LITHOTOMY. 



inftances, where calculi of vaft fr/e have been fpontaneo'.'.fly 

 voided through the meatus urinarius, cither fuddciily with- 

 out pain, or after more or lefs time and fufFerinT'. Heifter 

 mentions feveral well authenticated examples of this kind. 

 Middleton has alfo related a cafe, where a Itoiie, weighin:^ 

 four ounces, was expelled in a Ht of coughing, after lodg- 

 ing in the paflTage a week. CoUot fpt-aks of another in- 

 ftance, where a ftone, about as large as a goofe's egg, after 

 > lying in the meatus urinarius feven or eight days, and cauling 

 a retention of urine, was voided in a paroxyfm of pain. A 

 remarkable cafe is related by Dr. Moiineux in the early 

 part of the Philofophical TranfaAions : a woman voided a 

 tlone, " the circumference of which meafured, the longed 

 way, 7x^ inches, and round about, where it was thickell, 

 51 inches, its weiglit near 2| ounces troy." 



Sometimes, after the pafTage of large calculi, the patient 

 has been afflicted with an incontinence of urine ; but this 

 grievance, in general, lalls only a Ihort time. 



The naturally large iize, and dilatable nature of the female 

 urethra, have fuggeTled the plan of endeavouring to expand 

 this paffage by various means, fo that a ftone in the bladder 

 may be taken out with a pair of forceps, without ufing any 

 cutting inllrument at all. This method was propofed by 

 Douglas nearly a century ago, who not only recommended 

 fponge for the purpofe, but alfo dried gentian root, as 

 being more gradual in its expanfion, and better adapted to 

 the objeft. 



Mr. Bromfield has given the cafe of a young girl, where 

 he effefted the dilatation by introducing into the meatus uri- 

 narius the appendicula csci of a fmall animal in a collapfed 

 ftate, and then filling it with war.ti water, by means of a 

 fyringe. The piece of gut, thus diifended, was drawn out, 

 in proportion as the cervix veficse opened, and in a few 

 hours the dilatation was fo far accompliflied, that the cal- 

 culus had room to pafs out. See Chirurgical Obf. and 

 Cafes, vol. ii. p. 276. 



Mr. Thomas lately met with a cafe, where, after dilating 

 the meatus urinarius with fponge tent, he fucceeded in ex- 

 ti"afting an ear-picker, which lay acrofs the neck of the 

 bladder. The palTage was fo much enlarged, that the left 

 fore-finger was moll eafily introduced, and, (fays this gentle- 

 man,) " I beiieve, had the cafe required it, both thumb and 

 finger would have pafled into the bladder without the fmalleil 

 difficulty.'' 



After adverting to this cafe, and other fafts proving the 

 eafe with which the female urethra can be dilated, Mr. 

 Thomas remarks ; " If thefe relations can be credited, and 

 there is no reafon why they fhould not, I can hardly con- 

 ceive any cafe, in a young and healthy female fubjeft, and 

 where the bladder is free from difeafe, wliere a very large 

 ftone may not be extracted, without the ufe of any other 

 inftrument than the forceps, the urethra having firll been 

 fufficiently dilated by means of the fponge tents. For this 

 purpofe, the blades of the forceps need not be fo thick and 

 ftrong as thofe commonly employed." See Medico-Chirur- 

 gical Tranfaftions, vol. i. p. 123 — 129. 



Some furgeons have extrafted rtones from the female 

 bladder as follows : the patient being placed in the pofition 

 commonly adopted in the lateral operation, a ftraight ilaff, 

 with a blunt end, is introduced into the bladder through the 

 meatus urinarius. The furgeon then paffes along the groove 

 of the inftrument the beak of a blunt gorget, which, be- 

 coming wider towards the handle, eiTefts a part of the ne- 

 cetTary dilatation. The (lafF being withdrawn, and the 

 handle of the gorget taken hold of with the left hand, the 

 right fore-finger, viith the nail turned downwards, is now 

 introduced (lowly along the concavity of the iuilrument. 



