PRACTICAL 
LITHOTOMY AND LITHOTRITY BY THE SAME AUTHOR 
THE DISEASES OF THE PROSTATE; their Pathology and Treat- 
ment. With Plates. Fourth Edition. 8vo. 10s. 
STRICTURE OF THE URETHRA AND URINARY FISTULAS; their 
Pathology and Treatment. With Plates. Third Edition. 8yo. cloth, 10s. 
CLINICAL LECTURES ON DISEASES OF THE URINARY ORGANS, 
Delivered at University College Hospital. Filth Edition. 8vo. 10s. 
THE PREVENTIVE TREATMENT OF CALCULUS DISEASE, AND 
THE USE OF SOLVENT REMEDIES. Second Edition. Fcp. 8vo. 2s. 6d. PRACTICAL 
LITHOTOMY anb LITHOTRITY 
OR 
AN INQUIRY INTO THE BEST MODES 
OF 
REMOVING STONE FROM THE BLADDER. 
BY 
SIR HENRY THOMPSON, F.R.C.S. 
SURGEON EXTRAORDINARY TO HIS MAJESTY THE KING OF THE BELGIANS 
EMERITUS PROFESSOR OF CLINICAL SURGERY AND CONSULTING SURGEON 
TO UNIVERSITY COLLEGE HOSPITAL, ETC. ETC. 
THIRD EDITION, CONSIDERABLY ENLARGED 
PRESLEY BLAKISTON 
1012 WALNUT STREET 
PHILADELPHIA 
1880 TO 
STUDENTS IN MEDICINE 
ESPECIALLY TO THOSE, BOTH PAST AND PRESENT, OF 
Hmtersitg College f ospital 
WITH WHOM, AS COMPANIONS AND FELLOW-WORKERS, I HAVE SPENT 
SOME OF THE MOST PLEASANT HOURS OF MY LIFE 
THIS WORK IS INSCRIBED 
BY 
THE AUTHOR PREFACE 
TO 
THE THIRD EDITION. 
I have found it necessary to re-write some important 
portions of the present work. Since the appearance of 
the last edition, nearly ten years ago, my greatly in- 
creased experience enables me to speak on various 
points with more certitude than I could formerly have 
done. Thanks to the confidence with which so many 
of my professional brethren, both in town and country, 
have favoured me, it has fallen to my lot to watch over 
and to operate on several hundreds of calculous cases. 
The results of these I have analysed and reported here 
with scrupulous accuracy and care. Thus, a table will 
be found in the Appendix, containing the leading parti- 
culars of five hundred cases of Operation for Stone in 
the Bladder of the male adult; a brief resume of which 
I presented to the Eoyal Medical and Chirurgical 
Society of London about two years ago. 
I think I may be allowed to add that the facts there 
presented, collated after an expenditure of much time 
and patient labour, form the largest contribution which 
it has hitherto been permitted to any single operator to 
offer to the profession on this subject. I might have PREFACE TO THE THIRD EDITION. 
appended more than a hundred cases which have since 
come under my care ; but many of these being recent, it 
has been deemed wiser to reserve them for a separate 
and future communication. 
Next, I have devoted a new chapter to the subject 
of ‘ Lithotrity at a Single Sitting,’ furnishing the results 
of my practice of this proceeding, amounting now to 
nearly forty cases, all briefly cited. 
Lastly, it has been my aim to offer some further 
practical hints in relation to the performance both of 
Lithotomy and Lithotrity. If in this way I am able to 
furnish any aid, however small, to those who are still at 
the outset of a career, I shall be amply repaid for the 
pains bestowed on my subject. 
35, Wimpole Street : 
June 1880. PEEFACE 
TO 
THE FIRST EDITION. 
The larger portion of the matter contained in the follow- 
ing pages was prepared for the Lettsomian Surgical 
Lectures of the Medical Society of London for the past 
year. The limits prescribed, however, permitted me to 
select for delivery only a portion of the matter prepared. 
I have, therefore, determined on publishing the whole 
in its original form, believing that in this way only could 
I hope to do anything like justice to the subject itself, 
or to the views which are put forth in relation to it. 
I may premise that it is no part of my design to 
present a history of the means employed during the last 
2000 years to remove stone from the human bladder. 
Neither is any portion devoted to discussions respecting 
the chemical and physical constitution of calculi, the 
causes of calcidous formation, or the symptoms which 
the presence of stone in the bladder gives rise to : these 
subjects having, with the exception of causation, been 
fully and successfully examined. 
The sole object of this work is to present a considera- 
tion of the best operative procedures now in use for the 
removal of stone from the bladder of the male patient. X 
PREFACE TO THE FIRST EDITION. 
These will be described, with a view not only of enforc- 
ing those broad principles which are pretty generally, 
though, perhaps, not always sufficiently, recognised, as 
necessary to guide the surgical student, but of furnish- 
ing many useful practical details, which a considerable 
experience and careful observation of varied schools 
alone can supply. 
An exposition of these, it is believed, may prove not 
without value in relation to Lithotomy, and to some 
debated questions in connection with it; while some 
important considerations, bearing on the operation of 
Lithotrity, will, it is believed, be discussed here for the 
first time. Lastly, the various modes of operating will 
be compared, and their merits discussed, with a view to 
determine the relative scope and applicability of each to 
the numerous and varied exigencies which are presented 
by calculous patients. The principles so deduced will 
be exemplified in practice by the recital of cases from 
my own experience selected for illustration. 
And here I must be permitted to acknowledge the 
very many obligations which I have incurred, and the 
unusually valuable sources of information which have 
been kindly placed at my disposal during the prosecu- 
tion of my task. 
I am indebted to many of the best known hospital 
surgeons of this country for very complete and valuable 
information relating to nearly 1,500 cases, the value of 
which I can scarcely over-estimate, affording me a total 
of authentic reports from all sources respecting more 
than 2,300 cases, of which 1,800 are available for statis- 
tical purposes. (See pp. 225-6 et seq.) 
I have been entrusted by the son of the late Mr. 
Crichton, of Dundee, one of the most experienced and 
successful lithotomists in Great Britain, with the entire 
and unpublished notes of his practice. He cut, by the PREFACE TO THE FIRST EDITION. 
XI 
lateral method, during a career of about sixty years, 
upwards of 200 cases, and of most of them made valu- 
able observations on the spot, and sometimes at con- 
siderable length and in great detail. These will be fre- 
quently referred to. 
From Dr. Keith, of Aberdeen, whom I regard as pos- 
sessing as large an experience as any man living in this 
country, since he has operated on more than 300 cases, 
I have received most important aid. For his extreme 
kindness in freely placing at my disposal the history of 
each one of these cases, and all the leading particulars 
respecting it, noted while the patient was under his care, 
my most grateful acknowledgments are due. 
In Lithotrity, the unrivalled experience of Civiale, 
its renowned inventor and perfecter, has been unre- 
servedly communicated to me on all occasions ; and he 
has been especially desirous to afford me all the aid in 
his power in connection with my present task. I gladly 
seize the present opportunity of acknowledging to him 
my great and numerous obligations. 
It has been my aim to embody in these pages as 
much as possible of the fruits of these experiences, 
added to that which I have myself personally enjoyed. 
The aim and scope of every portion of the work, as 
regards both its plan and execution, although I am very 
conscious of numerous shortcomings, will be to carry 
forward, from the outset of the first chapter to the final 
propositions of the last, a series of logical deductions 
from sound experience in relation to practice, and thus 
to verify the title which I have selected, viz. Practical 
Lithotomy and Lithotrity. 
35, WmroLE Street : 
April 1803. CONTENTS. 
CHAPTER I. 
LITHOTOMY : GENERAL CONSIDERATIONS RESPECTING IT. 
PAGE 
Lithotomy: various Modes of performing now employed.—Necessity for 
Variety.—Perineal Lithotomy may be Lateral or Central—Description 
of Perineum.—Outletof the Male Pelvis.—Its Boundaries and Measure- 
ments.—Dissection of Perineum from Skin to Neck of the Bladder.— 
The Parts cut in Lithotomy.—The Parts to be avoided . . • . 1 
CHAPTER II. 
The Instruments necessary.—Preliminary Proceedings ; Assistants, Ac.— 
The First Stage : Management of the Staff ; finding the Stone.—Second 
Stage: the Incisions, superficial and deep; Probe-pointed Knives ; 
Gorgets : Lithotomes.—Third Stage: Removal of the Calculus.— 
Fourth Stage : the Tube ; t he Air Tampon ; Treatment of Hemorrhage, 
&c.—The after Treatment,—Aston Key’s Operation . . . .14 
THE LATERAL OPERATION OF LITHOTOMY. 
CHAPTER III. 
THE OPERATIONS OF LITHOTOMY PERFORMED IN THE CENTRAL 
PORTION OF THE PERINEUM. 
Numerous Attempts made to improve on Lateral Lithotomy.—The 
Bilateral Operation of Dupuytren.—The Medio-bilateral.—The Median. 
—Dr. Buchanan’s Method.—The Recto-vesical Operation.—Modifica- 
tions.—Cutting and Crushing combined.—Lithotomy as applied to 
Children 48 
CHAPTER IV. 
THE SUPRAPUBIC OR HIGH OPERATION. 
Origin of the Operation.—Method of Performing in Detail , . . 58 XIV 
CONTENTS. 
CHAPTER V. 
CAUSES OF DEATH FOLLOWING LITHOTOMY. 
Causes of Death at different Ages must be considered separately.— 
Causes of Death in Adults.—A. Deaths from Error or Mischance in 
the Operation.—Deep Incision may produce ILemorrhage or divide 
tissues too deeply: ‘ Infiltration of Urine,’ not so produced.— 
Mechanical Violence in removing Stone.—Cheselden’s Directions: 
Martineau, Pouteau, Keith, Humphry.—Perforation of Bladder by 
Staff.—B. Causes of Death not under control of Operator.—Organic 
Disease of Urinary Organs.—Exhaustion of Vital Power.— 
Peritonitis.—Septicaemia.—Tetanus.—Causes of Death in Children: 
why differing from the preceding.—Peritonitis : very rarely, Infiltra- 
tion.—Exhaustion, Ac . . .62 
PACK 
CHAPTER VI. 
DIFFICULTIES AND DANGERS MET WITH IN LITHOTOMY. 
1. Difficulties and Dangers peculiar to the Age of the Patient—those of 
Infancy.—In Age, Rigidity of Tissues; Enlargement of Prostate, &c. 
2. Difficulties from Personal Peculiarity in the Subject—Deep 
Perineum; Narrow Pelvis; Unusual Distribution of Arteries, &c. 3. 
Difficulties due to Peculiarity in the Stone—Size; Form; Number; 
Situation; Encysted Calculi; Contraction of Bladder on Stone.— 
Calculi adhering to the Bladder.—Accidents—Wound of Rectum ; 
Removal of Portion of Prostate ; Fragments remaining after Operation ; 
Secondary Haemorrhage ; Wound remaining Fistulous; Impotence; 
Incontinence of Urine; no Stone found at Operation . . ,78 
CHAPTER VII. 
THE RESULTS OF LITHOTOMY. 
My own Inquiry, embracing 1,827 Hospital Cases by numerous English 
Operators.—Complete Analyses of them.—Affords a True Result of 
Lateral Method before Lithotrity was general.—Results of Cheselden's 
Practice.—And Martineau’s.—Now that both Crushing and Cutting 
Operations are employed, results must be different.—Fergusson’s 
Cases.—Keith’s.—The Author’s.—Results of other Forms of ] 10 
CHAPTER VIII. 
LITHOTRITY. INTRODUCTORY. 
General Observations relative to its Rise and Progress.—The Importance 
of Treatment preliminary to the Operation—Its Nature, General and 
Local , . . . . 121 CONTENTS. 
XV 
CHAPTER IX. 
THE OBJECTS OF LITHOTRITY, AND THE PRINCIPLES ON WHICH 
INSTRUMENTS SHOULD BE CONSTRUCTED IN ORDER TO ATTAIN 
THEM. 
Objects of Lithotrity defined.—Principles which guide its Practice.—All 
Evil Results arise from Mechanical Lesion.—Lithotrites constructed 
to avoid producing injury.—Three Classes of Lithotrites : Fenestrated 
Blades; Plain Blades; and Intermediate.—The Mechanical Power 
employed: the Wheel and Screw. — French and English Models.—The 
Cylindrical Handle.—Size, Materials, &c .126 
CAGE 
CHAPTER X. 
LITHOTRITY. THE SYSTEMATIC APPLICATION OF IT IN THE 
VARIOUS STAGES OF THE OPERATION. 
Position of the Patient: ordinary and exceptional.—State of the Bladder ; 
Inject ions.—Introducing the Lithotrite.—Finding the Stone ; different 
Methods.—Practical Directions for Seizing and Crushing the Stone.— 
Method of Procedure, by several Sittings, or by one only : the former 
to be first considered.—Removal of Fragments ; Importance of remov- 
ing every portion.—Value of the Aspirator for this purpose : Evacuat- 
ing Catheters.—Treatment following the Sitting.—Impaction of 
Fragments—Removal of Foreign Bodies.—Fever; Cystitis; Orchitis; 
—Haemorrhage; Chronic Retention of Urine.—Use of Ether, &c. 
—Lithotrity in Children.—Recapitulation of Maxims , . . 139 
CHAPTER XL 
LITHOTRITY AT A SINGLE SITTING. 
Caution in Procedure, the marked Characteristic of the early Lithotri- 
tists.—Introduction of Anaesthesia shortened the Process.—Bigelow’s 
Proposal to remove all the Stone at one Sitting.—Cases referred to.— 
Modifications in Lithotrites necessary, and Improvement in the 
Aspirator.—Rules for employing it.—Risks inherent in the Single 
Sitting Method, especially with unnecessarily large Instruments.— 
Illustrative Cases . . . . . . . . . . .182 XVI 
CONTENTS. 
CHAPTER XII. 
THE EMPLOYMENT OF LITHOTRITY IN CASES WHERE, BESIDES 
CALCULUS, SERIOUS ORGANIC DISEASE OR OTHER COMPLICA- 
TION EXISTS. 
Lithotrity in—1. Organic Stricture of the Urethra,—2. Hypertrophy of 
Prostate— 3. Atony and Paralysis of the Bladder—4 Sacculation of 
the Bladder—5. Tumours of the Bladder—6. Renal Disease—7. 
Multiple Calculi .194 
PAGE 
CHAPTER XIII, 
THE RESULTS OP LITHOTRITY. 
Difficulty of estimating the Results of Lithotrity.—Small Phosphatic Con- 
cretions not to be regarded as ‘ Stone.’—Weight of Debrisshould always 
be recorded.—Brodie’s Experience.—ReportsbyCiviale.—The Author's 
Experience, embracing 422 Cases.—Its Results analysed;—!. The 
Recovery Rate.—Causes of Death ; Tabular View of all the Fatal 
Cases in the Series.—2. General Condition of Patients afterwards.—3. 
The Return of the Malady.—Nature and Composition of the Calculi . 201 
CHAPTER XIV. 
ON THE CHOICE OF PROCEEDINGS BEST ADAPTED TO DIFFERENT 
CASES. 
Importance of accurate Diagnosis.—Without it Choice of Operation impos- 
sible.—Sounding.—Classification of Stones.—Questions to be deter- 
mined respecting the Stone.—1. The Age of the Patient—Results of 
Investigation ; Ratios of Death at Different Ages in 1,827 Cases of the 
Lateral Operation, Metropolitan and Provincial; how affected by Age ; 
Prevalence at Different Ages.—2. Absence or Presence of Local 
Disease, their bearing on the Question of Operation.—3. Susceptibility 
to Constitutional Disturbance —Final Deductions as to Choice of 
Operation for different Patients.—When not to Operate.—Immense 
Importance of detecting the Stone at an early period . . .217 
APPENDIX. 
Brief Details of 500 Cases of Lithotomy and Lithotrity occurring in the 
Practice of the Author . . . ... . . . 239 
INDEX ...... 299 PART I. 
LITHOTOMY. 
CHAPTER I. 
lithotomy: general considerations respecting it. 
Lithotomy: various Modes of performing now employed.—Necessity for Variety, 
—Perineal Lithotomy may be lateral or central.—Description of Perineum, 
—Outlet of the Male Pelvis,—Its Boundaries and Measurements.—Dissec- 
tion of Perineum from Skin to Neck of the Bladder.—The Parts cut in 
Lithotomy.—The Parts to be avoided. 
The various operations which are employed for the Eemoval 
of Stone from the Bladder of the male subject maybe arranged 
under two heads ; viz.:— 
1. Those by which the stone is removed through an opening 
artificially made by the surgeon, either into the urethra or 
bladder; and comprehended under the term Lithotomy. 
2. Those by which the stone is crushed in the bladder, 
and removed through the natural passage or urethra, without 
cutting; the process being in all cases sufficiently indicated by 
the general term Lithotrity. 
I shall enter first upon the consideration of Lithotomy, as 
being the older operation, the most extensively known, and 
that which is generally best understood. It is to be regarded 
also as, perhaps, the most widely applicable operation, if all the 
cases of stone, in children and adults, are considered indis- 
criminately ; although it is certainly not to be so regarded if 
adult cases are considered separately. This question, however, 
will be discussed at length in the proper place. Moreover, 2 
SUCCESS OF LITHOTRITY HAS INFLUENCED LITHOTOMISTS. 
Lithotrity is better understood after the anatomical and surgical 
details of Lithotomy have become familiar to the mind, than 
when the converse order is pursued. Indeed, on many grounds 
it is advantageous to the student, in relation to both Lithotomy 
and Lithotrity, to make the study of the former precede that 
of the latter. 
The subject of Lithotomy is by no means so simple and so 
limited at the present day, as it was considered to be a few 
years ago. If we take the writings of our best surgeons of the 
last fifty or sixty years, who have devoted themselves to it, 
we cannot but be struck with the fact that no other mode of 
performing Lithotomy is described or alluded to, except for 
occasional trial, or as a matter for speculative remark, than the 
Lateral Operation. Most assert that it is the only method 
which should be employed, except in certain circumstances, 
which are extremely unusual, and it is right to add that some 
great authorities appear still to hold the same opinion. The 
last thirty years, however, have witnessed some change in this 
respect in Great Britain, and several attempts have been made 
to remove the stone by other modes of incision ; while the 
surgical practice of Paris has exhibited similar endeavours for a 
longer period of time. The introduction and progress of Litho- 
trity have in a great measure been the cause of this. Litho- 
trity has achieved such indisputable success with small stones, 
that those whose habits and inclinations lead them to prefer the 
use of the knife, have endeavoured to find a method of employ- 
ing it which should compete on equal terms with the crushing 
operation. But where no such bias exists, almost all surgeons 
are now convinced that the difference between a large stone 
and a small one is so great, both as regards the prognosis of 
the case and the problem offered to the operator, that it is 
impossible to regard even all calculous patients who are to be 
submitted to the knife, as belonging to one category and as 
amenable but to one mode of the remedy. It is believed to 
be neither philosophical nor politic to apply to every stone, 
whether it weighs one drachm or three ounces, invariably one 
and the same proceeding. We have learned the importance, 
in the first place, of ascertaining, before deciding on any 
operation, the physical characters of the stone, that is to say, DIFFERENT MODES OF LITHOTOMY NECESSARY. 
3 
its size and hardness; and secondly, the condition of the 
patient in relation to the state of his urinary organs and his 
general susceptibilities. Hence the student of our subject in 
these modern times has more than one mode of Lithotomy to 
understand, and several questions presented to his considera- 
tion, in order that he may arrive at a practical solution of the 
question when any individual patient comes before him, viz. 
What is the best operation for this particular case ? 
Hence, also, it is that, up to the present time, there has 
been little attempt to offer a comprehensive appreciation of 
the various methods now in vogue. The choice has been 
mainly limited to the alternatives of Lateral Lithotomy and 
Lithotrity, with recently, in some quarters, the added re- 
sources of the Median Operation. An attempt to supply this 
desideratum will occupy the latter portion of this work. 
The various procedures employed under the name of Litho- 
tomy must be arranged in two separate classes, viz. :— 
First. Operations by which the bladder is reached from 
the perineum ; and among these I shall notice six prin 
cipal methods, which will sufficiently include all minor 
modifications. 
Secondly. An operation performed above the pubes, and 
known as the High or Suprapubic Operation. 
First. Operations performed in the perineum, or Perineal 
Lithotomy. 
These are of various kinds, but all may be classified either 
as Lateral or as Central Operations. 
Lateral Operations are those which are confined within 
one of the lateral divisions of the perineum. The incisions 
are directed between the.central and lateral muscles of that 
region. They necessarily approach the pubic ramus, the pudic 
artery and its branches, and are directed transversely to these 
latter, near to their origin from the arterial trunks. They 
involve one side of the prostate gland, it may be nearly to its 
full extent, while in children, and in exceptional adult cases, 
they go beyond it. 
Central Operations are those in which the incisions are 
limited to the central part of the perineum, and are made in 4 
LATERAL AND CENTRAL LITHOTOMY. 
the line of the raphe itself, or tranverse to it, and lie mainly 
between the anus and the symphysis pubis. They do not 
approach the rami, or the great vessels, nor do they run 
transversely near to the origin of the branches from the 
pudic artery. In no case do the incisions reach the external 
limits of the prostate gland. 
I. Lateral Operations.—There is but one typical form of 
Lateral Lithotomy, although some of the details of its per- 
formance vary in different hands. It is the operation which is 
at present most widely employed in this country, and is well 
known as the Lateral Operation. Its origin is believed to be 
due to Pierre Franco, of Provence, about the middle of the 
sixteenth century. It was brought into note by Frere Jacques 
at the end of the seventeenth century; and was largely 
employed by his pupil Rau, in Holland, in the beginning of 
the eighteenth. The operation in its present form, however, 
differs somewhat from their methods, and is for the most part 
that which Cheselden adopted and practised in London with 
great success, in the early part of the last century, and which 
obtained for him a wide and enduring reputation. 
II. Central Operations.—Belonging to this group there 
are at least five in number. 1st. The Median Operation. The 
stone was removed by a median incision in the perineum, made 
close to, and parallel with, the raphe in the old Marian Opera- 
tion during the sixteenth century, and long afterwards. But 
the great improvement, and the far greater success which the 
Lateral method realised, led ultimately to the total extinction 
of the Marian. The disastrous results of this procedure were 
due to the violent laceration of the neck of the bladder and 
posterior part of the urethra, by which room was made for the 
extraction of the stone, and not to the median incision of the 
urethra, which was all that the knife effected in that operation. 
This distinction wras, nevertheless, lost sight of by most litho- 
tomists (Ledran may be partially excepted v) until the Italian 
surgeons, at the commencement of the present century (Man- 
zoni of Verona, then De Borsa, and subsequently Rizzioli) drew 
attention, by their success, to Lithotomy in the Median lane. 
1 See not only his Par allele, Paris, 1730; but Heister's testimony, Tnstitu- 
Hones Chirurg., vol. ii. pp. 116-17, and 167 (Amsterdam, 1730). VARIOUS CENTRAL OPERATIONS. 
5 
Mr. Allarton brought it into notice in this country, publishing 
his own method of performing the operation and the results, in 
1854. This plan has since been frequently tested by others, in 
this country and abroad, and certain modifications have been 
made by some, the 4 prerectal ’ operation of Nelaton, for example, 
but it is now generally known as the Median Operation. Dr, 
Buchanan’s method, in which he uses an angular staff, first 
employed by him in 1847, may also be classed under the head of 
central operations, although it is capable of becoming a lateral 
operation when required. 
A slight median incision also may be made for the purpose 
of introducing a lithotrite, crushing the stone and removing 
all the debris through the perineal opening; a combination of 
lithotomy and lithotrity, sometimes called4 perineal lithotrity.’ 
The Bilateral Operation—so named because the incisions, 
both external and internal, involved equally each side of the 
middle line—wras designed and made public by Dupuytren in 
1824. It was subsequently practised in Paris, by himself and 
others, for some years. As we shall see hereafter, it is, not- 
withstanding its name, a central, rather than a lateral, opera- 
tion. 
