LITHOTOMY. 



once fatisfy the curiofity of the profeffional reader, and 

 make liini for ever abhor a method that is fo repugnant to 

 the principles of good furgery, and the diftates of humanity 

 and common fenfe. 



The patient was bound in the pofition ufually adopted in 

 the more modern mctliods of cutting for the ftone. After 

 an opening had been made into the urethra, clofe behind the 

 bulb, much in the fame way as is praftifed in the performance 

 of tiic hiteral operation, the furgeon uled to introduce into 

 the bladd:T, along the groove of the itaff, an inllrument re- 

 fembhiip; a (Irong iron probe, and called a male conduttor. 

 The (lair was then taken out of the urethra, and the fe- 

 male, or grooved couduftor, guided along the male one into 

 the bladder. By means of thefe two implements, endea- 

 vours were next made to dilate the undivided portion of the 

 urethra, and the neck of the bladder, fufficiently to enable 

 the operator to introduce the forceps. After much time 

 fpent in ilretching the parts, the forceps were palled into 

 the cavity of the bladder, and the ftone was drawn out, 

 though, in general, not without confiderable force and vio- 

 lence. Sometimes the dilatation was attempted with a blunt 

 gorget ; fometimes by expandnig the blades of the forceps. 

 Many operators ufed different inlfrumcuts for the pi:rpofe, 

 called dilators.- Franco, Toilet, the Collots, and Alghili, 

 employed ihem. 



When we refleft that, in. this method, the proflatic por- 

 tion of the urethra was left undivided, a part which is very 

 incapable of much dilatation, we mud know that the open- 

 ing through which the forceps was introduced, and the ilone 

 taken out, was not formed by the claflic yielding of the 

 parts ; but by an adlual laceratioii of them, attended with 

 an immenfe deal of contufion and violence. In what a de- 

 gree luch mifchief muft have taken place in cafes where the 

 ftone was of large fixe, is eafdy conceivable. We cannot 

 wonder, therefore, at the fevere, aiid frequently fatal, con- 

 fequences of fo barbarous an operation. The patients very 

 often perilhed of inflammation of the bladder and abdominal 

 vifcera. An extenfive effufion of blood in the fcrotum, 

 ahfceffes and fiftula; in perineo, incontinence of urine, and 

 jmpotency, were alfo common confequences. With thefe 

 fafts before us, we muft feel furprife that the operation of 

 Marianas ftiould have been pradtifed for the fpace of two 

 hundred years, by fon^.e of the moft diftinguilhcd furgtons 

 in E".rope, as Pare, Le Dran, Lc Cat, Mery, Morand, 

 Ma'-cohal, Raw, &c. 



The foregoing account will ferve to convey a general no- 

 tion of the apparatus major, fo faniwus a fubjeCl in the 

 hittory of lithotomy ; hut fuch readers as wi(h to be ac- 

 quainted with all the different modes in which it was 

 praftifed by the clj furgeo^.s, ought to confult De la Mcde- 

 cine Operatoire, par Sabatier, torn. ii. ; and the Principles 

 of Surgery, by Mr. John Bell, vol. ii. Very clear and 

 more concifc dcfcriptions of the apparatus major may be 

 found in Sharp's Trcatife on the Operations, or in Ber- 

 trandi'sTraite des Operations. 



Apparatus altus. — Thi.^ is the technical name given lo the 

 method in which the ftone is extracted from the bladder, 

 through an incifion praftifed in the fundus of this organ 

 from above the pubes. The inventor of this mode of cut- 

 ting for the ftone was Pierre Franco, a fm-geon at Tour- 

 rieres, in Provence. He was led to attempt the operation, 

 from having under his care a child with a calculus, that 

 could not be brought towards the perineum on account of 

 its magnitude. Although the Httle patient fuffered much 

 in ii'p.jiition aft»rwards, the wound healed, and a pcrfeftrc- 

 'covery foUo-.ved. The profperous event of this cafe, it 

 fecms, was not enough to convince FraucOj that wounds of 



the bladder were lefs perilous than lie apprehended them tr,- 

 he, and at the lame time that he details the particulars oi' 

 the plan he purlued, he cautions us not to imitate him. 