When the urethra and neck of the bl idder have thus been 

 fufficiently dilated, the finder is withdrawn, and a fmall 

 pair of forceps paffcd into the bladder. The gorget is 

 now removed, and the flone taken hold of arid extracted. 

 See Sabatier'.s Med. Opcratoirc, torn. ii. p. 10^. 



Notwithilanding thefe favourable accounts of the prac- 

 tice cf dilating the female urethra, fur the purpoie of 

 removing calculi from the bladder, the genen.lity of fur- 

 geons prefer an incifion. It is certain, that fonie patienls 

 have found the method inlufferably painful ai'.d tedious. 

 But the Urongcft objedion to the praftice has arifen from 

 the incontinence of urine, which occafionally follows any 

 great diftcnfion of the urethra and neck cf the bladder. 

 Mr. Thomas believes, however, that this unpleafani fymp- 

 torn is quite as often a confequence of the opcraticn of 

 lithotomy, as now ufually performed. Medico-Chirurgical 

 Tr-2iif vol. i. p. 127. 



Lithotomy on females is much more eafy of execution, 

 and lefs dangerous, than the fame operatiuB on the male 

 fex. It mav be done in various ways ; but the furgeons of 

 the prefent time conllantly follow the mode of making the 

 requifite opening; by dividing the urethra and neck of the 

 bladder. A ftraight ftaff, or direftor, is introduced through 

 the meatus urinarius ; the groove is turned obliquely down- 

 wards and outwards, in a direftion parallel to the ramus of 

 the left OS pubis ; and a gorget or knife, is thus condufted 

 into the bladder, and makes the neceliary incifion. Some 

 operators prefer the lithotome cache, which, after being in- 

 troduced, is opened as far as is deemed proper, and then 

 drawn out with its edge turned obhquely outwards and 

 downwards. 



The French furgeons Louis and Flurant were the inven- 

 tors of particular biftouries for dividing both fides of the 

 female urethra at once ; the inftrument of the former cf- 

 fefted this purpofe, in pafling from without inwards ; that 

 of the latter in pafllng from within outwards. Flurant's 

 biftoury bears fome refemblance in principle to Frere Come's 

 lithotome cache, or to the cutting forceps w'ith which 

 Franco ufed to divide the neck of the bladder. The reafon 

 afligned for thefe biftouries is, that they will ferve to make 

 a freer opening for the paftage of large ftones, than can be 

 fafely made by cutting only in one direction. At prefent, 

 however, they are never ufed. Were the ftone known to 

 be very large, Sabatier feems to prefer the apparatus 

 altus. 



A cafe may prefent itfelf, where the pofterior part of 

 the b'adder, drawn downwards by the weight of the ftone, 

 might difplace a portion of the vagina, and make it pro- 

 trude at the vulva, in the form of a fvveUing. Here, there 

 would be no doubt of the propriety of cutting into the tu- 

 mour, and taking out the foreign body contained in it. 

 Rouftet performed fuch an operation, and Fabricius Kilda- 

 nus, in a cafe where the ftone had partly made its way into 

 the vagina by ulceration, enlarged the opening, and fuccefs- 

 fully extrafled the extraneous body. 



M. Mcrv once propofed the method of making an open- 

 ing into the pofterior part of the bladder, tlirough the 

 vagina, after introducing a common curved ftaff"; but the 

 apprehenfion of urinary fiftuls made him abandon the 

 projedl. 



The exiftence of extraordinary circumftances may always 

 render a deviation from the common modes of operating r.ot 

 only juftifiablc, but abfolutely necen"ary. Thus, Tolet net 

 with a cafe, where a woman had a prolapfus of the uterus, 

 with which the bladder was alfo difplaced. In the latier 

 vifcus, levcral calculi were perceived. An incilion wad 

 made into it, and the ftones extratttd, afier which opera- 

 2 tloll 



