LITHOTOMY. 



t!ie urine. The end of this inftrumcnt, being in conta6\ with 

 the ciil-de-fac extremity of the groove of the Itaff, mull be 

 difcugaged by a flight lateral movement. The llaff is now 

 to be withdrawn. The operator, with his left thumb and 

 index finger, is then to talce hold of the lithotome, about 

 the place wliereiits flie ath and handle meet. He is to conduft 

 the iiidrumcnt under the fymplufis pubis, turning the edge 

 downwards and towards the left lide ot the perineum, in the 

 direction of the external incifion. On prelfing -j lever, the 

 blade of the lithotome quits the flieath, when the inllrument 

 is to be drawn out horizontally. Thus the prodate and neck 

 of the bladder are divided. The forceps are then introduced, 

 and the ooeraticn finidied in the orduiary way. 



Tlie lithotome cache of Frere Come is yet employed at 

 the Wedminfter hofpital, and has been lately tried by Mr. 

 A. Cooper. It is Hill more commonly ufed in Frar.ce. 

 The 'objections, however, which ha%'e thrown difcredit upon 

 it, are, that from its mechanifm, and the ilrudure of tiie 

 parts about the pelvis, it is likely to wound the pudendal 

 artery ; that the bladder, if coUapfed, may be injured in 

 more than one place ; and .that if the knife be directed down- 

 wards too obliquely, the reftuin is apt to be cut. 



Apparatus alius as modified by Frire Come and Def- 

 thamps. — Abfolute neceffity led to the introduction of the 

 high operation by Franco in 1561 ; and the fame caule oc- 

 cafioned its revival, in 1658, by Frere Come. The opera- 

 tion, as performed by Franco, was defective : a high inci- 

 fion was alone made into the bladder; this vifcus was opened 

 above the pubes, below the point where the peritoneum is 

 refle£ted over the abdominal mufcles : the Itone was eafily 

 extracted ; but as there was no dependent opening from the 

 bladder, the urine was apt to infinnate it'.elf into the cellular 

 membrane about the pubes, to irritate and iBilame the parts, 

 and to produce either gangrene or fuppuration, and the 

 formation of finufes. Thefe difadvantages led to th^ difufe 

 of the apparatus altus, till revived and new-modelled by 

 Frere Come, who propofed to open the bladder in perineo, 

 and then, through an opening made juil above the pubes, 

 he introduced a fcalpel with a button point, with which he 

 flit up, for an inch or two, the linea alba ; the knob on the 

 end of the knife pufhing afide the peritoneum. After this, 

 he introduced, by the aperture in perineo, a flaff, with 

 which he made the bladder project through the opening be- 

 tween the recti mulcles. This done, he cut into the front 

 of the bladder, and either with his finger and thumb, or 

 with a pair of forceps, he took out the Itone. In this way 

 he extracted from the bladder a calculus, that weighed 

 twenty-four ounces. On this method Mr. Allan Burns re- 

 mark-, that it might with propriety be adopted, were it not 

 for the danger attendant on tne double incifion into the 

 bladder, and the protraction of the operation by the difiec- 

 tion about the penneum. Indeed, as modified by Def- 

 champs, who, in place of the mmdture in perineo, per- 

 forates the bladder from the reftum, it has met with the ap- 

 probation of Mr. Thomfon of Edinburgh, who confiders 

 this, on particular occafions, to be the moll advifable me- 

 thod of operating. Mr. A. Burns thinks, however, that 

 if the bladder be thickened and indurated, it will be impoi- 

 lible to raile it with the cannula above the pubes. Hence, 

 this plan is only adniiffible, wlieri we have reafon to fuppofe 

 that the Hone is too large to be removed by the pcri:;eum, 

 and that the bladder is healthy. Flere the punCture from 

 the rectum ishmple, attended with no increafc of the danger, 

 allows the bladder to be elevated with the cannula, and fe- 

 cures a dependent outlet for the urine. Thus we avoid the 

 r.eceflity of any difeharge by the wound above the pubes ; 

 lye run no riji: of the urine mfmuatiiig itfelf into- the cellular 



3 



membrane, no inflammation is excited, no finu-fes are formed} 

 conKiiuentiy, the perlon ought fpeedily to recover. lidin. 

