LITHOTOMY. 



favcd exceptiiiff two ; and it is well known, that out of two 

 hundred and thirteen perlons, of all ages, conftitutions, &c. 

 on whom lie operated, only twenty died. What lithotomill 

 of the prefent day can boaft of cqnal fuccefs ? We have 

 feen lithotomy performed rather frequently with cntting 

 gorgets of different dcfcriptions, in the manner that has 

 been of late years moll prevalent. Out of every feven or 

 eight operations, at lealt one has had a fatal termination. 

 We make this ftatement with fome degree of confidence, as 

 .we know it might be confirmed by the mod refpcftab'e and 

 impartial evidence. To what then are we to refer the few 

 failures which Chcftlden experienced, and the vaft number 

 .of deaths confeqiient to the prefent common plan of cutting 

 for the Hone. The reply, in our opinion, is obvious. Che- 

 feldcn made an ample and direft incifion into the bladder 

 with a fli.jrp knife, the inllrument, of all others, the betl cal- 

 culated for effecting a clean fmooth divifion of the parts, 

 without a:iy.kceratiin, contufion, or other additional injury. 

 The moderns often niiike their external incifion too fmall, 

 and too high up, while the internal cut, which is executed 

 •with a g«'rget, is almolt always too diminutive for the eafy 

 padage of any calculi above a very moderate fize. The 

 difficulty of extraction mull evidently be increafed by tiie 

 external wound being confiderably higher up, than the in- 

 ternal divifion of the proilate ghnd and neck of the bladder, 

 iince the paffage through wliicii the Hone muff be drawn 

 out, betides being too Imall, does not lead dlredlly into the 

 .cavity, of the bladder. Chefelden, in ufing the knife, had 

 cccation to exert no force nor roughnefs. The moderns, 

 whofe ijorgets are fotnetimcs very badly conilrucled, are 

 often under the neceffity of pulhmg fuch inffruments moft 

 forcibly, ere the epening into the bladder can be made. 

 The violence and injury which the parts" mull thus fuffer, in 

 addition to their fimple divifion, require from us no comment. 

 Chefelden, having the advantage of a free and direft opening 

 into the bladder, never bruifed and injured the interior of 

 this vifcus by tedious fearches after the ftone with the for- 

 ceps ; nor when he had gralped the foreign body, did he 

 ever bruife and lacerate the parts in drawing it out. His 

 conftant plan, on firft introducing the forceps, was ;o fcarch 

 «wi//y for the Hone luilh their blades Jimt. When he had got 

 Hold of the ffone, he ufed to extratlit " with a very »Tow 

 motion, in order to let the parts yield as much as poflible." 

 On the contrary, the moderns, generally having too fmall an 

 .opening, are often obliged to introduce and withdraw the 

 .forceps twenty or thirty times before they can accomplilh 

 the extraction of ilie ilone. Defirous of Ihortcning the 

 bufincfs, they are guilty of manu d roughnefs and violence; 

 xind not only the bladder, but the parts through which the 

 ilone has to pals, are dreadfully bruifed and injured. Some 

 operations which v/e have vvitncffed have been fo lone, and 

 executed with fuch awkwardnefs and want of gentlenefs, 

 that we cannot help fufpefting, that the bladder mud 

 ■actually have been in a Hate of intlammation betore the 

 ■poor patients were removed from the operating table. 



Chefelden undoubtedly was one of the moff expert and 

 fuccefsfal lithotomiits that ever lived in any counry, and 

 his mode of operating, which is fully explained to us, ought, 

 in our opinion, never to have been abandoned for the em- 

 .ployment of cutting gorgets. 