The Medio-Bilateral, a combination of the two preceding 
operations, as the term implies, was published by Civiale in 
1836, having previously been practised by him, and subse- 
quently both by himself and others, to some extent in France. 
The Recto-vesical Operation.—This may be regarded as a 
continuation of the Median operation from the perineum into 
the rectum, and is supposed to have been designed by Hoffman 
in 1791, though probably not practised by him. Sanson and 
Yacca are pre-eminent among those who performed and ad- 
vocated it in the commencement of the present century. 
In entering on the subject of Lithotomy performed in the 
perineum, whatever be the operation selected, it is necessary 
to study closely the anatomy of that region. It would, however, 
be superfluous to enter upon any systematic or minute ex- 
amination of it here; but I shall call attention to one or two 
points relating to what is usually termed its surgical anatomy, 
which appear to me to be important. 
A body is supposed to be tied up in the usual Lithotomy 6 
THE SURGICAL ANATOMY OF THE PERINEUM. 
position, to expose the perineal region : a region, let it be 
recollected, in which deep incisions are to be made, and 
through which the stone is to be extracted. 
It is important to keep steadily in view these two indica- 
tions, since the region contains vital organs, and is very limited 
in extent. 
Therefore—a. The incisions must be planned so as to 
avoid certain parts which it is dangerous to cut; and— 
b. They must be planned so as to secure the greatest 
amount of space for the passage of instruments inwards and of 
the stone outwards. 
The perineal region is a small space, measuring rarely much 
more than four inches in any direction, as generally regarded, 
and its limits are defined in the greater part of its extent by 
bone. Beneath its surface are the rectum, urethra, bulb, 
prostate gland, bladder, and the pudic artery, with some of its 
branches, besides less important parts. 
Its surface boundaries are often said to present a space of 
triangular form; the apex at the pubic arch; the base, a 
horizontal line uniting the two tuberosities of the ischium. 
Such a triangle is nearly equilateral, and each of its sides 
measures in the adult about three inches in length. Such a 
representation may be convenient to the anatomist, but it is 
artificial, and for the surgeon not quite exact. 
Sometimes the space is said to be lozenge-shaped, in which 
case the anatomist includes under the term not only the space 
above described, but another triangular portion, having the 
same base as the preceding, and the apex at the coccyx; the 
latter region covering in the lower part of the rectum and the 
ischio-rectal fossae. 
Now, the surgeon should study for his purposes the anatomy 
of the male pelvic outlet as a whole, just as the obstetrician has 
studied that of the female. He wants to know precisely what 
are the size and form of that outlet, as well as how the 
important organs are disposed therein. Neither the triangle 
nor the lozenge rightly represent it in relation to his require- 
ments ; while the division of the region into two separate 
portions for the sake of dissection is unfavourable to the for- 
mation of a correct conception of it as a whole. Furthermore, 7 
TRUE FORM OF MALE PELVIC OUTLET. 
the surgical student must soon perceive that neither of the two 
regions thus annexed includes space enough, either for the first 
incision required in the lateral operation, or for the removal of 
a moderately large stone outwards. 
The true form of the male pelvic outlet, and consequently 
that with which we have to do, is that of the conventional 
heart; the ace of hearts, with the apex upwards. 
Take the skeleton of an adult male pelvis, in which the 
bones are united by their ligaments, and place it in the position 
for lithotomy. Such an one is faithfully represented by fig. 1. 
Fig. 1. 
Pelvic bones in the ordinary position of Lithotomy, showing form of outlet. 
The apex of the inverted heart is at the lower border of the 
pubic symphysis ; the diverging sides are the rami of the pubes 
and ischia; the rounded lobes of the heart are defined by the 
great sacrosciatic ligament, and the notch dividing them is 
formed by the tip of the coccyx. 
The pelvic outlet thus described is represented in a diagram 
adjacent (fig. 2); but accurately drawn from the skeleton, on 
a scale of two-thirds of the natural size. This figure will be 8 
MEASUREMENTS OF MALE PELVIC OUTLET. 
employed to represent the outlet throughout this work in 
connection with the incisions employed in the various operations 
for Lithotomy. 
In a well-developed adult the measurements of this heart- 
shaped space are as follows ;— 
From apex under pubic symphysis to the interlobular notch 
at the os coccygis, about 3| to 4 inches. 
From the anterior part of one tuber ischii to the corre- 
sponding part of the opposite bone, about 3 inches. 
Fig. 2. 
Diagram of the male pelvic outlet, showing the situation of the prostate, urethra and 
anus : drawn on a scale of two-thirds of the natural size. 
From the apex to each tuber ischii at the part just named, 
about 3 inches. 
Consequently, the two last measurements include a right- 
angled triangle—the perineal triangle of the anatomist. 
From the apex to the centre of the anal orifice, about 2\ to 
2| inches. 
From centre of anal orifice to tip of coccyx, about 1 
to 1| inch. CHIEF STRUCTURES IN PERINEAL REGION. 
9 
From the apex to extremity of either lobe of the heart- 
shaped space, the line of incision in Lateral Lithotomy, about 
4j inches.1 
To commence: we will suppose an examination of the region 
on an untouched subject in the dissecting-room; or, better 
still, as it appears on the living body. First, there are the 
projecting tuberosities of the ischium, and from these the 
upward converging lines of the rami may be traced by the fin- 
gers near to the apex, where they are obscured by the body of 
the penis overlaying them as they approach it. Then, about 
an inch and a quarter below the anal orifice, may be felt the 
coccyx, and on each side the fingers deeply pressed encounter 
nothing but soft structures occupying the spaces indicated by 
the rounded lobes of the heart-shaped figure. In the middle 
line above the anus is seen a slight prominence caused by the 
corpus cavernosum and its enveloping muscle, and placed verti- 
cally upon it is the line of the raphe, which divides the region 
into two equal lateral portions. The anus itself is situated in 
a deep depression, and a transverse line drawn from the centre 
of one tuber ischii to another falls just above it. 
Observe, that the sides of this space, from the apex to the 
tuberosities of the ischium, are bone ; and that the interlobular 
notch of ‘ the heart ’ is bone also ; boundaries, therefore, which 
yield nothing to pressure, and cannot be overstepped by inci- 
sion. But, on either side of the notch, the tissues are soft and 
yielding; and incisions in the long axis of either lobe divide 
no important structure. Danger exists only at the external 
boundary, in the presence of the pudic artery; in the upper 
part, from that of the artery to the bulb; and in the central 
line, from the presence of the bulb itself and the rectum. It 
is through one of these lobes, and precisely in the direction of 
its longest axis, that the external incision in Lateral Lithotomy 
is made ; and, which is of equal consequence, it is in the direc- 
tion of that axis that traction must be exerted when the stone 
1 In some bodies the pelvic outlet is more contracted or narrower than the 
above measurements; the distance between the tubera ischii being in the adult 
only 21 inches, and in a few instances only 2\. This latter condition offers 
some obstruction to the removal of a large stone, and if the lateral operation is 
adopted in such a case, its line must be less oblique than usual. Vide Chapter 
VI. ‘ Difficulties and Dangers met with in Lithotomy.’ > 10 
FIRST DISSECTION OF THE PERINEUM. 
is of large size. It is in the upper and narrower division of 
the outlet, viz. that between the anus and the symphysis pubis, 
that the incisions lie, in all operations wdiich are strictly cen- 
tral, and traction is made directly in the middle line from the 
perineum to the operator. It can be demonstrated that it is 
impossible to remove so large a body through an incision con- 
fined to this portion of the outlet, and not involving the rectum, 
as through an incision in the axis of the lateral portion. 
Now, every proposal to perform Lithotomy in the perineum 
must first be tested as to the relation which its incisions bear 
to the outlet thus described; since, as we shall see hereafter, 
there is no single cause of death or danger following Litho- 
tomy, greater than that which ensues from the removal of a 
stone through an insufficient or an ill-placed opening. 
Bearing in mind the form of the space, let us proceed to 
make a surgical, not a minute or anatomical, dissection of it. 
The latter is necessary in its place, but that is not here. We 
want now only the salient points, to refresh the memory, not 
to encumber it with non-essentials. 
Without entering on the details of the process, let it be 
supposed that the skin, cellular tissue, and fat are removed: 
this completes the first stage of dissection. 
The accelerator urinse muscle occupies the middle line at 
the top of the space, and the sphincter ani surrounding the end 
of the rectum continues the line below it. The space is crossed 
transversely by the two transversus perinei muscles; and the 
erector penis lying on the pubic ramus of each side forms one 
side of a triangle, of which the transverse muscle is the base, 
and the accelerator the remaining side. From this are seen 
issuing the superficial perineal artery and nerve, with their 
branches. Below the transverse muscle is the ischio-rectal 
fossa, with a few unimportant branches of artery and nerve 
permeating it. The central point of the perineum is seen be- 
tween the bulb and anus, where the four muscles unite in a 
crucial form. All these are superficial to the triangular liga- 
ment, or deep fascia, of the perineum. 
The next stage of the dissection removes these muscles, 
and exposes the corpus spongiosum and the corpora cavernosa 
of the penis : the deep perineal fascia is seen in the intervals. DEEPER DISSECTION OF THE PERINEUM. 
11 
Here (as represented at fig. 3) it is left untouched on the right 
side of the subject, while it is removed, together with the 
compressor urethrae muscle, on the left, to show the course of 
the pudic artery, and its branch the artery to the bulb, which 
lie beneath it, the latter perforating the fascia. The left- 
corpus cavernosum is also divided to show the arteries more 
clearly. The position of these vessels forms the important 
point of this dissection. 
Fig. 3. 
The second stage of the dissection of the perineum, showing the course of the pudic 
artery, and artery to the bulb, the fasciae, &c. 
The last stage of the process consists in clearing awTay the 
whole of the perineal fascia, the vessels just named, and the 
deep fascia, now usually known as the pelvic fascia, which lies 
beneath the vessels, and forms a sheath for the prostate gland. 
The fibres of the levator ani having been divided on each side, 
the rectum is drawn downwards, and carefully separated from 
the prostate, maintaining the latter as much as possible in its 
normal position. To illustrate the situation of this organ and 12 
PARTS CUT IN LATERAL LITHOTOMY. 
neck of the bladder is the object of this, the last, dissection 
The result is shown by fig. 4. 
Deep dissection, showing the situation of the prostate in the pelvic outlet. 
After this brief anatomical resume, it will be easy to see 
what parts must be divided in the various modes of operating in 
this region. 
In Lateral Lithotomy the following parts must he cut.— 
The skin and superficial fascia; the transverse muscle of the 
perineum and transverse perineal artery; the deep perineal 
fascia, the membranous urethra, and muscular fibres surround- 
ing it; a little of the levator ani, the prostatic urethra, and 
part of the prostate gland itself. In addition to these, the 
following parts may he, and often are, cut:—a part of the ac- 
celerator urinae muscle covering the bulb of the urethra, and a 
little of the bulb itself; also the int ernal meatus at the neck of 
the bladder. Occasionally, especially when the vessel is given 
off lower down than usual, the artery to the bulb is divided also. 
In Central Lithotomy the following parts must he cut.— 
The skin and superficial fascia ; the tendinous structures which 
unite the muscles in the central point of the perineum, and a PARTS CUT IN CENTRAL LITHOTOMY. 
13 
few fibres of the accelerator urinse muscle ; some small arte- 
rial branches anastomosing across the middle line ; the deep 
fascia, the membranous urethra, and muscular fibres sur- 
rounding it; the prostatic urethra, and the lower part of the 
prostate gland itself. Besides these, the bulb of the urethra is 
generally divided to a small extent ; and when deep lateral 
incisions are made, the prostate is divided in the direction 
named, with a little of the deep fascia right and left of the 
median line and the muscular structure contiguous to it, as wTell 
as the internal meatus, according to the design of the operator. 
Further : it will appear that, in order to remove any large 
body by the Lateral Operation, room must be provided in the 
direction of the lower angle of the wound. The pubic arch 
limits the space unalterably in front, the ramus of the ischium 
equally so on the outer side; the rectum and coccyx occupy 
the middle line. Hence, in withdrawing a large stone from 
the bladder, traction must be made obliquely dowmwards to the 
right of the operator in the direction of least resistance, which 
is towards the hollow of the sacrosciatic ligaments, where the 
fibres of the gluteus muscle only cross the heart-shaped space 
already indicated as the true outlet of the male pelvis. 
Lastly : it will be equally obvious, that in the performance 
of Lateral Lithotomy, the following parts are to he avoided. 
In front, the artery to the bulb, and the bulb itself. In the 
median line, the rectum. On the outer side the pudic artery; 
which, however, could only be endangered by the most reck- 
less incisions ; still, its situation, at the margin of the ramus 
bounding the space there, is always to be remembered. In the 
last or deepest incision the boundary limit of the prostate is 
not to be overstepped in the adult, whenever the stone can be 
removed without doing so; but this point will be discussed at 
length when we consider the steps of the operation itself. 
In central operations (the recto-vesical excepted) the rectum 
must be avoided in the lower part of the incisions; and it 
should be the aim of the operator to avoid the bulb above, or 
to wound it as little as possible. Of incisions in the prostate, 
as in the preceding case, more will be said hereafter. 14 
CHAPTER II. 
THE LATERAL OPERATION OF LITHOTOMY. 
The Instruments necessary.— Preliminary Proceedings : Assistants, &c.—The 
First Stage: Management of the Staff; finding the Stone.—Second Stage : 
the Incisions superficial and deep; probe-pointed Knives; Gorgets; 
Lithotomes.—Third Stage : Removal of the Calculus.—Fourth Stage : the 
Tube; the Air Tampon; Treatment of Haemorrhage, &c.—The after 
Treatment.—Aston Key’s Operation. 
I shall first enumerate the instruments which it is desirable 
to have ready for use before performing the operation of Litho- 
tomy by the lateral method. The non-appearance of a single 
instrument of importance at the moment it is required may 
produce great embarrassment to the operator; hence a list 
should be at hand by which the instruments can be selected 
the day before the operation. 
Sounds of the proper form for detecting stone in the 
bladder (fig. 5). 
Fig. 5. 
An eight-ounce syringe (fig. 6), with suitable catheter for 
injecting by urethra; and a tube for washing out the bladder 
by a reversed current through the wound after the operation 
(% 7).1 
Fiill-sized staffs, as deeply and widely grooved as their size 
admits, consistently with maintaining their strength. The 
groove to be midway between the convex and the lateral aspects 
' This nozzle is after the suggestion of Dr. Gross of Louisville, Urinary 
Organ*, ilrd eft, p. 248. INSTRUMENTS EMPLOYED IN LITHOTOMY, 
15 
of the staff, to stop abruptly half an inch from the extremity, 
and not to extend so far up the handle as to permit the urine 
to escape (fig. 8). The curved portion not to be so long as 
it is usually made, since a small or contracted bladder is some- 
Fig. 6. 
Fig. 7. 
Fig. 8. 
Fig. 6. The syringe, with graduated piston rod 
Fig. 7. Nozzle for reversed current. 
Fig. 8. Staff, with lateral groove. 
times exposed to the danger of perforation when that portion of 
the staff protrudes far into the cavity. 
A knife, of which the blade and handle together measure 
Fig. 9. 
(for the adult) about inches long ; of this, the blade may be 16 
KNIVES AND GORGETS. 
about 3 or inches. The cutting edge should have a length 
of about one inch and a quarter from the point: for form, &c., 
see fig. 9. Smaller sizes are required for young subjects. 
A second knife, of which the blade and handle may measure 
together about 8 inches; of this the blade may be about 
inches. A large probe point should terminate the blade, and 
it should be so constructed that it may run easily in the groove 
of the staff. The cutting edge should extend to about inch 
from the point (fig. 10). 
Fro. 10. 
A blunt gorget about inches long, exclusive of the 
handle, curved from side to side and terminated by a probe 
point, to run in the staff (fig. 11). This is a useful instrument 
Fro. 11. 
See other gorgets at p. 30. 
where the perineum is so deep, or the prostate so large, that 
the finger cannot reach the bladder, as occasionally, but rarely, 
happens. 
Forceps of various forms and sizes. It is desirable to have 
the blades of good length, so that the angle produced by 
opening them is acute rather than the reverse: a better form 
of wedge is thus presented to the orifice, through which the 
instrument and the stone have to pass. The inner surfaces of 
the blades should be slightly roughened; they are sometimes 
lined with very thin canvas or kid leather, to afford a surer 
hold, and avoid any crushing of the stone itself. The ex- 
tremities of the blades must not meet; an interval of about 
one-eighth of an inch should exist between them when the FORCEPS AND SCOOPS. 
17 
instrument is closed. It is necessary to have curved as well as 
straight forceps. (Useful forms are shown at figs. 12 and 13.) 
Pig. 12. 
Fir,. 13. 
A scoop is sometimes useful, and succeeds in certain circum- 
stances in removing a stone, or fragments, better than the 
forceps (fig. 14). 
Fig. 14. 
An instrument for searching the bladder after the opera- 
tion, in case another calculus or fragments may still remain 
there. Nothing answers better than the sound represented at 
fig. 5. 
A strong instrument for crushing a calculus of unusually 
large size, and requiring to be broken before removal, is 
occasionally necessary. Several forms have been designed, 
but almost all consist of a pair of ordinary strong forceps, with 
screw or other power to approximate the handles. (See 
Chapter VI.) 
A pair of worsted web lithotomy garters, strong, but pliant; 
each measuring not less than three yards. An anklet, to 
accomplish more easily and more securely the same purpose, 
has been designed and employed by Mr. Prichard, of Bristol. 
(Figs. 15 and 16.) 18 
ANKLETS AND THE TUBE. 
His description is as follows:—4 These straps consist of 
padded leather bracelets fitting to the wrists, and buckling 
firmly round them; and some firm leather anklets, of the 
shape of the elastic bandages for the ankles, which can be 
buckled on over the ankles. The bracelets have a strong hook 
on the middle of their palmar aspect, and opposite each outer 
Fig. 15. 
Fig. 16. 
malleolus is an iron ring. The bracelets and anklets being put 
on when the patient is in bed, as soon as he is under chloro- 
form, or the staff is introduced, the hooks are passed through 
the rings and all is done.’ ’ I have used these anklets for some 
years, and much prefer them to the garters, as being more 
simple and secure. 
A tube to be introduced through the wound into the bladder, 
after the operation, if desired. One may be specially fitted for 
plugging in case of deep venous haemorrhage. (Fig. 17.) 
But the most certain mode of dealing with severe bleeding, 
the ligature failing or being insufficient, is the addition of an 
inflatable thin india-rubber bag to the tube, so arranged 
around it, that while its draining action is left intact, the bag 
can be distended with air, through a small flexible tube pro- 
vided with a stopcock (see fig. 18). It should be introduced so 
far that the whole cut surface is exposed to the action of the 
bag: indeed, the further end of this should just protrude 
Mr. Prichard’s anklet. 
The wrist-piece. 
1 Brit. Med. Journal, Dec. 22, 1860, p. 993. THE AIR TAMPON, ETC. 
19 
slightly into the bladder itself. This done and inflation being 
made, the distended bag produces pressure on every portion 
of the wound’s surface, closing every inequality, and effectually 
stopping all the haemorrhage. After twelve or twenty-four 
hours or so, a little air is allowed to escape, and the pressure is 
Fig. 17, 
Fig. 18. 
The tube surrounded with a 
piece of thin calico, or oiled silk, 
to retain the plugging in ease of 
haemorrhage. 
The Air Tampon. 
A. The tube. 
b. Thin india-rubber bag undistended. 
C. Line indicating form of bag distended by air. 
d. Flexible tube, with stopcock for inflating bag. 
E. Tapes to fasten tube in place. 
gradually relaxed, until the apparatus can be removed alto- 
gether. It was designed by my assistant Mr. Buckston Browne, 
and is known as the 4 dilatable air tampon.’ 
Big. 19. 
Tenaculum'(Dr. Keith). At a, the hook unites with the handle by a screw, and can be 
separated from it, for the purpose of leaving it in the wound beneath a deep-seated vessel after 
tying round it, when the ligature cannot be secured otherwise. 
Ligatures; artery forceps; curved needles and strong silk, 
tenaculum (fig. 19) to secure any deeply-seated arteries (see 20 
THE OPERATING TABLE. OPERATION. 
Treatment following the Operation, under the head Haemorrhage, 
page 37); bandages, sponges, lint. 
Other appliances.—Vessels containing hot and cold water, 
one of the former to heat the forceps and other instruments; 
napkins in abundance, oil; chloroform is of course to be given. 
Brandy, wine, smelling salts, and chloric ether, or sal volatile, 
should always be within reach. 
The operator should himself see that there is a strong, firm, 
and steady table, of proper size, and capable of being placed-in 
a good light. The table should be 2 feet 8 or 9 inches high, if 
the operator is seated in a chair of ordinary height; but a table 
of almost any height will do, if the relative proportion between 
it and the chair be maintained. The operator should be 
seated rather too low than too high. The fore-arms should 
occupy nearly a horizontal line when operating on a level with 
the patient’s perineum. Some surgeons prefer the kneeling 
position, with one, or even both knees resting on the floor. A 
blanket folded once or twice, and covered with some waterproof 
cloth, should be placed on the end of the table, over which the 
patient’s buttocks will be brought. Pillows or cushions will be 
required to support the head and shoulders. A shallow vessel 
containing sand or sawdust is useful to protect the floor from 
blood, urine, &c. 
The Operation.—It is usual to ensure action of the bowels 
by an aperient, on the day before the operation; if, however, 
they have been regularly and sufficiently moved in the natural 
manner, a purge is undesirable, since it only weakens the 
patient. But on the day of the operation, and about two or 
three hours previous to it, a full enema of warm water should 
be given. The surgeon should ascertain that the action of this 
has been efficient and completed at least an hour before the 
operation, or he may find the rectum distended, and about to 
act when the patient is on the table ; a condition in which the 
chances of wounding the bowel are augmented. By pursuing 
this method time is also given for a few ounces of water to 
collect in the bladder if desired, which would probably have 
been emptied simultaneously with action of the bowels. The 
left side of the perineum may be previously shaved with a 
common scalpel or a razor. PRELIMINARY ARRANGEMENTS : ASSISTANTS. 
21 
[Some surgeons, and especially at the present day, regard it as 
important that there should be a considerable quantity of water in 
the bladder. I venture to express an opinion that its use is over- 
rated ; and that it is sufficient to take the chance of the urine accu- 
mulating for an hour before the operation; at all events, any 
attempt to inject an irritable bladder is rarely of any service. 
Cheselden expressly says that he prefers the bladder empty, as the 
stone is then sure to be found close to the internal incision at the 
neck; whereas if the organ is full it may entangle the stone in its 
folds as it collapses. Mr. Crichton, of Dundee, was of the same 
opinion, and insists, in his MS. notes, that if the bladder is empty, 
or nearly so, the stone is certainly found at the neck of the bladder.] 
Assistants.—There should be one steady, experienced 
assistant to hold the staff; it is his duty to follow implicitly 
the operator’s instructions throughout. Two others also are 
necessary, each to support firmly a leg of the patient; one of 
them to draw the scrotum a little upwards, and to the right 
side ; or this may be done by the assistant who holds the staff. 
These suffice, in addition to the physician who administers 
the chloroform. Another may be sometimes useful to hand 
sponges, ligatures, &c., or to supply any want of the patient; 
all of which, however, may be done if need be by a nurse. 
The instruments should be carefully arranged by the operator 
himself (on a tray or otherwise), within easy reach of his right 
hand, so as not to be touched, and possibly deranged, by an 
assistant. 
I. All the preliminary arrangements being complete, the 
patient should be placed on the operating table, and be suffi- 
ciently covered with blankets. Chloroform having been ad- 
ministered, the staff should be carefully introduced, and the 
stone found, and struck by it if possible, the click being heard 
by the operator, and by one other person at least. If it cannot 
be felt with the staff, a sound of the proper form should be 
introduced, the bladder explored, and unmistakable signs of 
the presence of calculus elicited. It may be necessary in order 
to discover it, to inject a little warm water, particularly if the 
bladder has emptied itself during the sounding. If, after a 
fair search, the stone is neither heard nor felt, no operation 
can take place, and the search must be resumed on another day. 22 
FINDING OF THE STONE : THE STAFF. 
