LITHOTOMY. 



We ftiall now endeavour to give an impartial defcription 

 of the priixipal methods of cutting for the ftonc, beginning 

 with fuch dJ are mo.1 ancient, and concluding with thofo 

 vhich have been very recently fnggetled. 



Of the Apparatus minor, Methodus Celfana ; or cuiUng on 

 the grip:. — The operation which v.e are about to explain is 

 by far the oldeil fpecics of lithotomy, its antiqnity extending 

 back to time immemorial. Ahhoiigh we are indebted to the 

 immortal Cclfiis for tlie firll defcription of it, he vvai in all 

 probability not the original inventor. We learn from hiftory, 

 that Hippocrates made his pupils take an oath that they 

 would never attempt to cut for the Hone ; and, according to 

 Florus, the Latin hiflorian, the fon of Alexander, king of 

 Syria, periilied, when about ten years of age, in confequence 

 of this operation, wliich had been villainoufly undertaken, 

 though there was no Hone in the bladder. It is plain then, 

 that, long before the time cf Celfus, the ancients were ac- 

 quainted with fome mode of lithotomy, which we may infer 

 was what is now called the apparatus minor. This lad ap- 

 pellation, deduced from the fmall number of inllruments re- 

 quired, was not employed till the commencement of the fix- 

 teenth century, the period w hen another method, named the 

 apparatus major, had its rife. The phrafe of " cutting on 

 the gripe," came into ufe in confequence of the furgeon 

 having to cut upon the (lone, while he grafped it, with his 

 fingers introduced within the rectum. 



The manner of doing the operation is this. You iirft in- 

 troduce the fore finger ai^d middle finder of the left hand, 

 dipped in oil, up the anus, and prc-fling foftly with your 

 right hand above the os pubis, endeavour to bring the ttone 

 towards the neck of the bladder ; then making an incifion en 

 the left fide of the perineum, above the anus, dircftly upon 

 the (lone, you turn it out through the wound, either with 

 your fingers or a fcoop. Sharp on the Operations, 

 chap. 1 8. 



M iny objeftions have been urged againil this method by 

 furgical authors. 



1. In the firil place it is not applicable to adults, as, in 

 fuch patients, it would ft-ldom be found poffible to fix the 

 flonc by the fingers introduced within the reclum. Celfus 

 confined the operation to fubjefts betwem the ages of nine 

 and fourteen, which is rather extraordinary, as it is more cafy 

 of perlormaiice the younger the child is, though certainly it 

 hardly admits of being done at all after the patient is more 

 than fourteen. 



2. The fame parts are not always cut, as this depends very 

 much upon the degree of force with which the ftone is 

 made to projeft in the perineum, and the leaft incliration to 

 one fide or the other mull alfo make a confiderable difference. 

 When the incifion is favourably executed, the parts cut are 

 nearly the fame as thofe divided in the modern and mod ap- 

 proved mode of operating. But as the operator always cuts 

 dircftly on the projecting Hone, the parts expofed to the 

 knife muil vary in different cafes for the reafons already al- 

 leged ; and the records of furgery prove, that in perform.- 

 ing the apparatus minor, ti.e urethra may be quite detached 

 from the proftate, or the velicula feminalis and vas deferens 

 be injured. 



3. The neck of the bladder mufl fuffer very much from 

 rough ftones, when confiderable force is exerted in prelTing 

 them towards the perineum. That this is not mere con- 

 jechirc, is confirmed by the obfervatioas of Celfus, from 

 whofe account it plainly appears that, in his time, many 

 aftually died from the violence done to the bladder, in en- 

 deavouring to bring the ilone forwards, though the operators 

 failed in their attempt, and the patients were not cut. Fa- 

 bricius Fildanus was well acquainted with all the uncertainty 



Vol. XXI. ' 



of cutting on the gripe, and he endeavoured to improve the 

 method Ly introducing a flafi" through the urethra into the 

 bladder, fo that the operator might avail himfelf of the 

 guidance of this indrumcnl in making the requifitc opening 

 for the cxtradion of the ftone. Fabricius brought the ftone 

 into the neck of the bladder with his fingers, which were 

 paffed up the rectum, juft as Celfus dcfcribes, and then, 

 fiuidod by the ftaff, made fuch a divifion of the proftate and 

 reck of the bladder, as fuificed for the paffage of the cal- 

 culus outward. The extraftion was accomplifhed with a 

 fort of hook. 



