LITHOTOMY. 



It ^ns for a lon^ while prefumcd, that Raw made an 

 opcninjr into the bladder, without touching the neck of 

 this vifcus, or cuttinir the proftate gland. This, at Icaft, 

 was the feiitiment of Albiiius the father ; hut, in latter 

 times, the general conclufion has been, that Raw mud have 

 divided theie parts. 



After Raw's death in 1719, experiments were made, in 

 order to afcertain his mode of performing lithotomy. Anaong 

 others engaged in this objcft was Chefclden, who, when 

 the bladder was diftended with an injedion, fitccceded in 

 making an onenirfg into this vifcus, without injuring its 

 neck, ilaring tried this plan, however, on Ibme of his pa- 

 tients, he foon found, that it «'a'i very liable to be followed 

 by a fatal extravafation of urine in the pelvis, and, confe- 

 quently, he renounced it for ever. His experiments were 

 ftili carried on, and at length he was convi:iced, that in 

 operating with the indruments, and in the manner of Raw, 

 as dcfcribed by A'biius, it was impoffiblc to make an 

 opening into the bladder, without cutting the membranous 

 part of the urethra, and the proftate gland. Chefelden 

 ■ow flopped his inveftigations, and direfted all his abilities 

 to the eafy accomplifhment of fuch an operation. The 

 knife, commonlv empiayed on o'.her occafions, feemed to 

 Chefelden much more convenient than the pointed lithotome 

 ufed by the Dutch furgeons. luilead of the male and fe- 

 male conduttor in ufe with Raw, Chefelden preferred a 

 blunt gorget for guiding the forceps into the blidder ; 

 but iie altered the handle, which, inltead of reprefenting a 

 {brt of croC-:, was now oval, and made to incline to the 

 lef^. 



Having abandoned the method imputed to Raw by Al- 

 binu'', Cl'.efelden tried a fecond plan, which was as follows : 

 the patient being placed in the pofture ufually chofen for 

 lithotomy by modern cperalors, a grooved ftaff was intro- 

 duced into the bladder. The handle of this inftrument was 

 inclined towards the right groin, and firmly held by an af- 

 fiilant with one hand, while, with the other, the fcrotum 

 was f.:pported. The fl-cin of the perineum having been 

 made tenfe with the opera'or's left thumb, a free oblique 

 jncifion was made with a convex edged fcalpel, much in the 

 fame way as is commonly done at the prefent d.iy. The 

 fat was next deeply cut through. Th- left index finger was 

 then introduced into the upper angle of the wound, and the 

 groove of the fluff being felt throUi;h the parietes of the 

 ure'hra, a cut was made into this canal The afliTant that 

 h.».d the care of the Itaff, was now directed to draw its con- 

 cavity upward as- clofely as polTible under the arch of the 

 pubes, away from the refturr^ All that remained 10 be 

 done, was to divide the membranous part of the urethra and 

 the neck of the bladder. This was executed by pulliing 

 the point of the knife along the groove of the flaff, under 

 the guidance of the left index finger, which, in this flep 

 of the operation, was kept on the back of the fcalpel. 

 Having reached the prollate gland, the incifion was com- 

 pleted by the knife being moved downwards and outwards, 

 with its edge turned towards the tuberolity of theifchium. 



The left index linger, remaining in the wound, ferved to 

 guide the beak of the blunt gorget into the groove of the 

 ftaff. The operator now took* hold of the h.indle of this 

 lall inftrument, and, after bringing it downwards and 

 forwards, condufted the gorget into the bladder. The 

 ftaff was withdrawn, the forceps introduced along tiie con- 

 ■cavity of the gorget, and the flone extratled. Such was 

 Chefelden's fecond method. It was this operation which 

 Morand gave an account of to the French furgeons, after 

 teing it performed during his vifit to England at the ex- 

 pence of the Royal Academy of Sciences j and it is par- 



ticularly worthy of notice, tiiat foreign furgical writers 

 feem unaware, that Chefelden afterwards gave the preference 

 to a third plan of operating, which has been defcribed by 

 Douglas in his fecond Hiflory of the Lateral Operation,, 

 pubhfhcd 1 73 1. 



We are not very well acquainted with the reafons which 

 led Chefelden to abandon his fecond method. He had, 

 however, candidly confelTed to Morand, that in pufhing the 

 knife backwards along the groove of the flaff, he had in 

 two inflances wounded the reftum. Befides, it is con-- 

 jeftured, that the incifion of the proftate gland was often 

 too fmall for the free tranfmilTion of the flone. 



Chefelden's third, and what he confidered as liis befl me- 

 thod of cutting for the flone, did not differ in point cf 

 principle from his fecond plan. The fame parts were cut, 

 namely, the membranous part of the urethra, and the pr<;f- 

 tate gland. The change confided in a different mode of 

 executing the incifion, " which was now performed by 

 moving the knife from behind forwards," inflead of froms 

 before backwards, as in the fecond method. 



The following is the defcripticn of Chefelden's laft and 

 moll improved plan, as given to us by Douglas. " In per- 

 forming the lateral operation, he makes the firfl, or outward 

 incifion, from above downwards ; beginning on the left fide 

 of the raphe, or feam, betwixt the fcrotum and the verge of' 

 the anus, ahnoft as high as where the fl<in of the perineum 

 begins to dilate and form the bag that contains the teflicles, 

 and from thence he continues the wound obliquely out- 

 wards, as low down as the middle of the margin of the- 

 anus, at about half an inch diflant from it near the (kin, 

 and, confequently, beyond the great protuberasce of the 

 03 ifchium. 



"The firfl or upper part of this incifion is cut fuperHcial; 

 after that, • he plunges his knife much deeper by the fide 

 of the reftum, and fmilhos it by drawing his knife obliquely 

 towards himfelf.' Thefe three motions may always be ob- 

 ferved iu his external incifion ; but the.- la(l is performed 

 pretty much at random ; his knife firll enters the groove of 

 the ' rollrated or ftraight part of the catheter, through the 

 fide of the bladder, immediately above the proilate ;' and 

 afterwards, the point of it continuing to run in the fame 

 groove, in a direction downwards and forwards, or towards 

 himfelf, he divides that part of the fphiniter of the bladder 

 that lies upon the gland ; and then he cuts the outfide of 

 one-half of it obliquely, according to the direction of the 

 whole length of the urethra that runs within it, and finithes 

 his internal incifion by dividing the muftular portion c£ the 

 urethra on the convex part of the llafi." 



The fecond and third of Chefelden's methods,. then, refem- 

 bied each other in the parts cut ; but the firfl ar,d third 

 "were effentially different, notwithltanding the knife was in 

 each of them plunged at once into the body of the bladder 

 behind the prollate gland. Chefelden, in his firfl operation, 

 only imitated Frere Jacques and Raw, and paffed his kuite 

 into the bladder betwixt the veficulse femiiiales and tuber 

 ifchii. He flopped at the back part of the proftate gland. . 

 All his incifion lay behind this gland. " He cut the body 

 of the bladder only." But, in his lall operation, he cut no 

 part of the body of the bladder ; " he introduced his knife 

 c'ofe behind the prollate gland, and in drawing it towards 

 him, he of courfe cut only the neck of the bladder where 

 it is furrounded by that gland." Ji^iin Bell's Prinaples, 

 vol. li. p. 153. 



In operating after the manner afcribed to Raw, Chefelden 

 loft four patients out of ten ; bar in purfuing his own im- 

 proved method, his lucccls wa^ mod brilliant, for, of rifty- 

 two patients whom he fucceffyvely cut for the ftone, all were 



faved-j 