[But it is very desirable, and in most instances it is possible, to 
strike the stone with the staff itself, upon which the patient is to be 
cut. Because, supposing the stone to be struck with the ordinary 
sound, and some difficulty is experienced in passing the staff subse- 
quently, it is possible that the operator may have made a false 
passage, and unwittingly passed the instrument out of the urethra 
altogether. Or, the staff may have passed into an old false passage, 
which the sound, having a different curve, escaped. The obvious 
and necessary consequence is, that any operation performed on a staff 
so placed will not lead into the bladder, no stone will be removed, 
and the discovery of the error may not take place until it is too 
late to repair it. This unhappy accident has been known to occur, 
not very unfrequently, particularly in children. It could not happen 
if the surgeon were determined to hear the stone struck with the 
staff itself; and, especially if he has not had much experience, nothing 
less than this should satisfy him. An experienced surgeon knows 
whether the staff is in the bladder, without feeling actual contact 
with the stone, by the degree of mobility possessed by an instrument 
rightly passed, strongly contrasting with its fixed condition, when 
passed out of the urethra; but the rule laid down should be con- 
sidered always binding. It is especially necessary in young cases, 
because a staff passed into the cellular interval existing between the 
rectum and bladder has often a good deal of mobility, and thus is 
believed, but erroneously, to be in the vesical cavity.] 
The staff being placed in the bladder and confided to the 
chief assistant, the patient’s head and shoulders should be a 
little raised by two or three pillows, and the hand and foot of 
each side made fast by means of the anklets described. If the 
garter is still preferred, it is to be used as follows :—An assistant 
extends the right arm by the patient’s side, and drawing up 
the right foot by flexing as much as possible the knee and hip- 
joints, places it in the hand so that the palm embraces the 
outer side of the instep, and the fingers lie transversely below 
the sole, with the thumb across the dorsum. The garter is 
then folded double, with a running noose at the doubled end, 
which is placed round the wrist; the two free ends are crossed 
tightly under the sole and round the ankle, so as not to slip, 
and finally are tied with a bow on the outer side. Meantime 
the opposite limb is similarly treated. When all is made secure 
the buttocks are brought down until they project slightly over POSITION OF THE PATIENT, 
23 
the edge of the table. Each leg is firmly and steadily held by 
an assistant, who, facing the operator, places his nearest hand 
(e. g. his left if standing on the patient’s right) on the inner 
side of the patient’s knee, while his other grasps the patient’s 
foot, keeping it well backwards and outwards. The staff is 
confided to an assistant who stands on the patient’s left, and 
takes it in his own right hand. He should hold it so that the 
handle is perpendicular and strictly in the middle line, neither 
deviating to the right nor to the left; and as there must 
Fig. 20. 
The position of the patient when tied up for Lithotomy. 
necessarily be some base of support in so doing, it should be 
made to rest steadily but lightly against the lower border of 
the symphysis pubis. In this position, about two inches of the 
staff ought to be lodged in the bladder. With his left hand he 
may gently draw up the scrotum a little towards the right 
groin, and so keep it out of the way. 
The operator, having placed the necessary instruments 
within his reach, takes his seat and separates the legs as much 24 
THE STAFF : THE FIRST INCISION. 
as he deems necessary to expose sufficiently the perineum and 
part of the buttocks adjacent. He ascertains that the position 
is square to his own front, and that the patient is firmly 
placed. (Fig. 20.) 
By a glance, and by passing the fingers over the perineal 
surface, he observes whether the tubera ischii are wide apart, 
or whether they approximate more than usual; and he plans 
the line of the first incision somewhat in conformity with the 
result of his examination. (See page 9.) 
[Different authorities give different directions respecting the mode 
of holding the staff. Some prefer the convex part slightly projecting 
in the left side of the perineum; but the instructions given above 
describe the method which at the present day is pretty generally 
pursued by most experienced operators in this country.] 
II. The operator commences by introducing his left fore- 
finger into the rectum to ascertain that it is empty; a proceed- 
ing which appears also to have the effect of stimulating the 
bowel to contract and occupy the smallest possible space. He 
then places the fingers of the left hand upon the upper part of 
the perineal region to maintain the skin in its place, not to 
draw it upwards; and holding the sharp-pointed knife in his 
right, commences the first incision about a third of an inch to 
the left of the raphe, and an inch and a half in front of the 
anus, carrying the blade downwards and outwards for about two 
and a half or three inches in a direction midway between the 
anus and tuber ischii, but inclining a little nearer to the latter. 
The knife should, at its point of entry, divide the skin, and 
quickly sink more deeply towards the staff, the situation of 
which should be kept in the mind’s eye, into the superficial 
fascia and fat in the hollow which exists between the bulb and 
anus on the one side, and the ramus of the ischium on the 
other; the incision is then to be gradually made more super- 
ficial through its lower part. If a large stone is anticipated its 
entire length may extend to fully three inches. As a rule, 
then, the first incision should be free. 
[The line of the first incision is somewhat differently taken by differ- 
ent operators. Nearly all agree to commence a little to the left of the 
raphe, but not so in regard to the distance in front of the anus. OPINIONS AS TO FIRST INCISION. 
25 
Thus, Sir William Fergusson directs that it should commence one 
inch and three-quarters in front. Mr. Erichsen one and a half inch, 
Sir B. Brodie, Mr. Stanley, Mr. Skey, and Dr. Gross, advise one inch 
and a quarter, while Mr. Coulson and Dr. Keith of Aberdeen direct 
that it should be one inch only in advance. The latter attaches con- 
siderable importance to this point, and argues in its favour at some 
length in his work on the subject.1 Mr. Crichton always made his 
incisions low : I infer from his notes, as near as possible to the last- 
named spot. 
It is quite clear, also, that Cheselden, himself, commenced about 
one inch in advance of the anus.2 
The directions given by other well-known operators are not ex- 
pressed in precise terms, and on this account they are not quoted. 
Now, as it appears that nearly all advise an external incision of 
about the same length, that is, of three inches or thereabouts for an 
adult patient, it follows that the situation of the opening relatively 
to the pubic arch and to the bladder must differ, and somewhat 
materially. This discrepancy has sometimes been the source of per- 
plexity to the student; although it is true that where the incisions 
are commenced high up, the skin only is cut at first, and where they 
are low, the knife is made to penetrate into subjacent tissues at once, 
so that, in any case, the deepest part of the incision is made into the 
hollow between the accelerator and the erector penis muscles, just 
beneath and outside the bulb of the urethra. Nevertheless, it is the 
safer practice to err, if it be an error, by placing the incision too low 
rather than too high. The low incision avoids the bulb and the 
artery thereto; it enters the urethra in the membranous portion, or 
just at the apex of the prostate; and it places the axis of the wound 
in its best relation to the pubic arch, that is, as far as possible from 
that unyielding boundary of the perineal space. It thus affords room 
for removing a large stone, and lessens the chance of bruising the 
neck of the bladder with its external cellular relations in the act of 
extraction, the danger of which will be pointed out in Chapters V. 
and YI. But it is not to be overlooked that the lower the incision is 
placed, the more danger there is of wounding the rectum : and espe- 
cially so, if the operator overlooks the necessity for commencing a 
little further to his right from the raphe, when he enters the knife at 
1 Hospital Statistics of Stone, pp. 17- 21. By Dr. Keith, Aberdeen, 1849. 
2 Cheselden’s Anatomy of the Human Body, 5th ed. 1740; 6th ed. 1750: 
‘ I first make as long an incision as I can, beginning near the place where the 
old operation ends' 26 
DEEP INCISION ; ENTRY INTO THE BLADDER. 
an inch or inch and quarter, instead of an inch and three-quarters, 
above the anus.] 
The left forefinger now enters the wound and separates 
freely, especially at its deeper part, the fat and fascia in the 
direction of the staff, which should at this stage be just felt 
beneath, guarding, at the same time, the rectum by pressure 
downwards and inwards, while the knife follows, and by an 
additional small stroke or two enables the operator to define 
clearly the line of the staff, and press his finger-nail into the 
groove where it lies in the membranous portion of the urethra 
just in front of the apex of the prostate. Gruided by the nail, 
he carries the point of the knife into the groove at this spot, 
and he holds the knife so that the blade is neither vertical nor 
horizontal, but inclining rather more to the latter direction, 
while the point is directed a little upward. This important 
stage of the operation is illustrated by the annexed woodcut 
(fig. 21), in which the parts are shown by an anatomical section. 
The knife is now pushed steadily along the groove of the staff 
into the bladder, the operator being careful to remember that 
the depth of the incision in the prostate very much depends on 
the angle which the blade makes with the staff in that act. 
The hand, therefore, must not be lowered too much; if a small 
incision is required, the knife is to be maintained very nearly 
in a line with the extremity of the staff, so as to make an acute 
angle with it; the point being kept up only enough to ensure 
its transit clearly and closely along the groove, which must not 
be quitted for an instant. When the bladder has been entered, 
the knife is withdrawn to make way for the finger; but if the 
operator is of opinion that more room is wanted, he can enlarge 
the incision to the extent deemed necessary while withdrawing 
the blade, by carrying it outwards and downwards, in the line 
of its entry, so that the edge sweeps lightly along the outer 
angle of the wound. 
The operator now slips the point of his left forefinger into 
the groove of the staff, and along it, slowly and steadily through 
the wound in the prostate, slightly dilating it as it passes, until 
the last joint enters the vesical cavity (as it will in ordinary 
cases), and comes into contact with the stone, mostly felt lying 27 
INTRODUCTION OF THE FORCEPS. 
at the neck of the bladder. In this position he is enabled to 
ascertain its situation, and, at the same time, to make a kind 
of hold upon the bladder, and maintain his communication with 
it. He now orders the staff to be withdrawn, and taking a 
Fig. 21. 
Anatomy, in section, of parts interested, in Lithotomy. Position of hands in last incision. [Mr. 
Bagg h as represented this for me very carefully, from a dissection made expressly for the 
purpose.] 
pair of long straight forceps, introduces it by sliding the blades 
slowly and gradually along the palmar aspect of his finger, until 
they are fairly within the bladder. It is manifest that addi- 
tional dilatation of the wound in the prostate must be made in 
this act; and it is important that the forceps should not be 28 
KNIFE, OK GOKGET FOR DEEP INCISION? 
thrust in so as to form a rent in the soft tissues, but that the 
operator should coolly and slowly insinuate them in order to 
dilate gradually as much as may be necessary, and rupture as 
little as possible. Meantime a little of the urine will probably 
escape by the wound. 
[The mode of making the last or deep incision through the prostate 
and neck of the bladder is one which has been at all times regarded 
as possessing the highest interest for the lithotomist, and demands 
special attention. It has been described here as made with the sharp- 
pointed knife employed in the earlier stage of the proceeding. Such 
appears to be on the whole the prevailing practice among metro- 
politan operators. Nevertheless, other means, and a great variety of 
instruments, have been, and are still employed in its performance, 
for the purpose of attaining, as it is believed by those who advocate 
them, more safety and certainty in making the incision. Two 
principles of construction, and two only, have been adopted in the 
numerous forms of knife, bistoury, or gorget, which have been 
invented from time to time in order to accomplish this end. The first 
I riuciple has been to give the instrument, whatever its form and 
r ame, a blunt probe-point, which shall run easily along the groove of 
the staff, and be incapable of inflicting any wound. The other 
principle of construction consists in giving to the blade of the cutting 
instrument such a width as to determine the exact depth of the 
incision intended; so as to ensure that this depth shall not depend on 
the hand or judgment of the surgeon at the moment of operating, but 
solely on the pre-arranged depth of the blade itself. 
These principles serve to classify all the very numerous instruments 
referred to, and reduce them to a position in which we can consider 
their merits. 
The instrument which illustrates the first class is the simple 
probe-pointed knife, or bistoury; one of the earliest and best-known 
Fig. 22. 
Sir William Blizarci’s probe-pointed knife. 
forms being that of Sir William Blizard, whose name it still bears (fig. 
22). This, or some other form of it, of which several are exhibited 
in the adjacent figures, has been used by many of the best operators 
in order to make the deep or final incision, on the alleged ground of KNIFE AND GORGET COMPARED. 
29 
its complete efficiency and superior safety to the sharp-pointed knife. 
But before exchanging his scalpel for this instrument the operator is 
very careful that the opening made into the urethra upon the groove 
of the staff is sufficiently large to admit the prohe-point easily, and 
he secures the opening with his finger-nail during the change. Pro- 
vided this is accomplished, there is no possible objection to the use of 
the probe-pointed knife, and if an operator has a conviction that it is 
safer in his own hands than the sharp-pointed scalpel, he should 
certainly employ it. With regard to any liability to injure the 
bladder in the use of the scalpel, if it exists, there can be no hesita- 
tion as to the propriety of adopting the guarded point. It is said 
that the opposite wall of a bladder has been perforated by the scalpel 
in Lateral Lithotomy, but in such a case its point must have left the 
groove in the staff, and have been freely exposed in the bladder, an 
act which, under no ordinary circumstances, can form part of the 
operation. 
For the numerous varieties of instrument, designated by the term 
gorget, which illustrate the second principle of construction referred 
to, the probe-point also is always employed. Nevertheless, the oppo- 
nents of the gorget condemn it mainly because it is alleged to slip out 
of the groove, although it possesses the same guide which is believed 
to preserve the knife in its place. This discrepancy requires to be ex- 
plained, and it is not difficult to do so. The slipping of the gorget is 
not necessarily due to inherent vice in the instrument, but in part to 
the particular mode of applying it, which has usually, but not inva- 
riably, been pursued ; viz. to the depressing of the handle of the staff 
by the operator’s left hand at the precise moment when with his light 
he thrusts on the gorget to the bladder. Thus the groove in which 
the beak is destined to run is suddenly raised, and loss of contact is 
liable to result, especially if the left side of the instrument like the 
first cutting gorget {of Hawkins) had a convex shoulder. Cline re- 
moved this disadvantage, making the left side straight, and placing 
the beak at the end of it. The practice of this double movement 
must, I think, be regarded as a principal cause of the slipping of the 
gorget. Had the staff been held steady throughout, as is the usual 
mode in modern Lithotomy (Mr. Key’s operation excepted), the gorget 
could have traversed it as safely and as certainly as the probe-pointed 
knife. The double movement is doubtless to be done safely enough, 
but it might be hazardous in the hands of a tyro. 
A. second and an influential cause of slipping existed in those gor- 
gets, the cutting edge of which forms an obtuse angle with the back 
of the blade; so that the bladder was pushed before the instrument, 30 
VARIOUS GORGETS. 
?ig. 23 (used as dilators of the urethra and neck of the bladder, in Fig. 27. ( line's gorget.—Savigny’s work, pi. iy. fig. 3. 
?ig. 24. the £ aPPara*us major,’ or Marian Operation.—Heister, Institut. vol.: Fig. 28. Sir A. Cooper’s double-edged gorget.—Idem, pi. yi. fig. 4. 
u-tab. 28. Fk;. 29. Scarpa’s gorget.—From one sent by Professor Scarpa to Mr. Crichton, 
IG. 25. The dilator of Cheselden.- Heister, Institut, vol. ii. tab. 31, fig. 9. of Dundee, now in my possession. 
?ig. 26. The cutting gorget of Hawkins—Savigny’s Collection of Engravings Fig. 30. Hr. Keith’s gorget.—From one in my possession, 
of Surgical Instruments. Lond. 1798, pi. iv. fig. 1. 
Fig 23. 
Fig. 24. 
Fig. 25. 
Fig. 26. 
Fig. 27. 
Fig. 29 
Fig. 29. 
Fig, 30. KNIFE AND GORGET COMPARED., 
31 
instead of being penetrated by it. This objection was also overcome 
by Cline, who gave it an acute angle. The various gorgets which have 
formed the leading varieties of this instrument from its first employ- 
ment as one of the instruments in the ‘ apparatus major,’ or Marian 
Operation, to the present day, are shown in the wood-cut on the pre- 
ceding page. 
The famous charge of John Bell, that ‘ the gorget slips f and all 
the surgeons of Europe confess it,’1 has been repeated perhaps too 
readily, doing much to discredit an instrument with which we should 
not forget that some of the most successful practice in this country 
has been accomplished.2 But why it should slip more than the probe- 
pointed knife, if similarly used, does not appear, and has never been 
explained satisfactorily. 
The essential practical difference between the two instruments is 
this : that, with the narrow-bladed instrument, or probe-pointed bis- 
toury, the depth of the internal incision depends on the angle it makes 
with the staff when pushed through the prostate and withdrawn; 
while with the gorget, the depth of the incision depends mainly on the 
breadth of the blade; that the wound shall not be too small is thus 
ensured, and it will not be too large unless the gorget is too wide or 
is not kept, as it enters the bladder, closely in a line with the staff. 
Sir Benjamin Brodie used and recommended a probe-pointed knife, 
of which ‘ the blade is broad enough to divide a considerable portion 
of the prostate as it enters the bladder, without its being necessary to 
increase the size of the incision by cutting laterally afterwards.’ This 
was really neither more nor less than a narrow-cutting gorget (fig. 32). 
John Hunter’s lithotomy knife was wider still, and was, indeed, a 
cutting gorget in disguise (fig. 31). So was Langenbeck’s (fig. 33), 
which had a spring catch, converting it, at the operator’s will, into a 
probe-pointed knife. The knife which Mr. Smith, of Leeds, used, and 
with much success, is a wide-bladed, probe-pointed knife. He has 
four sizes, adapted to the requirements of different cases (fig. 34). 
Between all these broad knives, and a well-made cutting gorget of 
moderate width, there is really no essential difference. 
Dr. Keith, of Aberdeen, uses a peculiar gorget; for ordinary cases, 
one which is seven-eighths of an inch wide; and for cases of en- 
larged prostate, one which is one inch and an eighth wide (fig. 30). 
The peculiarity of his instrument is this : that its edge, made at first 
1 Principles of Surgery, ] 826, voi. iv. p. 227. 
2 Mr. Green cut forty cases with the cutting gorget (of Cline) without a 
single casualty. Cline himself was very successful. It was usually about 
three quarters of an inch wide, and one inch for cases of enlarged prostate. 32 
GORGETS AM) PROBE-POINTED KNIVES. 
sharp by the cutler, is afterwards just blunted by himself with a file. 
It thus divides the substance of the prostate through which it is 
pushed, but is quite incapable of incising in any way the coats of the 
bladder. But it is to be recollected that he makes the deep incision 
with the probe-pointed knife first, and then employs this to extend it 
and to conduct the forceps. The form of Dr. Keith’s gorget is very 
nearly that of Cheselden’s instrument as drawn in Heister’s Surgery 
Fig. 31 
Fig. 32. 
Fig. 33. 
Fig. 34. 
Fig. 31. John Hunter’s knife.—Savigny’s work, pi. iv. fig 12 
Fre. 32. Sir B. Brodie’s knife.-From one in the possession of Messrs. Weiss and Son 
Fig. 33. Langenbeck s knife. 
Fig. 34. Mr. Smith’s (of Leeds) knife.-From one sent by Mr. Smith to the author. 
(see fig. 25) ; but it tapers a little less than that of Cheselden. Mr. 
Crichton also employed the cutting gorget in a very large proportion 
of his successful cases. He subsequently employed the probe-pointed 
knife, continuing to use the gorget still in cases of deep perineum and 
enlarged prostate. The two gorgets which he employed (which, as 
well as those of Dr. Keith, are in my possession) are made on the 
pattern of Cline. It is only fair to state that most of his worst cases 
were cut with it, the very cases in which his success was so remark- 
able ; and that he confessedly substituted the knife on account of the 
outcry against the gorget, and not because he disliked the latter. 
To this same principle of construction belong the ‘bistouries THE BISTOURIE CACHEE FOK LAST INCISIOIS'. 
33 
cachees,’ or lithotomes of all kinds (fig. 35); i.e. the depth of the 
incision depends on the breadth of the instrument, and is therefore a 
result more of mechanical arrangement than of the intelligence and 
skill of the operator. As in the gorget, its incision is the fruit of 
well-considered p re-arrangement, not of the surgeon’s judgment 
exercised at the moment. The bistourie cachee, and the cutting 
gorget, different as they are in appearance, and in the manner of 
their employment, are essentially the same in principle; the gorget 
cutting the desired depth inwards by pressure, the lithotome cutting 
it outwards by traction. Only the gox-get, owing to its tapered form, 
cuts rather less deeply at the internal extremity of the incision than 
at the outer, while the lithotome cuts accurately to the same depth 
throughout, and consequently incises rather deeply the neck of the 
bladder, a fact of importance, and rendering the gorget, perhaps, the 
safer instrument of the two. Blunt gorgets, that is, gorgets which 
have no pretensions to cut, are rather directors than gorgets in the 
sense in which we have been considering them. They are intended 
T'rn. nr,. 
The lithotome or ‘ bistourie cachee,' as used by many foreign surgeons to make the deep 
incision. A, a screw which regulates the extent to which the blade protrudes from the 
sheath. 
to dilate an already-divided prostate, and to furnish a safe guide to 
the forceps in certain cases. It was in this light that Cheselden 
viewed the instrument. 
Now, with respect to the choice which may he exercised among 
these methods of making the last incisions, there is a certain ease and 
simplicity in the use of a single knife, the sharp-pointed scalpel, which 
has-commended it greatly to modern surgeons, and, unless there are 
some exceptional circumstances present, it must be admitted to be 
both a safe and convenient instrument. It was always rrsed by 
Liston, and has been employed at University College Hospital by 
Mr. Erichsen, myself, and our colleagues ever since. Sir William 
Fergusson also always employed it. 
But, on the other hand, there are circumstances in which the 
probe-pointed knife may be superior. When the stone is large, and 
the deep incision must therefore correspond to it, the latter is a safer 
instrument, since its point leaves the staff in that act. When the 
perinertm is deep, as in very stout subjects, and in those suffering 34 
parallelism between the incisions. 
from enlarged prostate, so that the finger cannot follow the knife as 
far as to the neck of the bladder, I prefer the probe-pointed knife for 
the last incision, as well as the blunt gorget to dilate it, and conduct 
the forceps into the bladder. I have adopted this method with 
advantage in a few cases where the prostate has been unusually 
large.] 
There is one more important point to be noticed in relation 
to the last incision. It is its want of exact parallelism with 
the external incision. The surgeon is often advised by authors 
to take care that the plane of the incision at the neck of the 
bladder should be identical with that of the external wound. 
Superficial and deep incision in Lateral Lithotomy. The former is represented by a 
dotted line ; the latter by a black line. 
Practically, it never is, and rarely can be so; and it is unwise 
to conceal the fact. A glance at the diagram (fig. 36) will 
show the difference between the direction of the two incisions. 
Neither is there any evil in this want of parallelism in respect 
of the withdrawal of the stone; while the near approach to a 
horizontal line is the safest direction for the last incision. 
That incision, indeed, was nearly if not quite a horizontal one MANAGEMENT OF THE FORCEPS. 
35 
with most of the best lithotomists of the last generation, 
whether using the knife or the gorget; sometimes, indeed, 
with the latter instrument, it inclined upwards. For it is ne- 
cessary to recollect that if the incision in the prostate be made 
in the same direction as that of the skin, the limits of the 
gland would be more easily exceeded. The line of safety 
through the prostate and neck of the bladder, whether we 
regard the distance of its enveloping capsule from the staff, or 
the situation of the seminal ducts, is a slightly oblique line, 
directed rather nearer to the horizontal than to the perpen- 
dicular. And, inasmuch as all such incisions, whether internal 
or external, produce in the tissues openings more or less oval 
in form, there is far less want of correspondence between the 
axes of different portions of the entire wound than might be 
theoretically supposed. The finger passing through a wound 
so made, if it be cleanly and neatly incised, feels it to be direct 
and cylindrical throughout. It is quite an error to suppose 
that want of parallelism between an internal and external 
incision made in soft tissues, to which a considerable amount of 
dilatation is to be applied, affects the form or capacity of the 
route. 