The apparatus minor, done in this manner, is by no means 

 an ineligible operation for young male children, v.henthe 

 furgeon can eafily grafp the ftone with his fingers, fro;n 

 within the reftum. We do rot mean to fay it is rafh to 

 make an incifion into the bladder with a common fcalpcl, 

 guided by a itafi", even though tlie ftone cannot be fixed 

 with the fingers, only the operation wou'd then not be that 

 of "cutting on the gripe," to which, at prefent, our re- 

 marks are limited. We agree entirely with Mr. John Bell,, 

 who, in commending the improved Celfian method, as 

 praftifcd by Fabricius, takes occafion to rem.ark, that you 

 cut upon the ftone, and of courfe m.ake, with perfcft fecu- 

 rity, an incifion cxadly proportioned to its fi/.e. There is 

 no difficult nor dangerous difi'eflion ; no gorget, nor other 

 dangerous inftrument, thruft into the bladder, with the rifle 

 of Its palTing between that and the retlum ; you are per- 

 forming, exprefsly, the lateral incifion of Raw and Che- 

 felden in the molt finiple and favourable way. John Bell's 

 Principles of Surgery, vol. ii. 



Of the Apparatus major, or SeS'io Alariana. — This me- 

 thod of cutting for the ftone was named Apparatus major, 

 from the great number of iaftruments ufed in the operation ; 

 and Sedio Mariana from one M,irianus, who publifhtd the 

 firft defcription of it. Johannis de Romanis, a furgeon at 

 Cremona, was the inventor about the year 1523, or 15251 

 though the exadt period is very uncertain. Marianus was 

 the ftholar of Romanis, and having learned his niafter's art. 

 of operating, printed an account of it in Latin. The date 

 of this treatife fecir.s rather undetei mined, Douchis irakin<T 

 It 1522, Sharp 1524, and Sabatier a period fubiequent to 

 1540. 



Lxperience has repeatedly proved, that, in co fequenee 

 of the ftiortnefs and dilatable nature of the female urethra, 

 calculi of crnfiderakle fize m.ay be extivfled fro:ii women 

 without employing any cuttii^g inftrumeiits at all. Tlie paf- 

 f ;ge may be gradually dilated, fo as to allow the forceps to 

 be introduced into the bladdtr, and the ft ne taken hold of, 

 and extiaiSed. The adapt;ition of this plan to male pa- 

 tients was the principal objci^ of the Marian operation. , 

 With this view, an incifion w as made into the urethra at the 

 bulb. That part of the can-.l which was Gtuated between 

 the wound and the i^eck of the bladder, being (hort and 

 fomewhat ftraight, was thought to bear a refem.blance to the 

 female urethra. Ir:flruments were therefore paffed into the 

 opening, for the purpofe of dilating fuch portion of the 

 urethra, fufjicicntly to let the forceps be introduced, and 

 th; ftone extratfed. It was never recollected that the male 

 urethra, where it is furrounded by the proftate gland, could 

 not rightly be compared with the m.eatub urinarius of the fe- 

 male, fince it was totally incapable of being dilated in a de- 

 gree at all adequate to the objects in view. Hence m.oll 

 dreadful injury was done to the parts, which, inftead of 

 yielding, were torn and conlufed in a manner fhocking to re- 

 late. 



. There were various mode.; of executing this barbarous 



operation ; the following partic-jlars, we prefumc, wal at 



^ oacft 