Of the hejl -way nf e.xecuiing the lateral operation with cut- 

 ting gorgets. — We fuppofe it muff iiave been ignorance of 

 anatomy, joined with timidity and want of judgment, that 

 could induce furgeons to give up fo excellent a plan of 

 .operating as that which was invented and pnictifed by Che- 

 felden ; for, admitting that it is fomewhat ealier to make 

 .the lateral incifion with a cutting gorget, there is yet a 



more intereffing and weighty matter for confideration, 

 namely, whether the recoveries after the latter operation are, 

 upon the whole, as numerous as thofe which followed Che- 

 feldeii's method. Thij emnient furgeon, as we have already 

 ■noticed, cut for the ffone fiftytwo patients in fnccefiion, 

 of whom only two died. No furgeon of the prefent day, 

 in the habit of i>fing a cutting gorget, can boall of fuccefs 

 at all equal to this. Our obfervation tends to'thc conclu- 

 fion, that about one out of every feven or eight patients 

 cut for the ftone, with fome kind of fharp gorget,' falls a 

 victim to the operation. According to our lentiments, a 

 furgeon fiionld not regulate his conduft fo much by the 

 facility, as the fuccefs of any plan; and a little more trouble 

 and difficulty ought to be no objections, where they ferve 

 to give the patient a greater chance of prefervation. We 

 know that a man cannot imitate Chefelden, without having 

 a requifite knowledge of the anatomy of the parts in the 

 perineum, and about the neck of the bladder. We can 

 conceive at the fame time, that a perfon might learn to 

 operate mechanically with a gorget, and yet be totally un- 

 acquainttd with the ffruclure and fituation of the parts in- 

 terelted in the operation. It is this removal of all occafion 

 for lludy and application, that has had more effec't, than any 

 thing elfe, in keeping up the prefent fyilem cf doing the 

 office of the knife, with that very obje6iionable inllrument a 

 cutting gorget. 



The patient is to be placed at the edge of a firm table, 

 and the ffaff is to be introduced into the bladder. 



Then two garters, each about two yards long, are to be 

 doubled, and put, by means of a noofe, round the patient's 

 wrills. The patient is now to be defircd to take hold of 

 the outfide of his feet with his hands, in fuch a manner, 

 that the fingers are applied to the foles, and the palms to 

 the inlleps. The two ends of the ligature are then to be 

 carried round the ankle, next over the back of the hand, 

 and under the foot. Laftly, they are to be tied. In this 

 manner, each hand and foot may be fecurely conneftcd toge- 

 ther, and the patient is fixed in the pofition the bell fuited 

 for the operation. 



The ftaff, the firll inftrument with which the furgeon has 

 any concern, is in faCt'nothingmore than a direftor, adapted 

 in ffiape to the courfe of the urethra, and furniffied with a 

 groove for guiding a cutting inllrument into the bladder. 

 (See Surgical Plites ) It is Ihaped very much like a found, 

 or catheter. However, it is generally fomewhat longer and 

 more curved, and while the handle of a found is as imooth 

 and highly poH.lied as poffible, that of a ilaff ought to have 

 a rough iurface, in order that it may be held with greater 

 tteadinefs and firmnefs. Two advantages arife from having 

 the ftaff fufficiently curved ; viz. its convexity is more 

 plainly dlltinguiihable in the perineum ; and on depreffing 

 the handle of the inftrument, that jiart cf the groove which 

 is at the neck and within the cavity of the bladder, may be 

 more readily made to affunie a direction correlponding to 

 the axis of this viicus. The utility of the length of the 

 inftrument is very obvious, as the operator is thereby lels 

 li;ible to fuppofe the extremity of the ilaff to be within the 

 bladder, when it is not fo ; and it is plain, that the groove 

 fliould always extend beyond the bc-ik of the gorget, even 

 when the latter inftrument has been pulhed as far as the 

 operator judges requilite. 



An affiftant is to hold the ftaff, making its convexity pro- 

 minent in the perineum, by preffing the whole inllrument 

 downwards, and inclining its handle towards the patient's 

 abdomen. The perfon who has charge of the Ih-.ft', ihouid 

 alfo turn the groove a little towards the left fide of the peri- 



I neum, 