III. The forceps being now in the bladder, one blade below 
on the floor, the other above, the instrument is opened freely 
and fairly, a handle lightly held in either hand ; and as the 
urine flows out, the stone may be found between them on 
closing ; if not, they are to be kept closed and slightly moved 
right and left, to ascertain on which side the stone lies. Sup- 
posing it can be felt lying on the outer side of the blades, which 
still occupy the position first described, the upper blade is 
raised, by simply depressing the lower handle, and when pretty 
widely separated, they are slowly turned over to that side and 
closed, when the stone will almost certainly be felt within the 
grasp of the instrument. If so, and the withdrawal feels easy, 
it is made at once, first rotating a little the forceps on its own 
axis, to make sure that nothing else is included but the stone. 
If the angle of the handles indicates that the blades are wide 
apart, the point of the fore-finger should be slid along the 
instrument to ascertain the size and position of the stone, and 
to readjust the latter if possible. The long axis of the stone 36 
MANAGEMENT OF THE FORCEPS. 
should correspond with that of the forceps, and its narrowest 
diameter should be presented to the blades. If the operator 
fails to seize the stone, he must still proceed cautiously, and 
avoid all rapid, plunging, and uncertain movements of the 
instrument in the cavity of the bladder. And when the stone 
is fairly seized, the extraction must be slowly and cautiously 
accomplished ; the greatest amount of dilatation of the neck of 
the bladder and prostate has generally now to be made, and it 
is more than ever necessary that it be done slowly and judi- 
ciously. The forceps must be held so firmly as to secure the 
stone, but not be grasped so as to crush it. They should be 
slowly moved from side to side while steady traction is made 
in the direction of the wound, and consequently in a line 
obliquely downwards towards the operator’s right side. It is 
quite impossible to overestimate the importance of slow and 
cautious action in this stage of the proceeding. 
The stone removed, a searcher should be passed into the 
bladder and a gentle exploration made, to ascertain whether 
others exist. The calculus itself may be examined for facets 
on its surface, which are almost always, but not invariably, 
indications that it was not the only calculus present. On the 
other hand, the absence of facets is by no means absolute 
proof that no other stones are in the bladder. If one or more 
are found, their extraction must be made by the methods 
already described, taking care not to injure the bladder by 
haste or violence, which is now the main evil to be feared. 
If the stone is found to be unduly large, so that, although 
grasped in the most favourable position for extraction which its 
form admits, the divergence of the blades proves to be too 
great, or is obviously so, for extraction through the wound, one 
of two courses, at least, remains to be adopted : either to en- 
large the wound, or, to crush the stone, in situ. These alter- 
natives, however, are rarely presented. Stones weighing 
nine ounces, and entire, have been successfully removed by the 
single incision. Crushing in situ, with an empty bladder con- 
tracting on the calculus, is a dangerous expedient. Neverthe- 
less, when the stone is too large to remove by any wound which 
it is prudent to make, this course has been of late years usually 
adopted. It has been successful with a stone weighing upwards HAEMORRHAGE FOLLOWING OPERATION. 
37 
of 14 ounces. See discussion of the subject in Chapter VI., on 
the Difficulties and Dangers met with in Lithotomy. 
IV. The Haemorrhage, which should be watched through- 
out, is now to be especially regarded before anything else is 
done. If an arterial jet is seen within reach, a ligature is to 
be used, or it may be arrested by torsion; if arterial bleeding 
is taking place freely from a deep part of the wound, its source 
must be carefully sought, and ligatured if possible. It is very 
rare indeed that an arterial jet cannot be so commanded, if 
ordinary patience and skill are exercised. But if the ligature 
cannot be applied in the usual manner, it may, perhaps, be 
passed beneath by means of a curved needle, and the current 
stopped by a knot made upon the bleeding point. A safe and 
efficient mode, when the difficulty is great, is to use a tenaculum 
of the common form, but connected with its handle by means 
of a screw, so that the handle can be detached at pleasure: the 
hook of the instrument is passed under the mouth of the vessel, 
a noose of thread or silk is thrown round the soft parts beneath 
and tied ; the handle is then unscrewed, and the hook left in 
its place. I believe I have saved a life on two or three occa- 
sions by tying in the tenaculum.1 
Of similar service, doubtless, is a contrivance by Dr. dross, 
which he calls c the compressing forceps.’ It consists of blades 
resembling those of a pair of slender dressing forceps, wdth a 
screw combining the handles : this or any of the numerous 
forms of bull-dog forceps acting on a similar principle, can be 
applied and left in place.2 
In the very rare instances of failure by such means, while 
nevertheless the pressure of a finger on the bleeding point 
itself, or on the pudic artery, commands the haemorrhage, a 
trustworthy assistant or two may be employed to keep up such 
compression for a few hours, at the end of which time, if it has 
been steadily and unremittingly applied, the object will have 
1 I am indebted to Dr. Keith, of Aberdeen, for the tenaculum with the 
screw (tig. 19, p. 20), which adds much to its convenience. In the cases re- 
ferred to in the text, the handle was immovable, and was much in the way ; 
in one instance the instrument remained ten days in the wound, coming away 
by itself at the end of that time. 
- I'rinary Organs, by Dr. Gross, 3nd cd. p. 260. 38 
HEMORRHAGE AFTER OPERATION-. 
been secured. In the absence of such means, and where all 
other methods have failed, a ligature placed round the pudic 
artery as it lies under the ischio-pubic ramus has been found 
successful. But if the hsemorrhage is venous, the blood being 
dark in colour, flowing freely, but not in jets, it arises most 
probably from some of the veins about the apex of the prostate 
which have been divided. This is sometimes a difficult matter 
to control. Ordinary plugging of the wound with lint or 
sponge is very inefficient, and may rather mask the occurrence 
of bleeding than prevent it, by confining the blood to the cavity 
of the bladder. A more efficient method is the employment of 
an addition to the gum-elastic tube often introduced after the 
operation, to convey awTay the urine. This consists in fastening 
round the tube, about an inch from the end, a piece of strong 
but soft muslin, or fine linen, arranged, if I may use such a 
simile, like a petticoat, reaching to the opposite end. The 
material is to be plaited in a few folds there, to give room, 
after the instrument has been introduced into the bladder, for 
strips of lint to be tightly packed into the cavity around the tube 
between it and the enveloping material described (fig. 17, p. 19). 
But this and all other modes of checking haemorrhage, the 
arterial jet alone excepted, which should always if possible be 
ligatured, are superseded by the air tampon described on page 
19, fig. 18. Even moderate arterial bleeding may be safely 
dealt with by this apparatus, relative to which however the 
law just laid down should as a rule be adhered to. With the 
tampon the operator may feel always safe; and indeed no one 
should ever perform lithotomy without one at his side. All 
provisions and directions relating to icebags, irrigation, etc., 
formerly described, are now unnecessary, since this is absolutely 
efficient if it be only properly applied. 
Supposing there is merely a little general oozing from the 
wound, it is sufficient to inject a large syringeful or two of cold 
water through a long bulbous-ended tube (fig. 7, page 15) into 
the bladder, from which it returns in a current, and then to 
introduce a simple gum-elastic tube about six or seven inches 
long, to prevent the inner portion of the wound becoming 
stopped by clot or otherwise, and producing retention of urine. 
The tube is fastened by tapes to a bandage round the patient’s AFTER TREATMENT OF THE PATIENT. 
39 
middle ; but care must be taken that the end of the tube does 
not project far into the cavity of the bladder and become a 
source of irritation there. But it is by no means certain that 
a tube is necessary. Many operators have discarded it alto- 
gether, and are satisfied with the result. I have done so for 
some years, and the wounds appeared to close better and more 
quickly in consequence, some indeed almost by the first intention. 
After Treatment.— The patient is next to be put to bed. 
This should be a firm, wTell-made mattress, guarded by water- 
proof cloth. A dry and warm draw-sheet is to be placed beneath 
his buttocks, so that the wound and all that issues from it is 
clearly visible. On this account it is desirable that the window 
of the apartment should face the foot of the bed. Each lower 
limb is to be semiflexed at the knee, and to repose easily, 
inclining outwards on a pillow. The attendant will watch 
sedulously the flow of urine and the oozing of blood during the 
first twenty-four hours; if the tube appears to be blocked, a 
feather must be passed through its entire length to ensure 
freedom of passage. What he desires and expects to see is the 
outflow of clear unstained urine before the end of that period; 
which demonstrates the cessation of haemorrhage and the proper 
action of the kidneys. Opium may be administered, and in a 
full dose, if there is much pain, spasm, or restlessness ; but it 
is better to do without it, unless manifestly wanted. I cannot 
coincide with the conventional practice of giving thirty to forty 
minims of tinctura opii, or Battley’s liquor, simply because a 
formidable operation has been submitted to, since in many con- 
stitutions it deranges the stomach and liver, constipates the 
bowels, and injures the capacity for taking or digesting nutri- 
ment. Cleanliness is of the greatest importance : the draw- 
sheets must be very frequently changed; the nates are to be 
kept clean by the occasional application of a soft moist sponge, 
and all sources of impurity are to be speedily removed. A 
clean napkin, folded several times, should be placed every hour 
beneath the end of the tube, and subsequently to its withdrawal, 
in the same situation, to absorb the urine. Mild, unstimulating 
diet, chiefly in the fluid form, such as milk and animal broths, 
should be freely afforded at first, until the stomach desires 
solid food, which may then at once be given. There should be 40 
TREATMENT AFTER THE OPERATION. 
no unnecessary haste to give aperients; and three or four days 
may well elapse after the operation without any anxieties on 
that head. I have seen mischievous irritation of the pelvic 
viscera set up by a purgative dose, for which no real occasion 
existed. As the case progresses, care must be taken, especially 
with elderly patients, to avoid irritation of the skin of the back 
and buttocks, which, if neglected, might produce bed sores. 
The surface is to be defended from the contact of urine by the 
free use of common ointment, and hardened by the occasional 
use of astringent lotion, or by simple brandy-and-water. A 
proper position of the patient is by no means unimportant as 
favouring the desired result; the head, shoulders, and upper 
part of the trunk should be kept rather high, so that the 
wound is placed as much in a depending position as circum- 
stances admit. The patient should lie alternately on his right 
and left side for a few hours at a time, so as to change the 
direction of the urine and other discharges. 
After the first twenty-four hours, the edges of the wound 
being a little swollen, urine frequently passes two or three 
times by the urethra; after twenty-four or thirty-six hours 
more it passes entirely through the wound. Subsequently, it 
may be expected, in the cases of adults, to pass in part through 
the urethra, by about the eighth to the twelfth day; and to 
cease issuing through the wound in about three weeks after 
operation. There is much difference, however, in this matter ; 
many weeks elapsing in some instances before the final healing 
of the perineal wound, which, indeed, in some few instances 
remains permanently fistulous; while in others healing really 
occurs by first intention. It would be unjust to the memory of 
Mr. Crichton to pass over the last-named circumstance without 
remark. It was a favourite subject with him; nevertheless, it 
appears to me difficult to regard it as one of great importance. 
He records thirty examples of it as occurring in his practice, 
a proportion which is extremely large. Of the cases presented 
to him, he selected the most healthy and vigorous for whom to 
attain this result; making his incisions free and clean, so as to 
offer surfaces adapted to unite readily. No tube was passed 
through the wound afterwards; a piece of wet lint was applied 
to it, and the legs fastened together. Occasionally retention of key’s OPERATION, 
41 
HEALING OF WOUND. 
urine occurred, with a good deal of pain, in which case the 
patient was put into a hot hip bath, which was a favourite 
remedy with him in all cases of severe abdominal pain arising 
within twenty-four or thirty-six hours of the operation. But 
if the stone was large, and had been difficult to extract, or if 
the patient was feeble, he generally employed the tube, and 
made no attempt at early union. It is remarkable how different 
are the opinions of operators as to the value of the tube. While 
some believe it to be a sine qua non to success, others attach 
no importance to it. That it can prevent access of urine to the 
newly-cut surfaces, as has been written concerning it, no one 
can seriously imagine after reflection, and certainly not after 
observation, since urine may be constantly found trickling by 
its side, as well as through it. It is undoubtedly a guarantee 
against retention, and may be made useful against haemorrhage, 
but it is also sometimes a source of irritation to the bladder, 
and I have seen a patient greatly relieved by its early removal. 
For the various accidents accompanying and following the 
operation, as well as the difficulties and dangers sometimes 
encountered in its performance, see Chapter VI. 
Key’s Operation on the Straight Staff.—The operation 
performed on a straight staff by Mr. Aston Key merits descrip- 
tion here, as a modification of the ordinary lateral operation, 
the consideration of which is now concluded. Mr. Key’s opera- 
tion finds favour with many of his former pupils ; and is still 
preferred by them, as it was by that able surgeon himself to 
the end of his career. The mode of performing it is given 
here in his owm words, which clearly delineate the method he 
adopted, and which is followed at the present day by the surgeons 
of Guy’s Hospital. 
‘ The mode of conducting the operation is as follows:— 
An assistant holding the director,' (or straight staff, fig. 37,) 
‘ with the handle somewhat inclined towards the operator, the 
external incision of the usual extent is made with the knife 
(fig. 38), until the groove is opened, and the point of the 
knife rests fairly in the director, which can be readily ascer- 
tained by the sensation communicated ; the point being kept 
steadily against the groove, the operator with his left hand 
takes the handle of the director, and lowers it till he brings 42 
key’s operation on straight staff 
Fig. 37. 
Fig. 38, 
the handle to the elevation described in 
PL III.,’ (that is, until the sound makes 
an angle with the horizon of about thirty 
degrees,) ‘ keeping his right hand fixed; 
then, with an easy simultaneous movement 
of both hands, the groove of the director 
and the edge of the knife are to be turned 
obliquely towards the patient’s left side; 
the knife having the proper bearing is 
now ready for the section of the prostate; 
at this time the operator should look to 
the exact line the director takes, in order 
to carry the knife safely and slowly along 
the groove ; which may now be done with- 
out any risk of the point slipping out. The 
knife may then be either withdrawn along 
the director, or the parts further dilated 
according to the circumstances I have ad- 
verted to. Having delivered his knife to 
the assistant, the operator takes the staff in 
his right hand, and passing the fore-finger 
of his left along the director through the 
opening in the prostate, withdraws the di- 
rector, and exchanging it for the forceps, 
passes the latter upon his finger into the 
cavity of the bladder.’ 
‘ In extracting the calculus, should the 
aperture in the prostate prove too small, 
and a great degree of violence be required 
to make it pass through the opening, it 
is advisable always to dilate with the knife, 
rather than expose the patient to the inevit- 
able danger consequent upon laceration.’1 
1 Treatise on the Section of the Prostate Gland in 
Lithotomy. By C. Aston Key. Loud. 1824. Pp. 28-BO. 
Figs. 37. 38. Key’s knife and staff, from fiis work, plate iv. 43 
CHAPTER III. 
THE OPERATIONS OF LITHOTOMY PERFORMED IN THE CENTRAL 
PORTION OF THE PERINEUM. 
Numerous Attempts made to improve on Lateral Lithotomy,—The Bilateral 
Operation of Dupuytren.—The Meclio-bilateral.—The Median.—Dr. 
Buchanan’s Method.—The Recto-vesical Operation. —Modifications.— 
Cutting and Crushing combined.—Lithotomy as applied to Children. 
The preceding chapter has been devoted to the Lateral 
Operation, in order to describe it fully, because many of the 
minute details of management are common to it and to other 
forms of Lithotomy, and are therefore given once for all; and 
because it may fairly be regarded as the standard with which 
such other modes of operating, next to engage our attention, 
should be compared. 
For the problem has been presented for years, and is still 
presented to us, although less urgently since the success of 
Lithotrity for the smaller stones has been completely esta- 
blished :— 
Is the Lateral Operation the best mode, in all cases, of 
extracting, through the perineal region, a calculus from the 
bladder ? 
That its results have not satisfied the expectations, or, at 
all events, the wishes, of many surgeons, is evinced by the 
numerous efforts which have been made from time to time, by 
the most experienced operators, to discover a better method. 
Witness the Recto-vesical Operation of Hoffman, Sanson, and 
Vacca—the Bilateral of Dupuytren—the Medio-bilatoral of 
Civiale ; and the Median of the Italian surgeons, with that 
form of it adopted here of late years, to say nothing of the 
endless lesser modifications which have been many times pro- 
posed, forgotten, and reproduced. 44 
central and lateral operations. 
One thing strikes a careful observer ; it is that all the 
other operations which have at any time held a position, or 
are exciting attention, in the surgical world, are essentially 
operations performed in the centre of the perineum, and not 
on either side, or lateral division of it. All are central in the 
sense in which it is opposed to Lateral. 
True, one is called Bilateral, but we shall soon find that it 
possesses characters which refer it distinctly to the central 
group. 
During the last fifty years especially, there has been a 
growing conviction that incisions made in the side of the 
perineum are attended by serious dangers, which may be 
avoided by incisions limited to the centre. 
First, it has been believed that severe haemorrhage is less 
likely to follow incisions in the centre than in the lateral 
division of the perineum, because the great vessels lie in this 
latter portion, provided further that the median incisions do 
not much involve the bulb. 
Secondly, it has been believed that the capsule of the 
prostate is less likely to be divided, and consequently that the 
cellular interspaces between the pelvic viscera are less likely to 
be opened by incisions in the centre than on one side only of 
the perineum. 
Unquestionably, it must be agreed by all that the ana- 
tomical necessities of the region, if alone considered, demand 
that, in the preliminary incisions of all Perineal Lithotomy, 
central or lateral, the operator should avoid the upper and 
outer parts of the perineal space, and that he should confine 
the deep ones within the limits of the prostate gland. But 
there is another necessity, not an anatomical but a vital one, 
less obvious, possibly, to the casual observer, but not a whit 
less urgent, and with which the former must be reconciled, 
viz:—the important fact that the internal opening must be 
sufficiently free to admit the instrument and the stone to pass 
without the exercise of so much force as to hazard the de- 
struction of the tissues at or about the neck of the bladder. It 
is the clashing of these two opposed considerations, the vital 
and the anatomical, which will, probably, always maintain a 
difference of opinion and of practice in Lithotomy. One school DUPUYTRENS BILATERAL OPERATION. 
45 
will be most influenced by the dangers to which Anatomy 
demands attention. Another school will be most impressed 
with the injury which the tissues suffer when incisions have 
been unnecessarily limited. The difficulty is to reconcile them ; 
to find precisely the safe medium of action. It must vary in 
different cases; and the knowledge and the judgment of the 
operator must decide the question in each. 
It was under the influence of anatomical considerations 
that Dupuytren was led to devise his Bilateral Operation. To 
avoid the arterial branches springing from the great trunk 
of the pudic on the lateral boundary; to avoid the bulb 
above and the rectum below ; to avoid by two minor inci- 
sions springing from the central axis any division of the 
prostatic capsule by the single large incision directed to one 
side, he planned the following procedure, and first performed 
it in 1824. 
Dupuytren’s Bilateral Operation.—Having introduced 
a staff with a median groove, he made a crescentic incision 
above the anus with the horns of the crescent downwards. 
Each extremity reached midway between the anus and the ad- 
jacent tnber ischii, and the middle or highest point was distant 
from the anus about ten or twelve lines. By this incision 
were divided the skin, the superficial fascia, and a little of the 
external sphincter. In the next, the membranous urethra was 
opened transversely, and sufficiently to admit the operator to 
introduce the end of a two-bladed lithotome into the groove of 
the staff. This was pushed onwards into the bladder, the 
stone felt with it, and the staff removed ; the blades being then 
opened to an extent previously provided for, they were steadily 
withdrawn in the middle line and in the horizontal plane. By 
this means an incision nearly transverse, but also somewhat 
obliquely downwards, was made of the neck of the bladder, and 
into each lateral lohe of the prostate. In a few years- after- 
wards some slight modifications of this proceeding were made 
by various operators, but they possess only historical interest, 
and have no practical value. Fig. 39 shows the two-bladed 
lithotome which he employed ; and fig. 40 a diagram of the 
incision superficial and deep. 
The Mldio-bilateral.—We next come to a method which 46 
DIAGRAMS OF DUPUYTREN’s OPERATION; 
Civiale describes in his ‘ Paralleled 1 published in 1836. 4 Being 
dissatisfied,’ he says,4 with the results of the bilateral operation, 
and shunning the lateral method on account of the anatomical 
objections referred to,’ he first practised a rnedio-bhateral 
Fig. 39. 
Fio. 40. 
The double-bladed lithotome, 
for the bilateral and medio- 
bilateral operations. A, the 
screw which regulates the ex- 
tent to which the blades open, 
o, the sheath with the blades en- 
closed. d J), the blades opened. 
Diagram of superficial and deep incisions in Bilateral 
Lithotomy. The former is represented by a dotted line, 
the latter by a black line. 
method in 1829, and has performed it ever since. It is 
remarkable that this operation, although now upwards of thirty 
years old (1863), appears to be little known in this country. 
i Parallel# de* 'Hirer* Mot/en*, &e. Paris, 1836. Pp. 192 and 217. AND OF MEDIO-BILATEKAL OPERATION. 
47 
I believe it has never been even described here, which is 
still more remarkable, considering its near relationship to the 
median operation, and the fact that this has been so much 
discussed here of late years. I have myself witnessed the 
successful performance of it in its author’s hands, and have 
been, I believe, the first to perform it in this country, in a 
case which occurred during the autumn of 1861, and have 
repeated it several times subsequently; but not during the 
last ten years. 
Civiale’s method of doing it was as follows:—Having in- 
troduced a staff with a median groove, which is firmly held 
resting against the pubes by an assistant, he made an incision 
about an inch and a half long in the raphe of the perineum, 
immediately in front of the anus, and carefully cut down in the 
direction of the staff, endeavouring to avoid the bulb, until he 
reached the membranous portion of the urethra. He then 
Fig. 41 
Incisions superficial and deep in the Medio-bilateral Operation 
carried his knife into the staff in that situation, by an incision 
sufficiently large to enable him to insert with ease the end of a 48 
THE MEDIAN OPERATION. 
double-bladed lithotome, resembling that of Dupuytren, but 
straight instead of curved, into the groove of the staff. He 
then pushed the beak of the lithotome steadily onwards into 
the bladder, and having done so, drew it outwards in the 
groove, towards himself, dividing the neck and the prostate 
horizontally, as well as the deep fascia in its course. The 
external wound is oval in form, a vertical incision in the 
perineum always becoming so; hence the skin is not cut 
transversely by the lithotome in the act of withdrawal. The 
finger is now introduced, and the forceps upon or guided by it, 
in the usual way; the external and internal openings are felt 
to correspond, and to form an easy and direct route for the 
removal of the stone. I have seen Civiale remove a stone 
weighing one and a half ounce by this method, the patient, a 
man forty-five years of age, making a good recovery. The 
breadth of the internal or horizontal incision is less than in 
Dupuytren’s operation, in which the two blades of his lithotome 
were extended so as to be one and a quarter to one and a half 
inch apart. Civiale advises that they should ordinarily be 
one inch apart, and never or very rarely more than an inch 
and a quarter (fig. 41). 
Median Operation.—The Italian or median method, known 
here as Allarton’s operation, is the next in order to be described. 
The operator having placed a staff with a median groove in the 
bladder, and entrusted it to an assistant to maintain strictly in 
the middle line, and resting closely on the pubic symphysis, 
places his left forefinger in the rectum, with its palmar surface 
upwards, to determine the apex of the prostate, placing the 
point of his finger upon it. Next, he transfixes with a long 
and straight bistoury, the cutting edge of which is directed 
upwards, the integuments of the perineum, in the median line, 
commencing about half an inch anterior to the anus, and carries 
it steadily onwards until it enters the groove in the staff, and 
pierces the urethra about the membranous portion, the finger 
in the bowel rendering this manoeuvre tolerably easy. Having 
pushed the point of the knife, which should cut for a small 
space at the back, onwards towards the bladder for the extent 
of a few lines, so as just to incise the apex of the prostate, he 
cuts upwards, dividing the urethra a little, and making an INCISIONS OF THE MEDIAN OPERATION. 