 See Traite des Hernies, Lyon, 1561. 



Doubtlefs, the advice delivered by Franco intimidated 

 his contemporaric's ; for we lind no notice taken of the 

 apparatus altus again till 1597, when this plan of ope- 

 rating was recoinmendtd by Roffetti, a well-informed and 

 judicious phylician, in a work entitled " Partus C:clariu3.'' 

 This author reprelents it as the belt and fatell mode of cut- 

 ting for the ftone ; but though he had clear ideas of the 

 poffibility of the method, his obfcrvations are not fupported 

 by any adtual experience of his own. Afterwards, the 

 operation was at firft reprobated, and then adopted by Fa- 

 bricius Hildanus, in cafes where the ilone was of confider- 

 able fize. It was commended by Riolan in his remarks upon 

 the anatomy of Vefliiigius ; and Simon Pietre, a phylician 

 at Paris, wrote a memoir in favour of the operation in the 

 year 1635. Since this period, the apparatus altus is men- 

 tioned by numerous writers, though few furgcons ventured 

 to perform it. However, it is faid to have been practifed 

 by Bonnet, an old furgeon of the Hotel-Dieu. At length 

 the faculty of Paris recommended the parliament to autho- 

 rife fom'e additional experiments- in regard to the apparatus 

 altus, and Francis Collet was appointed to make the requi- 

 fite trials of the operation. The refult was, that, in his 

 opinion, the method was attended with great danger, and, 

 confequently, the prattice in France was prohibited. 



The apparatus altus, however, was not every where aban- 

 doned. Proby, a furgeon at Dublin, praflifed it for the 

 purpofe of extrafting from the bladder of a young woman 

 a long pin, covered with a ftony incruftation, which he was 

 unable to get out through the urethra. (See Phil. Tranf, 

 for 1700,) Groenvelt, a Dutchman, who, in 1716,., ptib- 

 lifhed a treatife on lithotomy in Englifti, lays, that he was 

 under the neceffity of removing a ilone from the blad- 

 der by cutting above the os pubis. At length, in 171S, 

 Dr. Douglas wrote a dilTertation in praife of this method of 

 operating, which was foon afterwards put to the tell of ex- 

 periment by his brother, the furgeon, who was imitated by 

 feveral Englifli and German praftitioners. In confequence 

 of thefe proceedings, the operation was again revived in 

 France, and it was prailifed at St. Germain-en-Laye by 

 Berryer, a furgeon of that town, and by S. F. Morand, at 

 the Hotel des Invalides. The latter attempt proved un- 

 fiiccefsful. An account of both thefe cafes was pu: I !hcd 

 by Morand in 1727. Tlie t>peration v/as afterwardi much 

 on the decline in France, and probably would have been 

 tota'ly given up, had not a nev.' method of ['erforming it 

 been propofed by Frere Come. See Nouvclle Melhode 

 d'extraire la Pierre de la Vcflle Urinaire par deffus le 

 Pubis, a Paris, 1779. 



In the apparatus altus, the defign of the furgeon is to 

 make an opening into the anterior part of the bladder above 

 the OS pubis. The patient is to be placed upon a table, or 

 bed -of fuitable height, with his legs reaching over the 

 edge and relling upon a ftool. Two affillants are to keep 

 the patient's body and arms fteady, while two ethers take 

 hold of his thighs. The patient's trunk (liould be fome- 

 what bent forwards, in order to relax the abdon.inal mufcles j 

 but it is highly neceffary for the pelvis to be rather more 

 raifed than the cheft, fo that the inteftines may not gravitate 

 towards the bladder, and by deprefiing this vifcus, make it 

 more difficult to be got at. Befidcs, raifing the pelvis above 

 the level of the thorax prevents the ftone from falling to- 

 ■wards the neck of the bladder, from which fituation the ex« 

 traftion would be lefs eafy. 



The 



