LITHOTOMY, 



The operation has "been execHted in Tei-eral ways. 

 Tlie moll ancient mode was tliat of cutting direclly upon 

 the ftone, wliich was puihed upwards and forwards, towards 

 the lower and-front part of the abdomen, by two fingers in- 

 troduced into the rectum. Franco operated in this manner, 

 and he was imitated by Bonnet, Heifler, &c. While an al- 

 fitlant puilies the (lone uprvard, the furgeon is to make an inci- 

 fion through the (kin juft above the os pubis, and through the 

 lower portion of the linea alba : he is then to puntture the 

 bladder, enlarge the opening from above downwards with 

 a probe-pointed crooked biftoury, and, lallly, take out the 

 ttone with a pair of forceps. 



RotTctti was the inventor of a particular method. In 

 the apparatus altus, it is an objctt of tlie grcateft confc- 

 quence to make an opening into the hLidder without wound- 

 ing the peritoneum. Hence Rod'etti adopted the plan 

 of dillending the bladder with warm water, which was in- 

 jefted through a catheter placed in the urethra, and thus 

 made the vifcus rife to a convenient height above the pubes. 

 The fluid was injefted in the moli flow and gradual manner, 

 in order that it miglit give as little pain and uneafinefs as 

 pcflible. The quantity iutroduced was, in general, from 

 eight to fixteen ounces. Some authors objecl to an injec- 

 tion, and recommend the patient to retain his water till the 

 requifite diltention of the bladder has taken place. When 

 ihis receptacle had been lilled, the catheter was withdrawn, 

 and the fluid kept from efcaping by an affiftant, who com- 

 preffed the urethra. The integuments and linea alba were 

 then cut, as in Franco's method. A punCture was next made 

 in the bladder with a biiloury, having its edge turned towards 

 the pubes; and the furgeon with his left index finger, which 

 was direiJtly paffcd into the opening, kept the bladder from 

 defcending, while he finifhed the incifion of that vifcus, 

 by cutting from above downwards below the os pubis. The 

 bladder was ilill kept up with the index finger, until the 

 ftone was extrarted with the forceps. In order to be fure 

 of having the bladder diilended, and to be able to introduce 

 more injection if neceffary, Mr. Middleton ufed to keep the 

 catheter in the urethra till the incifions were completed. On 

 the other hand, Douglas was in the habit of cutting down 

 to the bladder betore he introduced the catheter. 



The apparatus altus has been objefted to as unadapted to 

 perfons who are either inclined to be fat, or wliofe bladders 

 are not capacious. Unfortunately, in the generality of 

 itone-patients, the bladder is much contrafted. Tlie iutro- 

 duClion of the injection has likewife been found a painful 

 and uncertain proceeding ; for, very often, a fufRcient quan- 

 tity could not be got into the bladder, fo that in operating 

 there was fome rific of wounding the peritoneum. The 

 method has alio been accufed of frequently giving rife to an 

 ■extravafatir-n of urine, and' floughing and abfcelTes in the 

 pelvis, in confequence of the greater facility with which that 

 fluid efcapes through the wound of the bladder than through 

 the urethra. Thefe unpleaiant events have been faid to take 

 place the mere eafily, as when the bladder contrafts, it 

 defcer.ds behind the os pubis, and the wound in it no longer 

 continues oppofite to that in the linea alba and integuments. 

 Keeping a catheter in the bladder, or the patient in an hori- 

 zontal podurc, has not, it is faid, availed in preventing the 

 frequency or fatality of fuch mifchief. 



However, Frere Come's method of performing the ap- 

 paratus altus, which we (hall hereafter notice, if repreiented 

 by the French furgeons as being free from theprc ceding incon- 

 veniences. When the account of this form of the apparatus 

 altus has been read, we entertain little doubt that the ope- 

 ration will appear, to all good judges, to have merit. Frere 

 Cume is faid to have cut nearly a hundred patients, in the 



manner alluded to, with alrr.ofl uninterrupted fuccefs. The 

 plan has the advantage of enabling a furgeon to cxtraft 

 larger Hones than can be taken out of the bladder by any 

 other method, as the incifion may be enlarged in proportion 

 to their fize, and the bladder is here more yielding than in 

 the vicinity of the proflate gland. Nor is the paflage of a 

 large ftone here reliited by any bony obftacles, as in other 

 modes of operating. See Sabatiers Mcdccine Opcratoirc, 

 tom. ii. p 5 [. 



It muil be confelTed, that fome difficulty might arife in 

 cafe the ftone were to break, as the fragments could not be 

 fo eafily taken out as in other methods. We are to re- 

 member, however, that this accident is lefs likely to happen, 

 bccaufe the parts through which the cidculus has to pafs 

 are all foft and yielding. Were it to take place, the larger 

 pieces of the calculus might be extrafted by means of 

 proper forceps, and the Imaller ones would be carried out 

 with the urine through the tube in the perineum. 



This method, againll which the records of furgery appear 

 to adduce no ferious objeclions, founded on as pofitive expe- 

 rience, has been entirely abandoned. Want of fimplicity is 

 alleged againll it ; but we think without much reafon, for 

 the operation, as will be feen frum the defcription, is not 

 difficult ; nor is the number of inftruments immoderate. 

 If, what Richter mentions be true, that Frere Come cut 

 nearly a hundred patients in this way with almoft invariable 

 luccefs, the jullification of further trials cannot be doubted. 

 The method, as modified by 13efchamps, who, inftead of 

 cutting the perineum, perforated the bladder from the rettum, 

 has received the high fanction of Dr. Thomfon of Edin- 

 burgh. See Edinburgh Surg. Journ. N^ 13. 



Latsrul operation. — Since the ill eonfequences of the ap- 

 paratus major were chiefly owing to the difiention, contufion, 

 and lacer.ition wjhich the membranous and proftatic portions 

 of the urethra, and tlie neck of the bladder itfelf fuffered, 

 the idea ot preventing luch mifchief, by cutting thefe parts 

 to a fufiicient extent, feemed almoft a certain and natural 

 effeiit of any reflection beftowed on the fubjecl. The 

 making of fuch an incifion conftitutes all the particularity of 

 the lateral operation ; but as the lower fide of the urethra 

 cannot be divided far enough without the reftum being 

 wounded, the cut is directed fideways, from which circum- 

 ftance the name of the method is derived. 



The lateral operation being that which, under various mo- 

 difications, has now taken the place of every other method 

 of cutting for the (lone, it feenis proper to give fome ac- 

 count of its origin and progreflive improvement, and of the 

 different modes of executing it, with gorgets and a variety 

 oi, lithotomes and knives. 



In September, 1697, a fort of monk, named Frere 

 Jacques de Beaulieu, went to Paris, taking with him nume- 

 rous certitlcates of the many cures which he had accom- 

 pliftied in fundry places, and announcing his defire to teach 

 the furgeons of that city a new method of cutting for the 

 ftone. He paid his refpeds to Marechal, then principal 

 furgeon to La Cliarite, and requefted leave to operate upon 

 fome of t!ie patients in that hofpital. Marechal, however, 

 did not think proper to trull the living to a man, of whofe 

 qualifications he was entirely ignorant, and ail that Frere 

 Jacques could get granted, was permiffion to exhibit his 

 mode of operating upon a dead body. The relult was, 

 that his plan was not confidered advantageous, and, diflTatis- 

 fied with the reception he had experienced, he quitted Paris 

 in Oilober, and repaired to Fcntalnbleau, the feat of the 

 court. Here he cut for the ftone a lad, who, in three 

 weeks after the operation, was feen walking quite well about 

 the ilreets. 



Y i Frere 