49 
external incision from an inch and a quarter to an inch and a 
half long, according to the presumed necessities of the case. 
He then introduces a long ball-pointed probe through the 
Fig. 42, 
Incisions in the Median Operation, 
wound into the bladder to serve as a guide for the left index 
finger, which immediately follows directly into the bladder, and 
the staff is at the same time withdrawn. The stone may now 
be felt, and the wound dilated by means of the finger. Mr. 
Allarton has recommended, if the finger be insufficient for the 
purpose, the use of Dr. Arnott’s hydraulic dilator; and Mr. 
Teale, of Leeds, has designed and employed a branched metallic 
dilator. I cannot, however, concur in advising the employment 
of mechanical force in dilating the structures forming the neck 
of the bladder, believing it far safer to make an additional 
section when necessary. Respecting the modes of making the 
incisions, I prefer dissecting from the skin inwards to the staff 
as in other operations, to the method by transfixion above 
described, and have done so in most of my operations by the 50 
INCISIONS OF THE MEDIAN OPERATION. 
median method: maintaining the left forefinger in the rectum 
during the final strokes of the knife to feel its position, and 
ensure the safety of the bowel. 
The incisions here described differ little from those of the 
Marian, except in being carried further back than in the 
ancient method, and hence leaving a shorter portion of the 
urethra, the prostatic only, to be dilated. As before noticed, 
the danger of the Marian arose from the practice of forcibly 
rending asunder the urethra and neck of the bladder, a pro- 
ceeding infinitely more fatal than division by the knife, which 
the anatomical theory, so greatly in the ascendant at that time, 
had, unhappily, proscribed. 
Of all the cutting operations for stone, it is unquestionable 
that the median still presents that in which the bladder is 
reached with the smallest amount of section by the knife. And 
it appears to become dangerous, just in proportion as injury 
by laceration or over-pressure, under the name of dilatation, is 
superadded to the incisions. These latter involve the bulb to a 
small degree, which is the only structure of importance divided 
by the knife besides the prostate, and this latter is only slightly 
notched at the apex in the ordinary mode of performing the 
operation. But when the deeper parts of the wound feel more 
than usually rigid and unyielding, or when the stone proves to 
be larger than was anticipated, it is advisable to make an 
incision in the left side in the same direction as in Lateral 
Lithotomy, but generally less extended, for the purpose of 
affording more space. This is accomplished after the urethra 
has been opened, by introducing a long, straight, probe-pointed 
bistoury, guided by the left index finger, and made to incise 
as much as the operator deems necessary. Unless this or some 
similar proceeding be adopted, the opening is certainly small, 
and feels tight to the finger, and, if the stone is large, appears 
to me to require an additional incision. 
After all, the anatomical axiom laid down at first must not 
be forgotten, viz. that any operation, the incisions of which lie 
altogether in the line above the anus and below the symphysis 
pubis, unless aided by a lateral section, never can afford an 
opening sufficiently capacious for the removal of large stones 
without dangerous laceration. Examine the pelvic outlet, and OPERATION ON THE ANGULAR STAFF. 
51 
contrast the want of space in this situation caused by the con- 
verging pubic rami, with the room which exists in one of its 
lateral divisions, and the correctness of this assertion will, 1 
think, be manifest. 
Buchanan’s Operation.—The Operation of Dr. Buchanan 
with the Angular Staff. This proceeding, generally known as 
the operation with the angular staff, is, however, not rendered 
distinctive solely by the use of that instrument. The angular 
staff does not constitute the main element which characterises 
it from other proceedings, although it is one of its features, and 
perhaps, at first sight, its most obvious one. Thus it is that 
this character has taken hold of the public mind, and, by its 
prominence, has somewhat concealed the more important attri- 
butes of the operation. It is essentially a central operation, 
but with a freer internal opening than is provided in the 
median. The angular staff is intended to be a safe and efficient 
guide to the deep part to be incised, viz., the membranous 
urethra and apex of the prostate. Such a staff has been used 
a century or more ago in the lateral operation, a fact which 
detracts nothing from any merit which may attach to the 
present procedure. 
Actuated by his conviction of the anatomical dangers of 
Lateral Lithotomy, Dr. Buchanan, of Glasgow, called attention, 
in 1847, to the advantages of operating in the central part of 
the perineum instead of the lateral, and of employing a staff of 
rectangular form, on which to make the necessary incisions. 
It is somewhat remarkable that his method has never been yet 
correctly described in our language, and I am indebted to Dr. 
Buchanan for a description in French, which he informs me is 
the most accurate now existing. I must confess that until I 
became acquainted with the latter I had not a correct idea of 
the proceeding. It may be briefly described as follows :— 
Instead of possessing any curve, the terminal portion of the 
staff, three inches in length, is directed at a right angle to the 
shaft, and contains a deep lateral groove. This is introduced 
into the urethra, and by means of the left forefinger in the 
rectum the angle is made to correspond in situation with the 
apex of the prostate, so that the gland can be felt just beyond, 
between the finger and the staff; the latter being well de- 52 
MODE OF PERFORMING THE OPERATION 
pressed, the angle is brought near to the surface and is readily- 
felt in the perineum. The staff is then carefully maintained 
in this position by an assistant. The operator keeping his 
finger still in the rectum, enters a long straight bistoury 
opposite the angle of the staff, and therefore immediately in 
front of the anus : he holds it in his right hand, with the palm 
upwards; the blade horizontal and the edge directed to the 
left; and he pushes it straight into and along the groove as 
Pig. 43. 
Incisions superficial and deep in Dr. Buchanan’s Operation 
far as to the stop at its extremity. He thus enters the bladder 
at once, taking care to keep the blade parallel with the hori- 
zontal or grooved portion of the staff throughout the whole of 
the thrust. Next he withdraws the bistoury slowly, but, as he 
does so, cuts outwards and downwards a distance rather more 
than equal to another breadth of his blade, and then directly 
downwards to the same extent, describing, in this manner, a 
curved line equal to about one-fourth of a circle round the 
upper and left side of the rectum (patient’s left), in which his 
finger still remains. An external wound, surrounding the ON the angular staff. 
53 
corresponding part of the anus, about one inch and a quarter 
in length, results from the operation. The knife is a long 
straight bistoury, about a quarter of an inch wide, with three 
inches of cutting edge, and the point sharp at the back as well 
as at the front, so as to penetrate with facility. 
This is essentially a median operation, all large arterial 
branches in the lateral part being avoided, while the bulb is 
not cut, but the left half of the prostate is incised to a small 
extent. 
Thus far it is, as expressed by Dr. Buchanan himself, about 
equal to the half of Dupuytren’s Operation. If the stone is 
large, an incision is made on the right side of the prostate, 
which has the effect of converting the proceeding very nearly 
into the operation referred to. But it is also capable of being 
extended in another way, since if the incision by the side of the 
rectum and through the prostate be continued much beyond 
the extent described by its author, in the original direction, 
it becomes a lateral operation placed very low in the pelvic 
outlet.1 
1 Dr. Corbet, of Glasgow, has added an external grooved director connected 
with the handle of this staff; after the introduction of the latter into the 
bladder, the point of the director has only to be pressed through the tissues 
into the angle of the staff, which it infallibly meets, and a route for the knife 
is made from the skin of the perineum to the bladder. (Medical Times, Dec. 
16, 1858.) Sir James Earle adopted the same system for Lateral Lithotomy. 
See a descriptive plate in his Practical Observations, 2nd edition, London, 
1803. Mr. Avery contrived a very ingenious apparatus by which a director 
was forced outwards by mechanism from the angle of the staff after the latter 
had been securely placed in the bladder; when the point of the issuing 
director had made its appearance through the skin, the operator commenced 
to travel along its route into the bladder. It may not be inappropriate to 
mention that Mr. John Wood, of King’s College Hospital, has designed and 
employed a staff, the lower part of which consists of two blades, which, at 
the will of the operator, may be made to expand a little in order to stretch 
the urethra and afford a wider groove for the knife. 
I hope I am not presumptuous in venturing to regard—I believe in common 
with many practised lithotomists—all these contrivances as entitled to rank 
rather among the curiosities of surgical appliance than as valuable aids to the 
operator. Elaborate mechanism cannot countervail the want of surgical tact. 
Where the latter exists, such aid is worse than useless, ‘ Tactus eruditum,’ 
the priceless and incommunicable heritage of experience, can only be acquired 
by the use of simple instruments ; by discarding complicated apparatus for 
all those purposes which can be attained by that most wonderful and intelli- 
gent instrument, the human hand. 54 
THE RECTO-VESICAL OPERATION. 
The Recto-Vesical Operation.—The patient is placed in 
the usual position, and a large staff with a median groove held 
firmly in the middle line. Taking a strong, straight, sharp- 
pointed bistoury in his right hand, the operator introduces it 
flat on the palmar surface of his left forefinger into the rectum, 
and feels with its tip the line of the staff. When about an 
inch and a half or an inch and three-quarters of the blade is 
concealed within the bowel, with the right hand he raises its 
edge, and carries the knife upwards to the groove in the staff, 
propelling the blade at the same time with the left forefinger. 
He thus divides, at this first incision, the upper wall of the 
rectum, the sphincter ani, and the integuments and subjacent 
tissues for about an inch in the middle line of the perineum. 
He should reach the groove of the staff in this first incision, 
and having done so, he next directs the nail of the left fore- 
finger, so as to enter the groove near to the membranous 
urethra, and guide the point of the bistoury into it there, the 
edge being now downwards. Having securely placed it in the 
groove, he pushes the blade from him along the staff, directed 
by the left forefinger, dividing the prostate and neck of the 
bladder so as to reach the trigone. The exact extent of this 
incision must depend on the size of the stone, and, as it may be 
presumed that this method should be employed only when the 
stone is unusually large, the incisions must of course be free. 
In no case, however, is it permissible to place in danger the 
peritoneal pouch, which limits the posterior border of the 
trigone. The finger can now easily examine the stone and 
guide the forceps in the extraction. The wound is favourably 
placed as an outlet for all discharges, and no haemorrhage need 
be feared. 
There are some variations in the manner of performing this 
operation, but the foregoing is the mode which has generally 
been regarded as the most successful, and the most likely to be 
free from disagreeable after consequences. 
Such are the methods of performing Perineal Lithotomy, 
which, after a careful consideration of the numerous proposals 
and modifications which have been made and practised, I have 
concluded to be the typical forms which are or have been em- 
ployed in modern times. Numerous others might have been COMBINATIONS OF CUTTING AND CRUSHING. 
55 
mentioned with which the names of several surgeons are con- 
nected, and who possibly may regard my selection as incomplete. 
Thus it may be considered by some that I should have included 
among them the Prerectal method, formerly introduced in 
Paris ; but it is difficult to admit that it possesses claims to be 
regarded as a new type, or, indeed, that it manifests much im- 
provement on any old one. This, however, is a matter of 
opinion. The operation so named is a modification of the 
Bilateral, in which the curved incision and subsequent dissec- 
tion are carried so close to the anus and rectum, that the first 
stage consists in a delicate dissection downwards of the upper 
surface of the rectum; a method adopted with the design of 
leaving the bulb untouched. The urethra is opened at the 
apex of the prostate, which is then incised with the two-bladed 
lithotome in the ordinary manner.1 
Attempts have also been made by several surgeons, both 
English and French, to combine cutting and crushing, so as to 
empty the bladder at one operation. The object has been, 
first, to open the urethra in the perineum, anterior to the 
prostate; a proceeding which we know involves very little, if 
any, risk; and then to introduce a crushing instrument, break 
up thoroughly the stone, and remove the debris at once. 
Theoretically this method has a better aspect than in practice. 
The difficulty in executing it is due in a great measure to the 
escape of urine by the side of the crushing instrument, so that 
before the work of breaking the calculus is completed the 
bladder is empty ; when the situation is no longer merely one 
of difficulty to the operator, but of danger to the patient. 
Much the same thing may happen in Lithotomy when the stone 
is crushed by inadvertence in the blades of the forceps; a good 
deal of instrumental manipulation is requisite in order to 
ensure the removal of every fragment, while the bladder is in 
some risk of being injured, or of becoming inflamed. As in 
the case of applying screw forceps to a stone too large to extract 
after the incisions have been made in the lateral operation, the 
risk of danger consists in the liability of the empty bladder to 
1 The Prerectal method is described by its author, Nelaton, in his Elemens 
dr Pathologic Chmvrgicale, tomev., p. 229. Paris, 1859. 56 
LATERAL LITHOTOMY IN CHILDREN. 
sustain severe injury.1 Recent improvements which have 
rendered the aspirator now employed in Lithotrity more efficient 
than formerly, tend greatly to diminish the necessity, if any 
existed, for removal of the debris of any ordinary stone by a 
perineal wound. 
Lithotomy as applied to Children.—In considering the 
various methods hitherto described, the common practice has 
been followed of assuming an adult to be the subject of the 
operation in each instance. And there is little occasion to 
modify them for the cases of children, the same procedures 
being applicable, for the most part, at all ages. Nevertheless, 
there are certain points of importance to be attended to in the 
application of Lithotomy to children, which will be briefly 
mentioned here. 
First, as to the kind of operation most generally applicable 
to the cases of infants and boys ; the lateral is generally, and 
no doubt correctly, held to maintain its superiority, as a rule, 
over other methods. The median and the medio-bilateral are 
both admissible. But especially where the stone is large, the 
lateral operation affords the opportunity of piaking a freer 
opening, and in a direction in which the incision is less liable 
than that of the median to injure the seminal ducts. At the 
same time, a lateral section carried beyond the limits of the 
prostate, which is an extremely small organ at this period of 
life, is almost free from danger, since it is beyond all question 
necessarily practised in almost all infantile cases, while the 
death-rate among them is not more than half what it is in 
adult age, at which time such sections, it is commonly believed, 
are extremely dangerous. 
In the performance of Lateral Lithotomy in children, the 
employment of one knife only is especially indicated. An 
exchange of the scalpel for the beaked knife exposes to some 
risk from the possibility of finding difficulty in the attempt to 
place the beak of a second knife in the opening made by the 
first, and thus of missing the groove of the staff altogether. 
The deep incision in the urethra and prostate should be made 
1 See also the subject considered in Chapter VI., under the head of Diffi- 
culties arising from the Extreme Size of the Calculus, with drawings of instru- 
ments for crushing it in the bladder, in Lithotomy. THE MEDIAN OPERATION IN CHILDREN. 
57 
with clearness and decision, and with sufficient freedom to 
admit the tip of the operator’s index finger with tolerable ease, 
otherwise he may drive the neck of the bladder along the staff, 
or slide the finger into the cellular interval between the bladder 
and the rectum. The staff should be strongly curved, and the 
finger and the forceps should be kept well up behind the sym- 
physis in their transit, in consequence of the high situation of 
the bladder, which, in very young children, lies, when distended, 
as much in the abdomen as in the pelvis. 
Hsemorrhage should be carefully guarded against, as its 
results in the shape of exhaustion are particularly dangerous in 
young subjects. The special sources of difficulty and danger in 
this operation will be considered in the sixth chapter, on the 
Difficulties and Dangers met with in Lithotomy. 
If the median operation is performed, it is desirable to use 
a guide into the bladder in the shape of a blunt gorget or some 
similar instrument, as the operator may find it extremely diffi- 
cult to introduce the finger into the small urethra of a child, 
when opened anterior to the prostatic or membranous portions. 
For this purpose I used with advantage, three or four years ago, 
an instrument of that kind, tapering in its contour, and having 
a probe point in its central axis. Mr. Bowman, and Mr. Teale 
also, about the same time, employed somewhat similar means 
for meeting the difficulty referred to, which each had en- 
countered. Figs. 23 and 30 present forms of gorget well adapted 
for the purpose, when made of the small size suitable for chil- 
dren (see page 31). By the use of any of these instruments 
the incised opening into the urethra is partly dilated and partly 
torn, a proceeding which appears to be attended by no evil 
results in children, whatever may be its effects in the adult 
patient. In the medio-bilateral operation, which I have em- 
ployed in the young subject, no such guide, of course, is neces- 
sary. The two-bladed lithotome glides easily along the staff 
into the bladder, and forms sufficient room for the finger in its 
withdrawal by laterally incising the soft parts. 58 
CHAPTER IV. 
THE SUPRAPUBIC OR HIGH OPERATION. 
Origin of the Operation.—Method of Performing in Detail. 
We now arrive at a consideration of the operations performed 
above the pubes, of which one is the type, known as The High 
or Suprapubic Operation. This appears to have been designed 
by Pierre Franco, and was certainly first performed by him in 
the year 1561. It w'as introduced into this country by Proby, 
at the close of the sixteenth century, and was frequently 
practised afterwards in the early part of the seventeenth cen- 
tury by Douglas, Cheselden, and others. Subsequently, it was 
studied with care and frequently performed by the Souber- 
bielles in France while Mr. Carpue, who had witnessed their 
practice, advocated it in this country. There are two or three 
modes of performing the operation, but that which appears to 
me the most complete, and which Civiale informs me he has 
practised several times, is as follows:— 
The patient is placed on a firm operating table of the usual 
height. He lies on his back, with the pelvis elevated at least 
four or five inches above the level of the loins and shoulders, 
so that the abdominal viscera shall not press on the bladder, 
but rather fall away backwards from it. The bladder, which 
should be capable of retaining a tolerably large quantity of 
fluid, is now to be injected to a full extent, so as to bring its 
apex to the upper border of the symphysis pubis, or above it. 
In this manner a sufficient space is obtained between the 
symphysis and the peritoneal investment of the anterior wall of 
the abdomen, where it quits it to cover the bladder. The 
limits of this interval admit of great extension, being filled 
mainly with cellular and fatty tissues of a very loose and exten- 59 
SUPRA-PUBIC LITHOTOMY. 
sible character, and this fact it is which furnishes the ground 
for operating in this situation. It follow’s, therefore, that if the 
bladder is not capable of considerable distension 
so as to rise into the interval in question, the case 
cannot be regarded as suitable. The surgeon 
now passes into the bladder the i Sonde a dard ’ 
(fig. 44), (an instrument having very much the 
form, size, and appearance of a large prostatic 
catheter), and by depressing its handle raises the 
point nearly to the level of the upper border of 
the symphysis. It contains within it a strong 
stylet with a cutting point, which latter is con- 
cealed close to the apex of the sound, and lies in 
its concavity, whence it can be made to emerge 
at the will of the operator. Having confided the 
‘ sonde a dard ’ to an assistant, he places himself 
on the patient’s right side, and commences the 
incision above the pubes, which should be about 
three inches or more in length, according to the 
amount of fat at this spot, and wdiich in some 
subjects is very abundant. It is to be made 
exactly in the median line, and at its lowest point 
should reach the top of the pubic symphysis. 
The cellular tissue and fat are divided to an 
equal extent, until the linea alba is recognised by 
its characteristic glistening appearance. Placing 
his left index finger on this, and verifying through 
it the upper border of the symphysis, he divides 
with the scalpel the linea alba at this point, in 
the median line, from a quarter to three-eighths 
of an inch, and then introduces the bulbous 
extremity of the aponeurotome (fig. 45), which 
by its form enables the tendinous 
structures to be incised without 
any risk to the parts beneath. 
The division is accomplished by 
directing the aponeurotome up- 
wards to the extent of one and three-quarters to two inches. 
The operator now takes the ‘ sonde a dard ’ from the hands of 
Fio. 44. 
The ‘ Sonde a dard.’ 60 
SUPRA-PUBIC LITHOTOMY. 
the assistant, who has hitherto held it in its place; and with 
the right hand depresses its handle between the thighs of the 
Fig. 45. 
The Aponeurotome. 
patient, directing the point to the wound above the pubes. 
With his left hand he seeks the end, now readily to be felt 
through the tissues still remaining uncut, and fixes it between 
the thumb, index and middle finger, taking care while doing 
so to remember that it is from the concave surface that the 
point will be protruded. Having rendered the instrument 
quite firm between his two hands, he directs the assistant to 
press the handle of the stylet so that the point issues from its 
place for two or three inches, and appears in the wound im- 
mediately above the symphysis. A communication with the 
bladder is thus perfectly established. The surgeon now takes 
an ordinary scalpel, and placing it in a groove existing for that 
purpose in the stylet, cuts downwards from the point of trans- 
fixion nearly to the neck of the bladder behind the symphysis. 
His forefinger is then applied, with its palmar surface upwards, 
to the top of the wound, to hook up the bladder, while the 
assistant withdraws the ‘ sonde a dard,’ having first replaced 
the stylet in its sheath. An instrument called the ‘ (xorgeret 
suspenseur ’ (fig. 46), but which we may term the hooked 
FIG. 46. 
gorget, now replaces the finger, and is committed to an assistant 
standing on the left side of the'patient. It is very important 
Hie hooked Gorget,’ ‘ Gorgeret suspenseur. SUPRA-PU13IC LITHOTOMY. 
61 
to maintain the top of the bladder steadily in place throughout 
all subsequent movements, and that the peritoneum, which is 
quite close to the wound at this point, should be preserved from 
injury. The surgeon now searches the interior of the bladder 
with his fingers, ascertaining the position and size of the stone, 
and introduces the forceps for its removal, which is generally 
tolerably easy, and may be effected by careful traction upwards 
and backwards. In a few' cases with stones of extreme size the 
fascia has been divided laterally to a small extent in order to 
afford additional space. I found this necessary in a case in 
which I operated, that of a gentleman aged sixty-seven, for a 
large, rather flat, uric acid stone, in 1877. 62 
CHAPTER V. 
CAUSES OF DEATH FOLLOWING LITHOTOMY, 
Causes of Death at different ages must be considered separately.—Causes of 
Death in Adults.—A. Deaths from Error or Mischance in the Operation.— 
Deep Incision may produce Haemorrhage, or divide tissues too deeply ; 
‘Infiltration of Urine’ not so produced.—Mechanical Yiolencein removing 
Stone.—Cheselden’s Directions ; Martineau, Pouteau, Keith, Humphry.— 
Perforation of Bladder by Staff.—B. Causes of Death not under control of 
Operator.— Organic Disease of Urinary Organs.—Exhaustion of Vital 
Power.—Peritonitis.—SepticEemia, —Tetanus.—Causesof Death in Children ; 
why differing from the preceding.—Peritonitis : very rarely, Infiltration. 
—Exhaustion, &c. 
We now arrive at the important subject of the causes of 
death following the operation of Lithotomy, And this will be 
studied with advantage before coming to an appreciation of the 
different modes of performing it already described. A careful 
consideration of numerous facts leads me to take views of 
this question which differ somewhat from those generally held 
respecting it. 
In the first place, it is impossible to regard the deaths 
following Lithotomy as a single aggregate or class, relative to 
which any leading particulars can universally apply. Nothing 
can be more deceptive than a method of dealing with the 
results of Lithotomy, whether numerically or otherwise, by 
which cases of all ages are treated indiscriminately in one 
category. The causes of death are not the same in adult life 
and in the period of youth ; indeed, they vary so much as to 
render a separate consideration of them necessary. Neverthe- 
less, it has been the custom to regard the fatal contingencies 
of all ages in the mass, without making this distinction. The 
differing liability to death at the two terms of life has, on the 
other hand, been amply demonstrated. I shall commence with a consideration of Lithotomy among 
adult patients. Afterwards the causes in children shall be 
investigated separately. 
Regarding adult cases, I shall divide the causes of death into 
two classes, the necessity for which must be obvious ; viz.— 
A. Causes of death originating in errors or mischance in 
the performance of the operation itself. 
B. Causes which are very slightly, or not at all, under the 
control of the operator, and existing for the most part 
in defective conditions of the patient’s constitution. 