 Med. and Surg. .lo.rn. vol. iv. 



Invenllon of Jlajfs, from '■juhicli the gorget eannot fTip The 



danger »f the gorget (lipping out of the groove of the flaJ 

 has been already iufficienlly commented on. L.e Cat, in 

 1747, and fir C. Blicke, more lately, endeavoured to ob- 

 viate Inch rilk, by propoling to ufe ilafi's with contra6ted 

 grooves. Tlie beak of the gorget is locked and fixed in the 

 groove of the llaff, till it has arrived near the end of this 

 latter inilrument, where the groove luis a wider coiillruction 

 Notwithllanding the plaulibility of this contrivance, there 

 are reafons which have deterred practitioners from employing 

 it. Few furgeons have been inchned to truft to the fort of 

 gorget that muit be ufed ; the point of contact of the beak 

 and body of the inilrument being neceffarily fo fmall, that 

 on the flightell deviation from the direct line, in pufhing 

 fuch a gorget into the bladder, the beak brertks off, the 

 gorget feparates from the flair, and the feminal vefl'els and 

 rectum are expofed to injury. Befides, another objeCtioa 

 n, that the gorget is frequently flopped in the groove 

 of this kind of fluff, at the moll critical period of the 

 operation. 



Methods of Le Dmn, Deafe, and Mu}r. — Le Dran, iir 

 1741, publiihed his Operations of Surgery. In this work, 

 the author defcribes an operation, the introduction of which 

 has been claimed by leveral lince his time. The principle of 

 the plan alluded to was to reduce the male into the date of 

 the female urethra. 



The late Mr. Deafe of Dublin, and Mr. Muir cf Glaf- 

 gow, reflecting that the great caufe of the gorget flipping 

 from the daft depends upon the former being pulhed along 

 a curved furface ; and obferving, that fuch an accident fel- 

 dom or never happens ou females ; have propofed, like Le 

 Dran, to make the male urethra relemblc the female. To 

 accomphfh this, they introduce, as ufual, a curved grooved 

 flaff into the urethra, and make the common incifion in 

 perineo : they then open the membranous part of tha 

 urethra ; but, inltead of nov/ introducing the gorget, they: 

 conduit along the groove a female flaff, and immediately 

 withdraw the curved one. With the left hand they take 

 hold of the handle of the ftraight italT, and withthe right 

 introduce the gorget. 



Double Jlciffs. — It is faid that feme operators have ex- 

 perienced confiderable diiT-culty iu finding the groove of the 

 flaft in the perineum. To facilitate this bufinefs is the prin- 

 cipal defign of the double daft", an inilrument which is novi^ 

 quite laid afide. In fact, the trouble of cutting into the 

 flaff is not great enough, to render any invention of this 

 fort at all important. 



The fird inilrument for this purpofe we find defcribed by 

 Defchamps, as the invention of Jarda, a furgeon at Mont- 

 pelher. According to Mr. A. Burns, it refembles Earle's 

 double daft"; but is more complex. It confifts of a curved 

 flaff, intended to be introduced along the urethra into the 

 bladder, and having connected to its handle, by means of a 

 hinge, another ftafl, fhorter than the former, and fharp at 

 its end. When Jarda had applied the fliort ftatf to tlie pe- 

 rineum, he puflied its point through the fl;in, behind the 

 bulb of the urethra, into the groove of the long llaff already 

 paffed through this canal. This fupplementary flaff, in 

 both Jarda and Earle's indrtvment, is intended to conduft 

 the knife into the groove of the ftafi. But Jarda aimed at 

 more : he wiflied to fecure the rectum from injury, by in- 

 troducing into the anus a limb of the inilrument, which he 

 expected would pulh the gut afide. By machinery, he alfo 



coiitriveit 



