- 

 nerea! difeafe, and be cured by mercurial treatment ? Yet, 

 iuch a fact have we recorded by Richerand, now an eminent 

 furgeon at Paris. See Nofographie Chirurgicale, tom. iii. 

 p. 506, edit. 2. 



Nothing, therefore, except founding the patient, will give 

 the furgeon certain information of the prefence of a calcu- 

 lus in the bladder. The fymptoms which prevail may ex- 

 cite ftrong lulpicions of the nature of the cafe ; but liuce 

 they may proceed from fo many other different caufes, they 

 are not alone a fufficient warrant for venturing on the pei-- 

 formance of lithotomy. When the furgeon undertakes this 

 important operation, lie muft know, with certainty that there 

 is a ftone in the bladder, and fuch pofitive knowledge can 

 only be acquired by aclually feeling and hearing the fteel in- 

 flrument, called a found, ftrikc againft the fojcign body. Nay, 



further, as the ftone may be in the bladder to day, but be pro- 

 truded to morrow on the outfide of the mufcular coat of this 

 organ, fo as to become as it were cncyftcd and incapahle of 

 cxtradlion, " it is an invariable maxim among all prudent fur- 

 geons never to begin the operation of lithotomy unlt-fs they can 

 clearly and diftindly perceive the (lone with the found, or at 

 leaft with the ftaif at 'lie time when the patient isbrouglit forth 

 to be operated upon." If the calculus cannot be plainly felt at 

 this period, the operation is net juftifiable. The im:.ortance 

 of this precept cannot be too highly appreciated by evVry 

 practitioner who va'ues eitiier hi-; patient's welfare or his 

 own reputation ; for were a different line of condu£t pur. 

 fued, an opening might be made into the bladder, no ftone 

 be found, and, unfortunately, the patient lofe his life from the 

 operation, which, however well executed, is never free from 

 a ferious degree of danger. 



The method of founding will be defcribed in a future vo- 

 lume of this Cyclop;Edia. See SouNDiNG. 



The ftone in the bladder is a diforder that is to be regard- 

 ed as more grievous the longer it has exilled, and the older 

 and more debilitated the patient is. The cafe is particularly 

 afflitiing when the fevere pain in the kiddies renders it not 

 unlikely that there may be at the faiiie time other calculi iu 

 the fub fiance of thefe organs. 



A ftone is feldom known to be .in the bladder until it is 

 too large to pafs out through the urethra. Should a very 

 fmall one be deteCled, we are recommended to try the effect 

 of introducing a large found or bougie, making the patient 

 drink abundantly of fome diuretic liquor, and deliring him 

 firft to retain his urine, and then expel it as forcibly as pofli- 

 ble, at the fame time that the found or bougie is withdrawn. 

 In tins manner, it is conceived, the ftream of the urine 

 might fometimes carry the calculus outward. Default had 

 it in contemplation'to adapt the port-crayon pincers, invented 

 for the urethra by Mr. Hunter, to a common catheter, for 

 the purpofe of taking fmall calculi out of the bladder. This 

 projeft, however, would be attended with much difficulty, 

 and the fides of the bladder would be liable to laceration in 

 confequence of becoming pinched. lailruments made on this 

 principle, however, are fometimes fuccefsfuUy employed for 

 taking fmall ftones out of the urethra. 



DiJf'Julwn of Jloiies in the bladder. — The poflibility of dif- 

 folving ftones in the bladder was a thing believed for a very 

 long fpace of time, and even ^t the prefent day is a fcheme 

 not altogether abandoned. The diflolution has been at- 

 tempted both by internal medicines, and by certain fluids in- 

 jected into the bladder. 



The knowledge of the compofition of urinary calculi at 

 once apprifes us that, as they confift of very different mate- 

 rials in different cafes, the fahie folvent cannot be applicable * 

 to all of them. 



It is obferved by Murray, one of the learned profeffors- 

 of chemiftry at Edinburgh, that long experience has fuffi- 

 ciently cftabliftied the advantage derived in calculous affec- 

 tions from the ufe of alkaline remedies ; and as the calculi, 

 compofed of uric acid, are thofe which appear to be muft 

 abundant, it is fuppofed to be from the chemical action they 

 e.-iert upon it that the benefit is derived. Where tiie pure- 

 alkali is ufed, a r>jal folvent power may be exerted ; and it 

 has been proved that the alkah is fecreted by the kidnies, fo 

 as to render the urine fenfibly alkaline, and ever.^apable of 

 afting on the calculus out of the body. Yet the folvent 

 power is very incon'iderable, and the remedy at the fame 

 time proves fo irritating, when taken to any confiderable ex- 

 tent, that the folution of a calculus, even of fmali fiza, cao^ 

 perhaps be Ccarcely expelled.. The pain and irritation which 



atteaii 