A. Causes of death originating in errors or mischance in 
the performance of the operation itself. 
a. The 4 deep incision ’ may be such as to produce fatal 
bleeding, either at first, or occurring as 4 secondary haemorrhage ’ 
some days after. Probably this does not often happen as the 
result of any reckless use of the knife, although such an event 
is possible; and when it does arise, is more commonly due to 
the physical necessity for making a free opening for a large 
stone. But it may be also due to mischance, as from the 
irregular distribution and presence of a large artery in the 
ordinary course of the incision, an occurrence, however, which 
is usually to be controlled by the use of the ligature. 
b. The 4 deep incision ’ may also divide the prostate and 
neck of the bladder so extensively as to open the cellular in- 
terspaces between the pelvic viscera, and produce, as it is said, 
urinary infiltration there. Thus the great majority of writers on 
causes of death after lithotomy coincide in regarding 4 infiltra- 
tion of urine ’ as the most common cause of death, a statement 
that I venture not only to call in question, but to regard as the 
source of serious error in practice. Infiltration of urine may 
be one of the causes of destructive inflammation of the peri- 
vesical cellular tissue, but it must be a rare one. The doctrine 
based on this belief is as follows :—If the internal incision 
passes beyond the limit of the prostate in any direction, so as 
to open up the cellular interspaces behind the deep fascia, 
urine is almost certain to find its way into them, and if it does 
so, fatal inflammation will result; in order, therefore, to 
avoid this danger, the internal incisions must be extremely 
limited. 
CAUSES OF DEATH AFTER LITHOTOMY. 
63 64 
INFILTRATION OF URINE RARELY OCCURS. 
But infiltration by no means necessarily occurs when urine 
passes over the newly made section of cellular spaces so called. 
In fact, cellular interspaces between muscles and viscera do 
not exist, except when made by the anatomist for the necessary 
purpose of demonstrating the planes of cellular tissue which 
unite adjacent organs, and facilitate freedom of movement 
between them. I very much doubt if urinary infiltration ever 
occurs when they are otherwise uninjured, in a person of fair 
health. To judge from the language held respecting this 
subject, one would imagine that hollow intervals exist, between 
the organs in question, over which urine had only to be poured 
in order to be drained mechanically into them ! Even in the 
child, where the cellular connections are of the loosest and 
most delicate kind, and where the bladder is active, powerful, 
and irritable, urine flows constantly after lithotomy over a 
wound which affords free access to them : nevertheless, with 
what extreme rarity do we meet with urinary infiltration in 
the child. But if the cellular connections are first injured or 
inflamed, a condition is produced in which urinary infiltration 
may perhaps take place with fatal effect. 
I am aware that this doctrine is opposed to the generally 
received notions on this subject. I speak with great respect 
for existing views, but careful pathological study of the subject 
has convinced me that the true cause of death in the majority 
of cases, the cause that it most behoves the operator to guard 
against, is violence in opening up the internal part of the wound 
and laceration of the tissues there, and not the primary passage 
of urine into the cellular connections about the neck of the 
bladder. Happy is it if it be so, since the former it is in his 
power to avoid ; the latter occurrence, were it common, would be 
a danger inherent in the operation, and unavoidable with a 
stone much above the average size. 
c. Mechanical violence inflicted in the removal of the stone, 
especially when the opening is of insufficient size, is another 
cause. 
This probably affords the true explanation of certain ap- 
pearances revealed by autopsy, and formerly regarded as the 
results of infiltration produced by too great freedom of incision. 
Thus, after a large stone has been with difficulty extracted, the DANGER OF LIMITED INTERNAL INCISION. 
65 
cellular connections of the neck and base of the bladder are 
found to be disorganised; sloughs of the connective tissue 
appear bathed in fluid seropurulent and urinous, and marks of 
peritonitis, especially severe in the pelvis, are observed. But 
there is good reason to believe that, in most cases, urinary 
extravasation is not the primary cause of the inflammation, but 
that inflammation produced by injury has been the occasion of 
the urinary extravasation. In some of these cases, insufficient 
incision has furnished the occasion for inflicting violence of 
another kind in attempting to remove the stone. Undoubtedly 
sound as the rule is, to keep the internal incision strictly within 
the prostate in adult patients, in practice I am satisfied that 
the desire to limit it has been carried to an extreme degree, 
and that another and not less serious danger of arousing in- 
flammation of the same cellular tissue has by this very means 
been increased; I mean the danger which attends an attempt 
to drag the calculus through an opening of insufficient size. 
From what I have seen of the practice of Lithotomy in various 
hands both in town, in the country, and abroad, I am persuaded 
that insufficient internal incisions are equally dangerous with 
those which are too free, and that the tendency of the present 
day is towards the former extreme. The purely anatomical 
view of the subject appears just now to be in the ascendant. 
The structural delicacy and sensibility of the organs involved 
are not sufficiently regarded. The student is taught to fear 
beyond all things an approach of his knife to the peripheral 
limit of the prostate, and, in over-dread of cutting it, he 
barely divides the prostate at all. Hence, the fatal injury which 
results from violence inflicted by the forceps and by the stone 
upon the neck of the bladder, and by the powerful traction 
upon it, which injures, often irreparably, the surrounding cel- 
lular connections, so delicate in structure, and loosely applied, 
for the purpose of permitting those varied conditions of size 
which the function of the viscus demands. Inflammation of these 
delicate structures is easily produced by that forcible dilatation 
of the neck of the bladder which insufficient incisions render 
necessary, while the pressure to which they are thus subjected 
sometimes produces sloughing. And, when inflammation has 
once extended through these structures, it may soon invade the CONSIDERATION OF THE DEEP INCISION 
66 
peritoneum, which in this manner, probably, is not infrequently 
implicated. In connection with this subject there is a very 
significant fact, the bearing of which will be presently examined, 
viz. that while it is certain that the boundaries of the prostate 
are almost invariably overstepped by the knife in children, 
infiltration of urine does not occur in their cases. That the 
prostate has often been completely divided in the adult with 
impunity, for the removal of large stones, is certain, and the 
risk incurred from that cause is unquestionably serious. Danger 
is always great in a ratio proportioned to the size of the calculus, 
but this arises quite as much from the violence inflicted in 
removing it as from the depth of the incisions employed. 
Let it not be imagined from these remarks that anyone can 
deprecate more strongly than myself the making of an incision 
in the prostate more deeply than the size of the stone demands, 
hut 1 am very certain that it is safer to extend the incision, 
wdien a large stone has to be extracted unbroken, than to 
inflict the injury which dragging it out by force necessarily 
involves. The advocacy of small internal incisions by Scarpa, 
who laid down as an axiom that an incision of five lines into 
the prostate with dilatation sufficed for the extraction of a 
stone of more than ordinary size ; 1 and a similar recommen- 
dation by Sir Benjamin Brodie, in his wrell-known lectures, as 
the chief means of preventing urinary infiltration, has greatly 
influenced professional opinion on this subject. So much so 
indeed, that almost all subsequent writers have agreed in 
regarding a free deep incision as a source of the principal 
danger in the operation, and have thus occasioned indifference to 
a danger no less grave, which attends incision which is unduly 
limited. I wish then to point out, that in shunning Scylla 
we may encounter Charybdis; that an obstacle to successful 
Lithotomy lies on either side of our path, and not on one side 
only ; that we must preserve the neck of the bladder equally 
from too deep an incision on the one hand, and from the 
mechanical injury necessitated by one which is too limited on 
the other. I fortify my position by reference to the significant 
fact that the most successful operators have been those who 
advocated sufficient incision as less dangerous than violent 
Mem aria ml Condutiore d' Hawkins, &c. Pavia, 1825. IN LATERAL LITHOTOMY. 
67 
extraction. Thus Mr. Marlineau, who is well known to have 
cut eighty-four cases (but including many children) at Norwich, 
with only two deaths, writes, in that brief and simple account 
of his method which he presented to the Medical and Chirurgi- 
cal Society in 1821 : ‘ Should the stone be large, or there be 
any difficulty in the extraction, rather than use much force, 
while the forceps have a firm hold of the stone, I give the 
handles to an assistant, .... while the part forming the 
stricture is cut, which is easily done, as the broad part of the 
blade becomes a director to the knife; and rather than lacerate, 
I have often repeated this enlargement of the inner wound two 
or three times.’1 Cheselden himself had recorded a similar 
opinion. Describing his method of extracting the stone, he 
says : ‘ I first feel for the stone with the end of them ’ (the 
forceps), 4 which having felt, I open the forceps, and slide one 
blade underneath it, and the other at the top; and if I appre- 
hend the stone is not in the right place in the forceps, I shift 
it before I offer to extract, and then extract it very deliberately, 
that it may not slip suddenly out of the forceps, and that the 
parts of the wound may have time to stretch .... and if I 
find the stone very large, I again cut upon it, as it is held in the 
forceps.’2 But, on the other hand, it is never to be forgotten 
—and Cheselden refers to it in the foregoing passage—that the 
neck of the bladder is susceptible of dilatation to a very con- 
siderable extent, if only it be gradually exerted. It yields, first, 
to the pressure of the finger as it passes through immediately 
after the knife ; secondly, it dilates further in the act of sliding 
in the forceps upon the finger ;.and lastly, it gives way still more 
when the forceps is withdrawm, with the stone between its blades. 
Its susceptibility of becoming dilated is of the utmost value to 
the lithotomist; indeed, if it did not exist, and largely too, none 
but small stones could be withdrawn through any incision 
limited to the prostate only. But in order to take advantage 
of it, the dilatation must be made slowly and gently. If done 
1 Med, Chir. Trans, vol. ii. p. ill. It seems necessary to state, from the 
manner in which Mr. Martineau’s practice is sometimes quoted, that this series 
of eighty-four cases did not by any means constitute his entire experience, the 
remainder of which was by no means successful. 
2 ChesfMen's Anatomy, 5th edition, 1740 p. 231. 68 
DANGER OF VIOLENCE EXERTED 
hastily, harshly, and forcibly, under the influence possibly of 
the contemptible vanity of achieving a rapid operation in the 
eyes of bystanders, it is not dilatation which has been accom- 
plished, but rupture. And by rupture I do not mean the mere 
enlargement of the wound in the prostate and neck of the 
bladder, which, probably, is often and legitimately occasioned, 
but the rupture of the surrounding cellular connections with 
the numerous veins and the capillary network which traverse 
them; results of an extremely dangerous character. In this 
way inflammation of the cellular tissue, pelvic abscess, or it 
may be phlebitis, are set up ; suppuration is produced in a 
situation where the pus finds its way to the peritoneum, and 
not to the surface. And when this state of things exists, a 
deep incision might have proved a safeguard rather than the 
contrary, by affording exit to the confined matter. 
It is wholly impossible, then, to overrate the importance of 
slowly and gently dilating the neck of the bladder and the 
incisions which have been already sufficiently made, and of 
giving abundance of time both in the act of introducing the 
forceps, and in that of withdrawing the stone. If there be any 
single proceeding in connection with the practice of Lithotomy, 
no matter what is the operation performed, which demands 
more than any other of care, attention, and self-command, I 
should say it is the manner in wdiich wTe traverse with instru- 
ments the wound in the neck of the bladder. Nevertheless, 
one may have sometimes observed that the operator rapidly 
passes and repasses instrument after instrument, especially if 
any difficulty arise, and pulls and twists, with breathless haste 
and excitement, the calculus through the narrow outlet. No- 
thing can be more dangerous, nothing more likely to occasion 
the evils which have just been described. I am strongly in- 
clined to think that in many hands the forceps, and not the 
knife, is the most deadly instrument employed in Lithotomy. 
On this important subject permit me to adduce here two brief 
quotations from the writings of two experienced and accom- 
plished lithotomists, one of the past and one of the present age. 
Poteau, during the last century in France, says : ‘ The extrac- 
tion of the stone is, perhaps, the most delicate part of the 
operation, since it has often caused fatal results when it has ON THE NECK OF THE BLADDER. 
69 
been done without sufficient prudence and management. If 
we permit ourselves to be seduced by the dangerous merit of 
doing the operation in the shortest possible space of time, the 
eagerness with which extraction is made occasions a rupture, 
often mortal; and I am persuaded that the thoughtless anxiety 
to acquire this false glory, that the public attaches to rapidity 
in operating, has killed more patients than any other evil 
manoeuvre. It is impossible to proceed too slowly in extracting 
the stone, and I believe it is to a scrupulous adherence to this 
precept that I owe in great part the constant success of my 
operations.’1 
Dr. Keith, of Aberdeen, after describing the method in 
which the forceps is to be applied, adds : 4 There are few opera- 
tions to which the adage Festina lente does not apply. To 
Lithotomy it is especially suitable, and to this stage of it pecu- 
liarly applicable. At it, 44 Make haste slowly ” should be ring- 
ing constantly in the surgeon’s ear.’ 
I cannot forbear to add the remarkable fact that, in the 
numerous opportunities of discussing the details of the operation 
of Lithotomy, which I have enjoyed, either personally or by 
letter, with many of the most experienced lithotomists of the 
day—and I refer especially to the provincial surgeons of our 
own country—that this is the single particular on which all are 
agreed. One, possibly, may attribute his success almost en- 
tirely to the use of the beaked, instead of the pointed, knife; 
another, to the smallness of the internal incisions ; a third, to 
the freedom of the same incisions ; a fourth, to the invariable 
use of the tube after the operation; a fifth employing it only 
in rare and exceptional cases; but one and all agree in the 
vital importance of extracting the stone with great care and 
gentleness, and of giving time in abundance to this part of the 
proceeding. I may add, that Dr. Murray Humphry, of Cam- 
bridge, who has had a large and remarkably successful experi- 
ence, attributes his success in great part to care in removing 
the stone. He writes me—after describing in detail his method 
of proceeding—4 the desideratum in the operation is to extract 
the stone with as little damage as possible to the parts.’ 
1 (Eurres Posth. tome iii. p. 350. 70 
PERFORATION OF BLADDER BY STAFF. 
d. An occasional cause of death connected with the opera-5 
tion is perforation of the bladder producing peritonitis. 
I have myself verified this accident in twro cases, and have 
little doubt that it is not a very infrequent cause, while it is 
certainly one which may be avoided without difficulty. Both 
cases occurred some time ago at the University College Hospital, 
and were publicly examined by me in the deadhouse there. (See 
table in Appendix, Cases Nos. 92 and 324.) I confess the cir- 
cumstance was at that time new to me, and I think it deserves 
careful attention. Before the time of these accidents I had 
often observed the extreme tenuity and, in some cases, softness 
of the vesical coats in disease. I have examined bladders at a 
very early period after death, and before much post-mortem 
change can have taken place, so soft as to tear almost like wet 
paper. Now nothing can be more likely to happen sometimes, 
unless we are on our guard as to this source of danger, than 
the pushing the point of a staff through the upper fundus of a 
contracted bladder, if the instrument be so long as it often is. 
1 have since been frequently struck with the unnecessarily 
long curve which some staffs have, and have felt, when seeing 
such an one in use, how dangerous its point must be in a bladder 
affected in the manner described. I am strongly inclined to 
think that in those cases of rapidly fatal peritonitis which are 
sometimes met with after lithotomy, if the search were carefully 
made, a minute rupture at the upper and back part of the 
bladder would be sometimes found. It may be very small, 
lying between the rugae of the organ, and easily escape observa- 
tion, yet give issue to a small quantity of urine into the perito- 
neal cavity; for it is not very easy to explain otherwise some of 
these attacks which carry off a patient in thirty-six hours or so 
after operation. Extension of inflammation from the bladder 
to its peritoneal covering has been suggested, but I think the 
mechanical cause a more probable one. Let me say that injury 
to such bladders may as readily be inflicted by the forceps as 
by the staff, but I do not think the knife has anything to do 
with it. Clearly, in the two cases in question, the little open- 
ings were not so made : both the character of the orifice and 
its situation preclude such an explanation. Besides, I am quite 
sure that the danger of perforating the bladder with the point DEFECTIVE CONSTITUTION OF THE PATIENT. 
71 
of the knife must be an extremely remote one, and impossible 
in fairly competent hands. 
I shall now consider— 
B. Causes of death which are very slightly, or not at all, 
under the control of the operator, and existing for the most 
part in defective conditions of the patient’s constitution. 
I have re-examined this part of my subject during the last few 
years, and especially by the light of a much larger experience 
than I had at the date of the last edition (1870). About two 
years ago I presented to the Royal Medical and Chirurgical 
Society, London, a resume of 500 cases of operation for stone 
on adult males only, of which seventy-eight were operations by 
lithotomy.1 All these were cases of large stone, or otherwise 
disqualified by some untoward circumstance for the performance 
of lithotrity. They were patients exhibiting advanced and grave 
examples of the malady. Hence among them were twenty- 
nine deaths following the operation; a number almost equalling 
those occurring in all the other cases (422) of lithotrity. 
Regarding the twenty-nine fatal cases of the first series, as well 
as the fatal adult cases of other operations, I think the follow- 
ing causes of death may be enumerated, and in the order of 
frequency of their occurrence. 
Organic disease of urinary organs, kidneys, ureters, and 
bladder. 
Exhaustion of the vital power. 
Peritonitis. 
Septicaemia. 
a. Organic Diseases of Urinary Organs. Associated with the 
presence of vesical calculus of large size, a very common condi- 
tion is pyelitis, or pyelo-nephritis of one or both sides. If of 
long standing, the affected ureter and pelvis are not merely 
inflamed, but become dilated, sometimes very largely so; they 
may even form receptacles for offensive urine. Consequent 
changes in the renal structure take place; a gradual thinning 
and disappearance of it, as if from pressure, while small puru- 
lent deposits in it occur in the latest stage. The disease, 
however, originated in the bladder, which might at first be 
thickened or distended, or finally sacculated, a condition varying 
1 Trans, of the Royal Med. and Chir. Soc. 1878, vol. *lxi. p. 159. 72 
KIDNEY DISEASE AND EXHAUSTION. 
greatly in degree and extent; but always an extremely grave 
circumstance in connection with operation of any kind, when 
the sac or sacs are of considerable size. These conditions should 
be well known to every student who attends the autopsies of 
his hospital, and are fully described by me elsewhere.1 Such 
changes existing, they are liable to be intensified both by the 
local effect of an operation on the bladder, and by the constitu- 
tional, or febrile, state which follows it. Acute inflammation of 
the bladder also sometimes results from lithotomy, and appears 
to aggravate the renal state, although it may not spread upwards 
by continuity of structure, and death rapidly follows. 
Again, the kidneys may be already damaged, although in a 
minor degree, by pre-existing calculus formation, or one of them 
may be still the seat of calculus; and thus danger may arise in 
event of operation. Bright’s disease is a very grave complica- 
tion ; while the long-continued presence of saccharine diabetes 
is undoubtedly a serious element of risk. Death sometimes 
occurs in any of these cases from uraemic poisoning, through 
insufficient eliminating power of the kidney; or by acute inflam- 
mation and suppuration destroying their structure. 
b. Next in order may be ranked Exhaustion of the vital 
powers. In other words, a patient free from any pronounced 
organic disease lingers a longer or shorter period after the 
operation, having perhaps afforded good hope of recovery during 
the first few days, after which he fails to improve, becomes 
gradually weaker, and dies without acute disease in any organ. 
Such exhaustion may be manifested slowly or rapidly, and 
either with or without the occurrence of secondary haemorrhage, 
which may often occur insidiously, and before it can be checked ; 
while primary haemorrhage, on the other hand, is to be regarded 
as controllable by the surgeon. Nevertheless, the patient may 
have unavoidably lost more blood than usual, which at advanced 
years, and perhaps with impaired digestion also, he is unable to 
restore. This contingency lowers the powers of life, impairs 
adhesive action in the tissues, diminishes the power of resisting 
deleterious influences, and prolongs the period of convalescence 
if it does not endanger life. Haemorrhage is, therefore, in- 
evitably allied to exhaustion, which ought not to occur very 
Clinical Lectures. 5th ed. Lect. xvii. PERITONITIS AND SEPTICAEMIA. 
73 
frequently apart from that cause. There are, of course, some 
old and worn-out cases in which the slender chance of recovery 
by means of operation is embraced by the patient only in his 
last extremity ; when with powers past recruiting, he must be 
brought to the operating table. These are exceptional, however ; 
in most cases a patient should not be submitted to this ordeal 
in an exhausted state. But if haemorrhage be unavoidably 
severe, or be not checked by every means at hand, we risk a 
fatal encounter with exhaustion, and indirectly not a few deaths 
are thus met with. It follows then, that the surgeon should, 
during the operation, regard his patient’s blood as valuable in 
the highest degree, and whatever may be his views respecting 
its loss under other circumstances, he should rest assured that 
every ounce of blood lost in Lithotomy is, pro tanto, a positive 
injury, at all events to an elderly patient. 
It is worthy of remark, however, that not a few of those 
cases in which death is attributed to 4 exhaustion,’ no autopsy 
being made, wTould by anatomical examination be found the 
subjects of pyelo-nephritis. No really diagnostic signs of this 
condition can be established during life : an observation of the 
physical state of the internal organ alone can enable the 
surgeon to declare its presence with certainty, however strongly 
he may have suspected it during life. 
c. Peritonitis, as already seen, may arise by perforation 
of the bladder by the’ staff, and also as a secondary result of 
violence, or of sloughing and suppuration at the base of the 
bladder. But it appears also to arise independently of these 
local conditions, possibly sometimes by extension from an in- 
flamed bladder, and sometimes as one of the manifestations of 
blood-poisoning. 
d. Septiccemia.—The occurrence of septic poisoning from 
any cause is not very common in connection with Lithotomy. 
Among the twenty-nine deaths which occurred in my own cases, 
only one could be reckoned under this head. In that case, the 
presence of pyaemia was rapidly manifested by articular swell- 
ings, with death on the seventh day. This fact is worthy of 
note, in connection with the keen interest now felt in researches 
as to the nature and origin of septicaemia; as an illustration 
of the small liability to receive infection which some wounds 74 
CAUSES OF DEATH IN CHILDREN. 
exhibit. The wound in lithotomy can scarcely be guarded by 
any arrangement which could be devised from access of common 
air, nor from much that is manifestly impure, and no attempt 
has been made in these cases to prevent such access; yet 
with many instances of prolonged contaminated exposure, often 
amounting to some weeks, only one example occurred. 
Indeed, the Lithotomy wound may be regarded, on the 
other hand, as an example of the ‘ open-air ’ treatment; no 
dressing or covering of any kind has ever been applied in my 
cases; and as much fresh air as possible has been admitted. 
e. Tetanus.—Two or three cases are on record of death 
by tetanus following the operation of Lithotomy. Beyond the 
bare mention of this fact, no further remark appears to be 
necessary respecting this extremely rare event as a consequence 
of the operation. 
The Causes of Death in Children.—The causes of death 
in children are widely different from those which are met 
with in adults. This distinction, as far as I can ascertain, has 
not, as yet, been sufficiently pointed out. The causes of death 
after Lithotomy have been treated as if they were uniform 
at all ages; although it is very obvious from observation of 
their cases, that the fatal result in the adult and in the child 
almost always happens through a different chain of events. 
This has rendered less distinct in each respectively the danger 
to be most feared, and, consequently, the cause most to be 
avoided. On investigating this subject in the adult, we have 
seen that haste and violence in extracting the stone, and 
sometimes unnecessarily extended incisions, are the causes of 
that diffuse inflammation of the cellular connections around 
the base of the bladder, which proves so generally fatal. We 
shall find in the child that the danger is not, or is very rarely, 
due to diffuse inflammation, and that incisions beyond the 
prostate can scarcely be reckoned dangerous, since they are 
constantly practised, yet no class of patients exhibits half so 
many recoveries per cent. We shall find that the most fre- 
quent cause of death in children is peritonitis, which is by no 
means common in the adult; and after that, and nearly as fre- 
quent, is constitutional exhaustion. 
