LITHOTOMY. 



Earle, acknowledge the dangers of this operation in the 

 fulled and mod uiiqualiflLxl terms : ' I have more than once 

 known a gorget, though pafled in the right direftion, 

 piilhed on fo far, and with fuch violence, as to go through 

 the oppofite fide of the bladder." (Earle on the Stone, 

 p _^?.) I have myfelf, (fays Mr. John Bell,) feen it driven, 

 God knows where, deep out of fight, up to the hilt, with- 

 out one drop of urine iffuing, without the operator ever 

 reaching the rtone. Obferve but the force witli which the 

 operator drives in the gorget ; mark the tti-uggle with 

 which he difengages the beak of the gorget from the groove 

 of the ftaff ; hearken to the audible clack with which the 

 beak of the gorgef fiioots off from the groove of the Itaff ; 

 and if this moment of violence do not confpire with the out- 

 cries of the unhappy patient to perfuade you of the dangers 

 of this ope/ation, you can have but little pretenfion to either 

 feeling or knowledge. Such is the rude violence with 

 which the gorget is driven inwards, tliat Bromfield, even 

 when operating with a bluiit gorget, a mere dilutur burft 

 through the bladder and peritoneum ; his gorget went almoll 

 beyond his reach into the abdomen, while the bowels of the 

 boy fell down into his hands. 



" But, (lays Mr. J. Bell,) there is one paramount ob- 

 jection, independent of the many dangers which atrend this 

 pu(h of the gorget ; ' the inftrumcnt, guide it how you 

 will, makes an inciilon inadequate to the ealy cxtiaCtion of 

 the (lone !' I have often compared the incifions I have 

 made with the knife and with the gorget, upon the dead 

 body. I have obferved alfo, in the time of operating, how 

 difficultly the opening of the proftate admits even the for- 

 ceps, how impoffible that fuch an imperfedf incifion flionld 

 eafily allow the e.xtrattion of the ftone. In all cafes of par- 

 ticular difficulty, where, ufing the privilege of an afiiitant, 

 I have introduced my finger, I have felt diftindtly the 

 ftridure of the gland, the greater part of it being left en- 

 tire. The incifion in the gland otten admits the forceps fo 

 difficultly^ that I am well affured the gland itfelf has fome- 

 times, by the mere pulhing of the forceps againll this firm 

 and narrow opening, been entirely fepavated from the urethra ! 

 and after the forceps are pulhed fuccefsfully through this 

 narrow opening, and the ftone caught betwi.xt their blades, 

 all that remains of the gland is inevitably lacerated with 

 much danger and pain. But I would more willingly quote 

 any authority than that ef my own difl'ettions, or experience. 

 Camper, who has ftudied this fubjeci, fays " incredibile ell, 

 quam parva plaga ab omnibus etiam dexterrimis infligatur ; 

 nunquam forcipem robuRam exciperet nifi dilataretur. 

 Kawkenfius folo conduftore, cujus margo dexter in aciem 

 affurgit, idem praeftat ; oimies plagain dilatant, ut calculum ex- 

 trahant ; dUacerdur igitur fempL-r vejics ojlium et projhita." 

 P. 14. 



" But, (continues Mr. J. Bell,) higher and better autho- 

 rity remains behind. Deafe was, if I judged rightly of his 

 talents, a ilern and rude furgeon, but perfect in all the 

 theory and praftice of his art ; he was not very explicit in 

 his communications with me, but from the manner and the 

 movement of his hand, in demonftrating to me, rather than 

 from what he faid, I conclude that he cut after the manner 

 of Raw, making the nicifion with the right hand, while he 

 held the llafF with his left. " In all the trials, (fays Deafe,) 

 that I have made with the gorget on the dead fubjedl, I 

 have never found the opening into the bladder fufficiently 

 large for the extratlion of a Itone of a middling iize, with- 

 out a confiderable laceration of the parts. I have frequently 

 taken the largell fized gorget, and could not find, that in 

 the idult fubjeft, I ever entu-ely divided the prollate gland, 

 if It was any way large j and in the operations that were 



Vol. XXr. 



performed here on tlie living fubjeft, the extraftion \va« 

 painfully tedious, and effected with great difficulty, and in 

 fome cafes not at all." See John Bells Principles of Sur- 

 gery, vol ii. p. 173—176. 