It will make our path clearer if we first consider the causes PECULIARITIES IN CASES OF CHILDREN, 
75 
which render Lateral Lithotomy so much less fatal in the child 
than in the adult, a fact notorious to the youngest student of 
surgery. I believe them to be threefold. First: Lithotomy 
is not a very fatal operation in the child, because the sexual 
organs are not yet endowed with that special sensibility, the 
development of which constitutes the state of puberty ; a sen- 
sibility which, depending on most intimate connection between 
those organs and the cerebro-spinal system, necessarily associates 
them by the closest ties with all the other vital functions in the 
economy. So that any shock or injury received by the adult 
sexual apparatus very frequently involves constitutional sym- 
pathies of a very grave character. In the child there is, in 
fact, no sexual apparatus; that is to say, its condition is at 
present rudimentary, and the young patient is exempt from 
the danger which exists in the circumstances pointed out. 
This is the first and the chief fact in favour of the child. The 
second consists in this : that the processes of growth, and, 
consequently, of repair, are more vigorous during childhood 
than during any other term of life; and injuries are more 
rapidly and more easily surmounted than when those processes 
are less active. There are special adverse influences at certain 
periods of childhood, which counteract, to some extent, the 
beneficial effect of this, as we shall presently see. Thirdly, 
the position of the bladder in children favours the continuous 
and complete discharge of urine, and of all noxious secretions 
after operation, a fact which is doubtless of some value in their 
cases. 
Now, the liability to death after the operation of Litho- 
tomy in childhood varies very much at different epochs of that 
period. A table in another part of this work containing 850 
cases of children, show's that, from the first to the fifth year 
inclusive, the deaths are about one in fourteen cases : they then 
decrease, so that between six and ten years inclusive, they are 
only one in twenty-three or twenty-four cases. Between eleven 
and sixteen the mortality gradually rises to one in nine and a half 
cases, and from the sixteenth to the twentieth year to one in 
seven cases. 
During the first three or four years of life Lithotomy is far 
less successful than during the subsequent period. The first 76 
PERITONITIS, THE MOST COMMON 
detent ion with its dangers is now encountered, and the excitable 
nervous system of infancy neutralises some of the advantage 
which arises from the reparative power of childhood already 
referred to. But as these two constant sources of disease and 
death during the earliest years cease to be effective, we find 
the boy of six to ten years but very slightly exposed to risk 
from Lithotomy, the mortality being one in twenty-three or 
twenty-four cases, or little over four per cent. The develop- 
ment of puberty shows its influence in a marked manner 
between twelve and sixteen, and during the first onset of its 
influence on the system between sixteen and twenty, before 
the man is fully developed, and before the body has become 
established and fortified, Lithotomy is slightly more hazardous 
than at any period during the subsequent twenty years. 
It has been already stated that the most frequent cause of 
death in children is peritonitis. The bladder in children is 
an abdominal organ rather than a pelvic one, and has more 
intimate relations with the peritoneum than the bladder of the 
adult possesses. On examining its structure also, it is easily 
seen that the peritoneum is more entitled to its anatomical 
distinction of constituting one of the vesical coats in the child 
than in the adult. Hence, violence in extraction tells much 
more readily and directly on the peritoneum in the former 
than in the latter. In the adult we have seen that if the 
peritoneum is inflamed, it is rather by an extension through 
primary inflammation of the cellular tissue around the neck of 
the bladder, than by direct irritation occasioned by the opera- 
tion. The converse condition is the rule with children. The 
undue manipulation of instruments in the cavity of the bladder, 
or exertion in withdrawing the stone, appears to excite perito- 
neal inflammation much more readily than any other lesion. 
That it does not happen in children by the intermediate step 
of urinary infiltration, is obvious from the fact that the pros- 
tate in them is so exceedingly small as to be almost always, if 
not invariably, cut wholly through in Lateral Lithotomy, yet 
without the occurrence of that accident. Indeed, it is not 
possible that either forceps or finger can pass into the bladder, 
unless the incision exceeds the thickness of that organ. In 
considering this matter there appears to be a tendency to for- CAUSE OF DEATH IN CHILDREN. 
77 
get a fact I have already alluded to, viz. the non-existence at 
this period, except in a rudimentary form, of any sexual organs. 
I have dissected many prostates in children; the size of one at 
seven years, let us add therefore at the most favourable age for 
Lithotomy, may be estimated from the fact that it weighs 
about thirty grains; while between eighteen and twenty years 
it weighs two hundred and fifty grains, or nearly nine times 
as much. And yet no infiltration of urine takes place; lax, 
delicate and yielding as are the cellular connections necessarily 
exposed in these subjects. 
Here then, again, as in the adult, the fatal injury from the 
operation is more commonly due to violence than to any other 
cause, but telling directly on the peritoneum, rather than on 
the cellular connections of the bladder. Such is the inference 
I deduce from the study of numerous eases of death in children, 
respecting which I have been in a position to form opinions. 
Some corroboration of the view's here put forth may be found 
also in the fact respecting deaths which have been known 
occasionally to follow the mere act of sounding in children: 
viz. that it is always due toperitonitis. Fletcher, of Gfloucester, 
in his most instructive record of ‘ Failures in Lithotomy,’1 
relates the case of a child, six years old, and in excellent health, 
who died of acute peritonitis in three or four days, after a 
prolonged sounding for suspected stone. Mr. Crosse also men- 
tions a case precisely similar.2 
The next cause of death is exhaustion. Young children 
bear the loss of blood badly, and when it is considerable, an 
occurrence which, however, is rare, the patient sometimes sinks 
from subsequent exhaustion. The condition of calculous chil- 
dren also, if the stone has long existed, is occasionally low in 
the extreme, and they gradually sink without any apparent 
effort to rally, no active attack having declared itself. 
Besides these two principal causes of death, there are occa- 
sional examples of fatal result from shock after very prolonged 
or severe operation; from disease of the kidneys and bladder, 
from phlebitis and intrapelvic abscess, which demand no special 
remark here. 
1 Med. CMr. Notes and Illustrations, Part I. LoncT. 1831, p. 89. 
2 Treatise oft Calculus. Lend, 1835, p. 43. 78 
CHAPTER VI. 
difficulties and dangers met with in lithotomy. 
1. Difficulties and Dangers peculiar to the Age of the Patient—those of 
Infancy.—In Age, Rigidity of Tissues ; Enlargement of Prostate, &c. 2. 
Difficulties from Personal Peculiarity in the Subject—Deep Perineum ; 
Narrow Pelvis ; Unusual Distribution of Arteries ; &c. 3. Difficultiesdue 
to Peculiarity in the Stone —Size ; Form ; Number; Situation; Encysted 
Calculi ; Contraction of Bladder on Stone. Calculi adhering to the 
Bladder. Accidents—Wound of Rectum ; Removal of Portion of Prostate ; 
Fragments remaining after Operation; Secondary Haemorrhage; Wound 
remaining Fistulous ; Impotence ; Incontinence of Urine ; no Stone found 
at Operation. 
There are several exceptional circumstances, any one of which 
may, when present, become an occasion of more than ordinary 
difficulty to the surgeon in the performance of Perineal Litho- 
tomy. Furthermore, it is certain that the degree of difficulty 
for the surgeon must be generally regarded as the measure of 
danger to the patient. There is therefore no duty more neces- 
sary, and certainly there is no inquiry more interesting, than 
that which relates to the sources of such difficulty and danger ; 
because most, if not all of them, may be discovered and identi- 
fied, not, indeed, by a reference to the practice of any single 
lithotomist, but by an extended research into the experiences 
of many. And the value of this inquiry will appear from a 
fact, the validity of which will be admitted by all, namely, that 
to be forewarned of the presence of difficulty, and prepared to 
meet it, considerably diminishes its magnitude in most cases. 
For the sake of convenience I shall arrange these difficulties 
in three classes. 
First, difficulties which are peculiar to the age of the 
patient. DIFFICULTIES DUE TO YOUTH OF PATIENT. 
79 
Secondly, difficulties which arise from peculiarity in the 
subject—and 
Thirdly, difficulties which arise from some peculiarity in 
the stone, or in its relation to the bladder itself. 
1. Difficulties which are peculiar to the age of the patient. 
—The period of infancy is one which presents peculiar diffi- 
culties to the operator, difficulties not present at any other 
period of life. The structure of the organs interested is ex- 
tremely soft and yielding ; and the connective tissue which 
unites them is lax and feeble to a remarkable degree. From 
this condition arise two sources of difficulty and danger, which 
the operator has not unfrequently to encounter. First, the 
staff is liable, if undue force be used, to be pushed through the 
walls of the urethra, commonly at some point in its floor below 
the pubic arch, and thus to find its way below the bladder, 
between it and the rectum, where the mobility of the instru- 
ment, permitted by the laxness of the cellular connections 
there, may lead the operator to believe that its point is in the 
bladder itself. The same thing may happen in the adult; but 
from the cause stated, co-existing with the sharp curve upwards 
of the urethra in this situation in the child, it more readily 
happens in the latter. If this error is made, and is not dis- 
covered in time, the operation fails to extract the stone, and 
mostly inflicts a fatal blow on the patient. And its not unfre- 
quent occurrence proves that it is by no means a remotely 
possible danger. There is one great rule which, as far as I 
know, is the only absolute safeguard against the performance 
of an operation on a staff which has not been passed into the 
bladder ; and it is, to require clear audible or tactile proof of 
contact between the stone and the staff on which the patient is 
to be cut. We may find the stone with a sound, while the 
patient is on the table, but the staff may be passed immediately 
afterwards with perfect ease and not find it, the difference of 
form in the two instruments being considered sufficient by the 
operator to account for the two different results. It is wise 
not to be so easily satisfied. I have known occurrences of 
which the following is an illustration. A patient having 
marked symptoms of stone had been repeatedly sounded in the 
country, but no stone was found. The instrument which had 80 
DIFFICULTIES DUE TO YOUTH OF PATIENT, 
been employed for the purpose had the curve of an ordinary 
catheter. He was sent to London, and was there sounded with 
the small-beaked sound, which at once struck a stone in the 
bladder. Placed on the operating table, the staff passed easily ; 
clear contact with the stone was not demonstrated, but the inci- 
sions were made. Until then there was no suspicion that the 
staff was not in the bladder ; but it was soon discerned to be in 
a false passage, one which had been originally made by the 
large-curved sound, at the repeated examinations referred to; 
the opening of this false route had been avoided by the beaked 
sound, biit entered by the large-curved staff. Happily, the 
operator was able to withdraw the staff, slide it along the upper 
aspect of the urethra into the bladder, and continue the opera- 
tion, which was a successful one. When such an occurrence is 
met with, this is the course to be pursued ; the surgeon must 
not hesitate an instant to withdraw his staff, to slide another 
staff of any curve that will pass safely into the bladder and 
detect the stone there, and then to finish the operation upon 
it. But if, owing to the false passage, he can pass no instru- 
ment after a fair amount of endeavour, all proceedings should 
be suspended without any further use of the knife until another 
day. 
The other difficulty which arises in young subjects from the 
soft and lax nature of the tissues, is the facility with which the 
membranous urethra may be separated from the prostate. 
This sometimes happens, when, after the deep incision, an 
attempt to introduce the index finger into the urethra fails, 
and issues instead, in pushing onwards the prostate and neck 
of the bladder until separation takes place. The accident may 
occur in two ways. The operator may, through fear of having 
his deep incision too free, make a section of the urethra and 
prostate insufficient to admit the tip of his finger, and in 
attempting to dilate the opening with it instead of incising 
afresh, the catastrophe occurs. Or, from this insufficient 
incision, as Dr. Murray Humphrey points out,1 the forefinger 
of the surgeon may, in failing to enter the urethra, make a 
kind of cavity between the bladder and rectum, and he may 
believe that he is in the first-named cavity. He may pass the 
1 See Lecture in the Lancet, April 23, 1864. DIFFICULTIES IN THE CASES OF CHILDREN. . 
81 
forceps into this, and even feel the stone, thinly covered by 
the coats of the bladder, and attempt to make extraction. 
But, secondly, in the act of opening the membranous urethra, 
he may lose his hold upon it with the nail of the left index 
finger, and repeat the incision once, or even twice, before he 
fairly gets his knife into the groove of the staff, and runs it on 
towards the bladder. The urethra meantime may have shifted 
its position slightly, and three or four adjacent separate notches 
have been made into it. If only a small amount of force be 
employed in the subsequent attempt to pass the finger into the 
urethra, its separation from the prostate may also take place. 
This source of danger has been pointed out by Sir William 
Fergusson in some valuable clinical remarks on the operation 
in children.1 
The remedy, when this accident has occurred, is first to 
ascertain that the point of the staff is still in the bladder, and 
then to make a free incision of the prostate with a sharp knife 
—for these soft tissues are not easy to cut, and require both 
point and edge for a perfect section—so that the finger may be 
introduced into the cavity : this will generally be successful. 
A pre-acquaintance with the danger, however, will be the best 
safeguard against its occurrence. 
A difficulty which sometimes presents itself in the cases of 
children (very rarely in adults) is prolapsus of the rectum 
during the operation. Young calculous patients are frequently 
subject to this affection from the straining which their complaint 
occasions, and when a considerable protrusion occurs at the 
moment of operating, some embarrassment may be occasioned. 
All that is necessary, however, is to press up the bowel without 
haste, so as to ensure its fair return, to put a small pad on the 
anus, and direct an assistant, placed on the patient’s right side, 
to keep his finger firmly on the pad until the operation is 
completed. 
The other extreme of life is also liable to its peculiar diffi- 
culties. There are two which are met with, and only in elderly 
subjects ; namely, unusual rigidity of the neck of the bladder, 
and hypertrophied prostate. 
The first has been less generally regarded than perhaps it 
1 Lecture, Lancet, July 2, 1864. 82 
DIFFICULTIES IN AGE: RIGID PROSTATE. 
deserves to be. In some elderly subjects, the fibrous structures 
which form the neck of the bladder, and enter into the com- 
position of the prostate and surrounding parts, have become 
unnaturally rigid and unyielding. In early life the converse 
condition exists, hence the impunity with which considerable 
dilatation can then be made. This condition of rigidity varies 
much in degree in different subjects, and is quite distinct from 
hypertrophied prostate, but as a rule it corresponds more or 
less to the advance of age : there are, however, some exceptions. 
In a marked case the tissues yield little to the finger, or to the 
forceps ; the opening sufficient for the removal of a stone of 
given size in ordinary cases here feels tense, and inadequate 
for its purpose. The forceps being introduced, it is perceived 
that dilatation is not taking place, and unless deeper incision 
is employed the stone cannot be extracted without violence. 
In either case risk is incurred by violent laceration, or by 
extended incision; the smaller risk, however, probably lies, in 
careful hands, with the latter, although it is undoubtedly true 
that more force is admissible in this condition than in the 
normal state of the tissues. It is referred to by Mr. Crichton, 
in his MS. notes, as usually associated with enlarged prostate, 
and while he enlarged his incisions he did not hesitate to use 
more force in extracting than he was ordinarily accustomed to 
employ. Civiale has remarked its existence, and regards it as 
diminishing the prospects of success; where this condition is 
marked, and the stone is large, a second incision may be made 
through the right side of the prostate, supposing that in the 
left to be already sufficiently free. This was Liston’s practice 
at University College Hospital; he performed it in nine cases 
there for very large stones with seven recoveries ; among them 
was one stone weighing 3f ounces, and another of ounces. 
The prostate enlarged by hypertrophy, or deformed by 
tumour, is another difficulty presented by age. I am not dis- 
posed, however, to rank it high in the scale either of difficulty 
or of danger. It sometimes prevents the forefinger from enter- 
ing the bladder; it increases the distance between the operator 
and the stone, and thus augments the difficulty of seizing and 
extracting it; and it does the same by placing the stone in a 
disadvantageous position, that is, lying deeply behind the neck, HYPERTROPHY OF THE PROSTATE. 
83 
or there may be projecting tumours at the entrance of the 
bladder, situated between the stone and the inner end of the 
wound. Hence such tumours have not unfrequently been torn 
away by the forceps in the process of removal, and apparently 
without any additional risk. On the other hand, deep internal 
incisions in an enlarged prostate are comparatively free from 
danger, and there is no fear of reaching its external limit. The 
gorget is a safe and efficient instrument in these cases for 
extending the deep incision ; it forms a conductor for the 
forceps into the bladder when the finger cannot reach it, and 
keeps projecting tumours out of the blades, which might other- 
wise be lacerated, or brought away in their grasp. When the 
stone lies deeply behind an enlarged prostate, the curved 
forceps may be useful, although I have rarely found more than 
one pair of straight forceps necessary in any case. Sometimes 
the stone may be brought into good position for extraction, by 
placing one or two fingers in the rectum, and raising the stone 
towards the level of the internal wound. 
In elderly subjects, also, it occasionally happens that the 
bladder has become atonied, and has not been able to empty 
itself by its own efforts for a long period of time. In the gush 
of water outwards after the deep incision, the bladder collapses 
rather than contracts, and the stone may be enveloped in folds 
of the organ, a circumstance sometimes productive of much 
trouble. Careful manipulation of the forceps, or of the scoop, 
with pressure by an assistant on the hypogastric region, will 
generally enable the surgeon to reach and remove it. In these 
cases, however, it appears to be wiser to operate with a nearly 
empty bladder than a full one ; the stone is then more likely 
to be found at the neck, close to the internal incision. 
2. Difficulties which arise from some personal 'peculiarity 
in the subject. 
Among the first in this category may be noticed the deep 
perineum. Sometimes this is constituted by a variety of for- 
mation in which the bladder is more deeply placed as regards 
the surface than in ordinary cases; and resulting most com- 
monly from unusual depth in the ischia and pubic rami. The 
difficulty is also commonly presented when the patient is ex- 
ceedingly stout, the layer of adipose tissue over the perineum, 84 
DIFFICULTY FROM NARROW PELVIS. 
and especially on the nates, sometimes adding very materially 
to the distance between the surface and the bladder. In this 
case it is necessary to make the external incision longer in 
proportion at both extremities, remembering that the incision 
in such a subject commences on a plane three-quarters of an 
inch to an inch further from the bladder than in an ordinary 
case. Otherwise, the wound will be too narrow in proportion 
to its depth, and especially if the stone be a large one. The 
remarks respecting the use of the blunt gorget in cases of 
hypertrophied prostate apply here also. 
Another difficulty is presented by the unduly narrow pelvis. 
The pelvic outlet may be congenitally contracted, or it may be 
deformed by rickets. Cases are on record in which it was im- 
possible to bring any stone through the outlet, but such are 
extremely rare. Still it is not so uncommon to find the passage 
sufficiently narrowed to occasion some difficulty in extracting a 
stone of moderate or large size. The distance between the two 
ischial tuberosities is always a matter of observation to the 
lithotomist before operating, and his incisions are placed so as 
to allow him a fair equal distance between the rectum in the 
middle line and the osseous boundary on the outer side. But 
this is not all: it is particularly desirable in such cases to 
present, in the act of withdrawing the stone, which has usually 
a short, as well as a long diameter, the short one to the narrow 
diameter of the pelvis. 
In the case of a boy four and a half years old, this difficulty 
occurred to myself, at the time of the operation, not having 
observed it previously. There was a large stone, and having 
made the incision by the lateral method, I found unusual 
difficulty in extraction. An unsuccessful attempt had been 
made before, but what the cause of difficulty had been I was 
not aware of. However, with management, I safely removed 
it in a few minutes. Ultimately the child died. At the 
examination the pelvis was removed: there was so much dis- 
tortion, due to rickets, that the antero-posterior diameter 
measured only seven-eighths of an inch, on the dry specimen ; 
while the calculus was almost three-quarters of an inch thick, 
being one inch and an eighth long, and seven-eighths of an inch 
broad. Had this condition been discovered beforehand, no UNUSUAL DISTRIBUTION OF THE VESSELS. 
85 
doubt the suprapubic operation might have been performed 
with advantage. The case was published in the ‘ Medical and 
Chirurgical Transactions,’ vol. xlvii., with a drawing of the pelvis 
and of the stone. Sir Astley Cooper speaks of a case in which 
Clive found the ischia so abnormally approximated, that having 
introduced the forceps and seized the stone, he was unable to 
withdraw, and consequently broke it and removed the fragments 
separately.1 
Another case observed, but not operated upon, is recorded 
by Mr. Bransby Cooper.2 
Other difficulties peculiar to the subject are: the unusual 
distribution of the vessels, rendering serious haemorrhage un- 
avoidable ; the existence of the haemorrhagic diathesis; the 
presence of organic disease in the kidneys or elsewhere; of 
extremely nervous or irritable temperament; of plethora, obe- 
sity and debility combined—a not uncommon, but most un- 
promising condition; and lastly, of great exhaustion from 
long-continued suffering. The unusual distribution of arteries 
referred to is a difficulty wdiich cannot be foreseen or avoided. 
The pudic trunk being defective, its place is sometimes supplied 
by an ‘ accessory pudic,’ which lies close to the border of the 
prostate ; the arteries of the bulb may be given off further back 
than usual; the main artery of the prostate itself may also enter 
the gland in a situation exposing it to the knife in Lithotomy. 
In all these cases, the skill, the energy, and the patience of the 
surgeon may be taxed to their utmost, to arrest the haemorrhage 
occasioned by the division of these deeply lying vessels (see 
remarks on Haemorrhage at page 37). The other conditions 
named above will be briefly referred to in the final appreciation 
of various methods of treating varied classes of patients. 
3. The third class of difficulties encountered in Lithotomy 
comprises those which are due to 'peculiarities in the stone, or 
in its relations with the bladder itself. Other things being 
equal, it has usually been held, and it was proved by Mr. Crosse, 
of Norwich, in his comprehensive view of the contents of the 
Norwich Museum, that, after moderate dimensions are exceeded, 
1 Lectures on Principles and Practice of Pvrgery, By B, B. Cooper. 
London, 1851, p. 601. 
2 On. cit. p. 599. 86 
DIFFICULTY FROM MAGNITUDE OF STONES. 
the danger and difficulty of the case exist in proportion to the 
size of the calculus to be removed. In other words, danger and 
difficulty exist in proportion to the extent of the incisions, or 
to the degree of violence employed in extraction. Thus, 
reckoning all the examples in that museum, he showed that the 
proportion of deaths to cures when the stone weighed between 
one and two ounces, was about one to five and a half cases ; 
when between two and three ounces, there were four deaths in 
five cases ; and of the twenty calculi above that size, viz. from 
three to seven ounces, twelve died and only eight recovered. 
This rate of mortality must be considered rather high. On the 
other hand, if we turn to the practice of Mr. Crichton, a re- 
markable success in this class of patients is exhibited. In the 
records which I possess of his practice, I find no less than eleven 
cases, in which he removed, by the lateral operation, stones 
weighing upwards of four ounces, most of the patients being 
very feeble and broken down in health. Among them were 
only two deaths; a very successful result, it must be confessed. 
No. 1, aged 73, weighing 4 ounces, cured. 
2, „ 60, „ 4£ „ do. 
3, elderly, „ „ do. 
4, „ 70, „ 5 „ do. 
а, ,, 66, „ 5 ,, do. 
б, ,, 65, ,, 5ij ,, do. 
* > » lb, ,, 6 ,, do, 
>> 1'% » b » do. 
9, „ 72, „ 6£ „ do. 
10, about 65, „ 7 „ death. 
{Broke in extraction, largest frag- 
ment weighed 6 ounces, 2 or 3 ounces 
of debris besides ; died on third day. 
The greater part of these were cut during the earlier half 
of Mr. Crichton’s career, when he opened the bladder with the 
cutting gorget, and in some he divided the right side of the 
prostate as well. His method was, as we have already seen, 
marked by freedom of incision in these circumstances, and care 
in extraction. In order to get as firm a hold as possible, after 
having adjusted the position of the calculus in the forceps, he 
was accustomed to slip up, by the side and over the end of it, a 
bent hook or scoop in order to make traction and prevent slip- 87 
MODE OF DEALING WITH LARGE STONES. 
ping. Two only of the foregoing series were purposely broken 
into fragments before extracting, and in each case it was done 
by simply compressing the handles of the stout and strong 
forceps wThich the operator was accustomed to use, and not by 
means of any unusual or complicated instrument. 
Fig. 47. 