We coincide entirely with Mr. J. BcU refpccling the dan- 

 gers and difadvantages of the cutting gorj^et, and could ad- 

 duce feveral cafes where operators have committed, with this 

 inltrument, the moll fatal blunders. It is alfo our con- 

 vitlion that many deaths, after the operation, are owing to 

 the confequenccs of the opcnuig being, in general, too 

 fmall, fo that the forceps are fometimes introduced and with- 

 drawn twenty times before the ftone can be cxtrafted, and 

 when this is aceompliflied, it is with immeufe violence and la- 

 ceration. The moil perfect lithotomy appears to us only to 

 ad.r.it of being done with a fcalpel and a llaff ; and the more 

 we reflett on the fubjeft, the more we are convinced of the 

 excellency of Chefelden's praftice. 



0/ fome particular methods and bijlruments. — The fi.bjecl of 

 lithotomy is almoft an endlefs one, and many ftieets of this 

 work would be taken up by a full explanation of all the 

 various methods. Such readers as wifh for lo minute and 

 lo::g an account, are particularly referred to Sabatier's Me- 

 decine Operatoire, torn. ii. and to Mr. John Bell's Principles 

 of Surgery, vol. ii. May it be fufficient m this publication 

 to make mention of fome of the moll intereiling of thefe nu- 

 merous propoials. 111 doing which, we fhall avail ourfelves of 

 fome remarks contained m an inllrudlive paper inferted in the 

 Edinb. Med. and Surg. Journal, vol. iv. by Mr. Allan 

 Burns, lefturer on anatomy and furgery, Glafgow. 



Frere Come's method •with the lithotonie cache. — John de 

 Saint Come, of the order of Feuillans at Paris, was the 

 inventor of a knife, concealed in a iheath, out of which 

 the blade fprings, on touching a kind of lever at the fide of 

 the handle of the inllrument. The diftance to which the 

 blade Harts out, may be regulated by the furgeon before the 

 operation, according to the extent of the wound that he 

 may be defirous of making. The patient being placed as in 

 the lateral operation with the gorget, and a ilaff introduced, 

 the furgeon, with a fcalpel, is to begin the firft incifion on 

 the left fide of the rapht; of the perineum, about ten lines in 

 front of the anus. This cut is to be continued obliquely 

 downwards and outwards, as far as the centre of a line ex- 

 tending from the anus to the infide of the tuberofity of the 

 ifchium. The external incifion is to divide the integuments 

 of the left fide of the perineum, the accelerator urin^e, the 

 erector penis, the tranfverfus, and the front fibres of the le- 

 vator ani. Thefe parts having been cut, the index finger of 

 the left hand is to be introduced into the left angle of the 

 wound, with its radial fide downwards. The right edge of 

 the groove of the ftaff is to be placed between the nail and Ikin 

 at the end of the finger. Tiie point of the fcalpel is to be 

 condudted into the groove of the ilaff along the nail, which 

 faces the left. The index finger is now to be turned, in order 

 that its extremity may prel's upon the point of the knife, 

 which all along is to be held with the right hand, like a 

 writing pen. The urethra is thus to be flit open to the ex- 

 tent of five or fix lines. The nail of the left index finger is 

 next to be placed in the groove of the ftalf, and is to ferve as 

 a means of guiding the end of the lithotome iiito that groove. 

 As foon as the latter objed has been accomplilhcd, the linger 

 is to bo withdrawn ; the furgeon, with his lett hand, is to 

 take hold of the handle of theftaff ; and by one fimultaneous 

 movement, he is to raife the two ends of the inllruraents to- 

 gether towards the fymphvfis of the pubes, by which means 

 the litho»ome will be eafily conduded into the bladder. The 

 entrance of the lithotome into the cavity of this vifcus will 

 be Indicated bvcclTation of n-fi (lance, and the freer iffae of 



Z the 