Frencli forceps, with a screw in the handles, for breaking large stones. An apparatus is 
used for drilling the stone, if the forceps cannot crush it. The figure on each side of the centre 
represents a perforator, which is introduced through a ring at b, passes between the blades, and is 
worked in the one case by a drill bow, and in the other by the wheel H. 
These results demonstrate what the lateral operation is 
capable of effecting in the removal of large calculi. Neverthe- 
less, both in London and in Paris, it has been a common custom 
to employ for stones of about four ounces and upwards, some 
special apparatus for fracturing the calculus in order to extract 
the fragments through a smaller wound than would be necessary 
for the entire stone (see figs 47, 48, and 49). This principle 88 
VARIOUS INSTRUMENTS FOR CRUSHING 
of action is dictated by prudence. To limit the incision as 
much as possible, without doubt conduces to the safety of the 
patient. Still, it is impossible not to be aware that great 
1'ig. 48. 
Another instrument for the same purpose, acting by pressure and by drilling. A, the toothed 
extremity of the drill. 
additional hazard is involved in the employment of such 
apparatus in the bladder; and in contemplating it for any 
particular case, this must not be overlooked. 1 have witnessed LARGE STONES WITHIN THE BLADDER. 
89 
Pig. 49. 
Apparatus for crushing the stone before withdrawing it in the operation of Lithotomy, a. 
The forceps. B. Portion applied to the handle of the forceps, and fixed there by screws, 
into which the piece c is inserted, c. Fixes the position of the stone between the blades of the 
forceps. D. A drill, introduced through the tube seen on the upper blade of the forceps, which 
being turned either by hand, or by a bow, perforates and breaks up the stone. 90 
VARIOUS MODES OF DEALING 
its application more than once, and have been impressed with 
difficulties arising from three causes:— 
1. The manipulation requisite for fixing the stone securely 
in the grasp of the instrument when the bladder is emptied of 
fluid, as it invariably is, and for crushing it subsequently, must 
be always considerable, and liable to produce mischief. 
2. The removal of numerous angular fragments from the 
empty bladder is a fruitful source of severe injury to it. 
3. The danger of leaving some small fragment in the cavity 
renders much manipulation and much washing-out necessary, 
or the risk of a second formation may possibly be incurred. 
These grave considerations should be weighed by the 
operator before deciding on any course. In performing 
Lateral Lithotomy for a large stone, a well-constructed and 
powerful crushing instrument should undoubtedly be at hand. 
Stones have been successfully removed by such means which 
never could have been brought through the pelvic outlet 
entire. Mr. Mayo, of Winchester, thus accomplished the 
removal of one weighing ounces, avoirdupois ; the patient 
recovering with a small fistula.1 Instruments for this purpose 
existed at a very early period in the history of Lithotomy; 
even before the time of Celsus, who refers to’ the practice.2 
Ambrose Pare describes his improved forceps, with screw-power 
in the handles, in order to crush the stone before removing it.3 
Le Cat modified them, and invented an instrument for perfo- 
rating the stone also ; his instruments, especially those with 
which he made the incisions, were extremely complicated.4 Of 
late years numerous attempts have been made to improve these 
instruments, commencing with those of Mr. Earle.5 The best 
now existing is, perhaps, that which was employed by Civiale 
during the last three or four years of his life. Consisting of a 
pair of forceps, it enables the operator to fix securely the stone 
between the blades, before employing the drill to perforate and 
split it into fragments. From the form and nature of its action, 
it happens frequently that a large portion of the fragments may 
be retained between the blades, and withdrawn at once. Civiale 
1 Med. Chir. Trans, vol. xi. 1821, p. 54. 
2 Celsus, De Medicind, lib. vii. cap. 26. 3 Park’s Works, lib. xvii. cap. 42. 
4 Parallel# de la Taille lateral*, 1766. See plates and descriptions at the end. 
4 Med. Chir. Trans, vol. xi. 1821, With a plate. reports between twenty and thirty instances of its application, 
and states that the results were extremely successful. The 
annexed drawing (poge 89) is from an instrument in my 
possession which he sent me in 1867. He combined its use 
with the medio-bilateral operation, for all calculi weighing an 
ounce and a half, or thereabouts, and upwards.1 
For the removal of extremely large stones, weighing from 
four to six or more ounces, the choice rests, perhaps, between 
Lateral Lithotomy with this adjunct, the High, and the Recto- 
vesical operations. If the bladder is capable of being moderately 
distended with urine, a stone of unusual dimensions may pro- 
bably be more safely removed entire in this situation than by 
adopting the plan of crushing it after the lateral operation is 
performed. The great source of difficulty and danger in the 
latter mode is the empty state of the bladder, and I believe it 
is scarcely realised by those who have merely made or designed 
instruments for the purpose, and who appear to have overlooked 
the important distinction between this condition and that which 
obtains in ordinary Lithotrity, where fluid is mostly present. 
But if the bladder is habitually contracted round the stone, and 
does not admit of distension by fluid ; those who are most 
acquainted with the high operation tell us that it is by no 
means a safe operation to undertake in such circumstances. 
And it appears to be more common to meet with a contracted 
bladder than with a dilated one when a stone of unusual magni- 
tude is present. Such was the condition of things in a case 
which wras under my own care in 1857, and from which I 
possess two calculi weighing ounces.2 These formed, for 
all the purposes of operation, but one calculus, being so closely 
locked together that it is scarcely possible that either could 
have been removed separately. The patient was in so miser- 
able a condition when he came under my notice that I could not 
advise any operative measures, and attempted only to palliate 
it, and perhaps enable him to regain some vigour. This, how- 
ever, proved impossible; his urinary organs being all but 
destroyed by long-existing chronic inflammation. At the 
autopsy I endeavoured to remove the mass by the high opera- 
tion, and found it totally impossible, without opening the abdo- 
WITH VERY LARGE CALCULI 
91 
1 La Lithotritie et la Taille. Paris, 1870, pp. 410 et seq, 
2 Trans. Path. Soc. vol. ix. p, 205. 92 
LARGE CALCULUS KOT ALWAYS DETECTED WITH EASE 
minal cavity. The bladder had long ceased to be a receptacle 
for urine, which trickled off as fast as it arrived from the 
kidneys; the stones being closely enveloped by its thickened 
and diseased coats. T doubt if any operative means would have 
been successful in his case ; but judging from the examination 
referred to, it appeared to me that the best chance would have 
been offered by practising extended incisions on the plan of the 
Recto-vesical operat ion. This latter procedure must be regarded, 
for the majority of cases, as permitting the largest opening with 
the smallest amount of risk for stones which are unusually large. 
In the method of performing it, described at page 54, little 
danger exists from haemorrhage ; the amount of tissue cut is by 
no means considerable; and the opening is admirably situated, 
in the very centre of the pelvic outlet. On the other hand, 
a strong probability exists of the subsequent occurrence of in- 
tractable recto-vesical fistula. Experience of this operation has 
shown that this distressing condition follows, taking all cases 
together, about once in four or five instances. But when it is 
resorted to for stones of extreme magnitude, the chances are 
somewhat greater still that the wound will remain fistulous. 
There is a practical point of importance to be noticed in 
connection with very large stones. It is the very slight evidence 
of their presence which is obtained by sounding in certain cases. 
I first became aware of this on examining the patient just- 
alluded to. I was convinced from his symptoms that he was 
the subject of calculus ; but still, although repeatedly sounded 
by me and by one or two others, distinct evidence of the fact 
was at first wanting, for a clear note could not be obtained. A 
sensation indicating the presence of mortar-like matter was felt, 
on the instrument passing through the neck of the bladder, and 
after that, nothing. 
I find in Mr. Crichton’s notes the record of a similar fact. 
In one of his earliest cases, occurring in March, 1792, the signs, 
he says, were very indistinct; and, on his proposing to operate, 
one of the surgeons who had come to assist him left the room, 
stating that he could not be a party to any operation in such 
circumstances. Mr. Crichton, however, felt satisfied that a stone 
was present : operated at once, and removed a hard one weigh- 
ing six ounces, the patient making a good recovery. He 
records also a second case almost parallel with the foregoing. ILL-FORMED, BROKEN AND MULTIPLE CALCULI. 
93 
Other characters of the stone causing difficulty to the 
operator are, unusual form and extreme brittleness. A long 
stone, and a thin, flat stone, are both difficult to remove, and 
require careful adjustment in the forceps, or the aid of the 
scoop, before attempting to extract. I have also had the 
opportunity of observing that such stones are especially difficult 
to seize with the Lithotrite. Large round tuberculated stones 
are also formidable, and for equal weights are obviously much 
more so than smooth oval stones. A stone, also, which easily 
crumbles into fragments is always a source of trouble and 
anxiety. It prolongs the operation, makes much instrumental 
manipulation necessary, and the fear of leaving a fragment be- 
hind is always present. The scoop and the syringe as a rule 
afford the best means generally of dealing with these cases. 
The syringe should have a nozzle like that represented at fig. 
7, page 15 ; a form for which we are indebted to Dr. Gross of 
America. On this account it is that Lithotomy, after the 
failure of Lithotrity, is sometimes associated with risk and 
difficulty, and especially if the bladder has proved irritable 
previously. Similarly, multiple calculi are sources of some 
difficulty, although less so than are numerous fragments. In- 
stances of two, three, or four calculi are common. I have 
found upwards of eighty in a single bladder. Examples of be- 
tween one and two or three hundred are on record. 
Next to great size, the unusual situation of a calculus may 
be a source of much difficulty and embarrassment. A certain 
proportion of calculi become encysted in the bladder. Not so 
many, perhaps, as the statements made by operators who have 
found difficulty in extracting calculi, and who have consequently 
believed them to be encysted, would lead us to infer. But we 
have the best anatomical evidence that it is not extremely rare 
for this to happen. A calculus may be altogether contained in 
a cyst in the bladder, a small part of its surface only being ex- 
posed at the mouth of the cyst. I had the opportunity of 
watching at University College Hospital an example of this, 
which was once, and once only, struck with a sound during life, 
although sounding was repeatedly performed. The patient 
remained during a large part of 1850 under the care of Mr. 
Arnott ; at death the condition described was found, and it 
was then obvious that the chance of striking such a calculus 94 
ENCYSTED CALCULI OF THE BLADDER. 
was exceedingly remote, and that no operation could have 
removed it.1 
But it is not uncommon, when this condition occurs, that 
fresh calculous matter is added, little by little, to the exposed 
surface, so that, in process of time, a calculus is formed, pro- 
truding into the bladder, in which situation it increases in size ; 
a narrow neck exists uniting the vesical to the encysted portion, 
and the whole acquires a form somewhat r-esembling that of an 
hour-glass. 
One of the most interesting examples on record is that of 
a man, aged fifty-one, with stone, who applied to Dr. Murray 
Humphrey, of Cambridge, who operated by Lateral Lithotomy, 
removing a large stone. Two years and a quarter afterwards, 
symptoms having recently appeared, Dr. Humphrey performed 
Lithotrity three times, but this being unsuccessful, he cut him 
again in the same spot. Two years and a half after he came 
again with recent symptoms, and Lateral Lithotomy was again 
successfully performed. In the next year he again complained, 
and Lateral Lithotomy was adopted a fourth time, still in the 
site of the old cicatrix, but an encysted stone was discovered, 
and after many attempts could not be extracted owing to its 
distance from the wound. In six months he once more showed 
himself, and this time Dr. Humphrey did the recto-vesical 
operation : was able to reach the cyst, incised the sac with a. 
hernia knife, dilated it with the tip of his finger, and, with 
much difficulty, guided the forceps, extracting a stone the size 
of a walnut. Death occurred in two days with peritonitis. At 
the autopsy, the sac was found just above the entrance of the 
right ureter; it was ulcerated at the lower part, and urine had 
found its way from it under the peritoneum. A second case 
fell to the lot of Dr. Humphrey, in which, at the second lateral 
operation, he discovered a cyst behind the prostate ; he length- 
ened his incision, applied a probe-pointed knife to the neck of 
the sac, and emptied it of softish material with the scoop, and 
a portion or two by the dressing forceps a day or two after; the 
patient made a good recovery.2 
1 Very fine examples of encysted calculus are contained in the Museum of 
the Royal College of Surgeons, See preparations Nos. 2019, 2020, 2021. 
2 Report of some Cases of Operation. By G. M. Humphrey, M.D., F.R C.S., 
Surgeon to Addenbrooke’s Hospital, Cambridge. London, 1856. VARIOUS EXAMPLES, 
95 
I exhibited at the Pathological Society, in 1861, for Mr. 
Cadge, of Norwich, a good specimen of encysted calculus. It 
was removed by him during life with a portion of the cyst 
adhering, like a collar to the neck, uniting the two portions, 
and the patient recovered.1 Two such cases occurred in Mr. 
Crichton’s practice, who minutely describes his proceedings in 
the MS. notes ; one case in 1842, one in 1844. In all three 
cases the stone was situated near the neck of the bladder, and 
in the two latter on the right side. Mr. Crichton says of each 
patient that he observed when sounding (which he repeated two 
or three times, the signs being rather indistinct), that the stone 
seemed always to be fixed at the right side of the bladder. He 
writes: ‘The bladder was cut into, and the presenting portion 
of the stone laid hold of by the forceps and quickly extracted, 
broken off at the neck: a grooved director was then introduced 
into the bladder, and insinuated between the edge of the sac 
and the encysted portion of the stone, which, by a little 
perseverance, was so much raised from its confinement as to 
allow the forceps to get a hold, and another portion broken off 
and extracted. This was several times repeated till the whole 
was brought away.’ The same proceeding was adopted in both 
cases ; and both recovered. Very recently Mr. Lawson pre- 
sented a good example of encysted calculus at the Pathological 
Society, which he had removed with the forceps aided by the 
scoop; in this case it was partially contained in a sac, and no 
supplementary portion projected from it.2 
The following is a brief account of a case which I operated 
on in May 1869 :— 
A gentleman aged seventy-four years had suffered for some years 
with very painful symptoms. I sounded him, found a large stone, 
and proposed Lithotomy. Having cut him by the lateral method, 
and extracted a rather large phosphatic stone and many loose frag- 
ments, I then explored the bladder, and felt a rough surface like cal- 
culus, which I ultimately was able just to reach with my finger, situ- 
ated just behind the neck of the bladder, a little to patient’s right side. 
It was quite immovable; a small calculous surface was exposed, sur- 
rounded by mucous membrane, and a mass of considerable size was 
1 Trans. Path. Soc. vol. xii. p. 1356. I exhibited a case of my own also (post 
mortem) ; see vol. xii. p. 138. 
- Trans. Path. Sac. vol. xiii. 96 
EXAMPLES OF ENCYSTED CALCULI. 
clearly outside the cavity of the bladder. Placing the other index- 
finger in the rectum, I encountered a hard tumour, corresponding to 
that felt in the bladder, and movable between the fingers of each hand. 
It was evident that the mass consisted of an encysted calculus, as large 
as a walnut, and a small portion of its surface only was exposed in the 
bladder. Upon this, large phosphatic crusts had formed, become de- 
tached, and produced calculi in the interior. I made some attempts 
to remove the encysted stone, but ineffectually, for it was too deeply 
embedded to be displaced, except by unjustifiable violence, and I was 
compelled to be content with emptying the cavity of the bladder. 
The patient did very well for a few weeks. His condition was 
explained to himself and his friends, and I declined to recommend 
any further operation, having satisfied myself at the first, that it was 
impossible to do more. He was aged and feeble, and sank in about a 
month. At the autopsy the condition described was discovered, and 
I possess now the soft parts, showing the sac filled by a uric acid stone 
of the size described. 
More recently I have operated on another case, which, how- 
ever, occurred in the bladder of a woman ; a fact which enabled 
me not only accurately to verify the exact condition, but also 
to deal with it successfully. 
A lady, aged 52, was sounded by me in June, 1874, and a stone 
was easily detected. On July 6, Mr. Clover gave her chloroform. I 
introduced a lithotrite, intending to crush, 
but failed to seize and dislodge it from the left 
side of the bladder, where it appeared to be 
fixed. Withdrawing the instrument, I dilated 
the urethra with my finger, and found a 
calculus of which one-third appeared to be in 
the bladder, and about two-thirds, as far as I 
could judge, by means of another finger in 
the vagina, contained in a sac outside the 
cavity of the bladder. These conditions were 
verified in the same way by my assistant, 
Mr. Foster, and by Mr. Clover, the only per- 
sons present. Reintroducing my finger, I 
insinuated my nail within the margin of the 
sac, and in about two minutes, by carefully 
working the finger round the stone, succeeded 
in turning it out of its bed, entire, into the cavity of the bladder, 
whence it was readily removed by the forceps after a slight incision 
Fig. 50. 
Outline of size and form of 
encysted stone. 97 
EXAMPLES OF ENCYSTED CALCULI. 
in the left side of the urethra. She made an excellent recovery, and 
is now living and in good health. The calculus, which is in my 
museum, is is form something like a kidney but with a deeper indent- 
ation showing the line of the neck of the sac. An outline of the stone 
is presented at fig. 50. 
More recently still I saw a case with Mr. Savory, in a 
gentleman of eighty years of age, in which with great difficulty 
we succeeded, by the use of small lithotrites, in extracting a 
smallish calculus which was sacculated near the neck of the 
bladder. Every portion was thus removed from the interior of 
the sac in five sittings. 
The rarity of such occurrences is, however, demonstrated 
from the fact that few operators meet with more than one or 
two cases in a lifetime. Deschamps and Brodie each record 
but one case. 
Sometimes a little embarrassment is occasioned to the 
surgeon by his discovery that the calculus is more superficially 
placed in the perineum than he expected ; on his encountering 
it, in fact, before arriving at the bladder. A vesical calculus 
may be found occupying partly the bladder and partly the 
prostatic urethra; or two or more independent calculi, locked 
together, may be thus placed. It is necessary, of course, to 
remove that which first presents, after which there is usually 
not much difficulty in entering the bladder, and extracting the 
rest. Indeed the whole calculus may be outside the bladder 
lodged in a sac which has some communication with the ure- 
thra, so that urine finds its way, more or less, into the interior 
of the sac. The following are brief sketches of two such cases 
on which I have operated. 
A gentleman, aged 44, came to me from China with severe urinary 
symptoms. I found organic stricture of the urethra, admitting only 
No. 2 catheter. This' was treated by continuous dilatation, and while 
doing so stone was felt. On February 17, 1878, I divided the 
stricture externally, doing the median operation at the same time, 
and finding just outside the neck of the bladder a sac filled with 
numerous calculi, the fragments fitting by their polished facets. Mr. 
Clover gave ether and Mr. G. B. Browne held the staff. He made an 
excellent recovery, and I have recently seen him perfectly well. 
On August 3 of the same year, I operated on a gentleman aged 98 
SPASMODIC CONTRACTIONS OF THE BLADDER. 
63, brought to me by Mr. Brewer of Huddersfield, who was present. 
I encountered three large calculi in a cavity close to the neck of the 
bladder, from which I had considerable trouble in removing them. 
Their position was well made out beforehand by rectal examination. 
The calculi fitted each other by polished facets and weighed two ounces. 
During the first nine days he appeared to be recovering rapidly, then 
rigors occurred, and he died three days afterwards from inflammation 
of the lungs, evidently the result of septicaemia. • 
Examples exist also in the Museum of the Royal College 
of Surgeons, in preparations Nos. 2026, 2027, and 2039. A 
large stone may even escape from the cavity of the bladder into 
the sac of an abscess in its walls, which has recently burst: 
a very remarkable example of this rare condition is seen, No. 
2029. 
Spasmodic contraction of the bladder, rendering the re- 
moval of the stone difficult, is described by some high authori- 
ties. It is regarded as something distinct from the condition 
which is present when the bladder has been merely emptied 
of urine, and therefore somewhat closely surrounds the stone. 
South, Brodie, and Gross speak of it, the two former recording 
cases in which it has been met with. Great care in the efforts 
made to extract, avoiding violence either with the scoop or 
forceps, and even waiting a little, are necessary in such cases. 
True spasmodic contraction of this kind is probably extremely 
rare, and when present it is not unlikely that chloroform may 
overcome it. When the bladder has become preternaturally 
small, and its coats are habitually applied closely to a large 
stone, there is sometimes great difficulty in removing it. The 
forceps must be manipulated with great care, and an additional 
hold with a well-curved scoop passed between the bladder and 
the stone, and beyond the latter, aids materially in dislodg- 
ing it. 
Sometimes the stone is lodged in the upper .part of the 
bladder behind the pubic symphysis. Possibly this may be due 
sometimes to the spasmodic contraction just alluded to, but 
more generally, I believe, its position there is to be attributed 
to peculiarity in the form of the viscus, caused by hypertrophic 
thickening of the coats. The stone is habitually lodged there, 
and the vesical walls become thickened, partly by the process ADHESION OF STONE TO THE BLADDER ? 
99 
referred to, and in part from inflammatory deposit into their 
structure, impairing their power to dilate or contract.1 Here 
pressure above the pubes, firmly maintained by an assistant, 
will enable the operator to dislodge the stone. 
It is not very uncommon to hear of operations for the 
removal of calculus, in which it is said that the stone was ad- 
herent to the bladder. But it is quite certain that evidence 
resting solely on the sensations of the operator while in the 
act of removing the stone cannot be regarded as of much 
weight, since many conditions may occasion difficulty in its 
removal, erroneously suggesting to the mind the existence of 
some organic connection between the bladder and the foreign 
body. It may be said that a kind of organic connection be- 
tween the inner coat of the bladder and a stone has been 
observed in the subject, but the phenomenon is excessively 
rare. A few trustworthy examples are appended in a note 
below, two of them having been examined by myself.2 
The mucous membrane of the bladder is, although very 
rarely, found to be coated with a layer of adhering calculous 
matter, and this is one of the forms of 4 adherent calculus ’ that 
anatomical researches have produced. In the Museum of the 
Royal College of Surgeons is the preparation of a bladder (No. 
2024), the mucous membrane of wdiich is studded with small 
calculi, partially embedded in minute sacculi, but between the 
calculi the mucous membrane is covered with a thin layer of 
1 Excellent examples of this condition may be seen in the Museum of the 
Royal College of Surgeons. The preparation No. 2016, for example, is that of 
a bladder divided into an upper and lower cavity by a partial contraction in 
the middle ; the upper portion was filled by a calculus, which it would have 
been next to impossible to extract by Perineal Lithotomy. 
2 A case met with in the dissecting-room of the Middlesex Hospital. A man 
aged 60 years had three calculi in his bladder, two being adherent; fibres of 
submucous tissue being incorporated with the calcareous substance. They were 
carefully dissected by Mr, Nunn. See Trans, of the Path. Soc. vol. vi. page 
250. 
A smaller calculus, similarly adhering, was found at the Middlesex Hospital 
by Dr. Yander Byl, in the body of a woman aged 50. Trans, of the Path. Soc. 
vol. ix. p. 296. 
A very large calculus was found adhering to the upper part of the bladder 
by Mr. M. Henry, at an operation for Lithotomy. The stone was carefully 
examined afterwards, and a layer of closely adhering membrane of recent forma- 
tion was found attached to one of its ends. Idem, p. 342. 100 
ACCIDENTS IN OPERATING : WOUNDS OF RECTUM. 
calculous material; at least half the inner surface is thus 
coated. This condition would be a very embarrassing one in 
any operation. No. 2025 exhibits a similar appearance, only 
much less marked in degree. In No. 2023, the prostate has an 
enlarged median lobe, which is similarly coated : several small 
speculated stones co-exist. The following case occurred to Mr. 
Wormald at St. Bartholomew’s Hospital. A lad aged 19 was 
admitted with symptoms of stone. When sounded, calculous 
matter was felt with the end of the sound in every direction. 
The circumstances of the patient were regarded as unfavourable 
to operation, and he died in a few weeks. At the post-mortem 
examination a thick crust of concretion concealed the entire 
mucous membrane of the bladder, and could be peeled off in 
flakes. The kidneys wTere the seat of tubercular deposit.1 
There are several accidental circumstances occasionally met 
with in Lithotomy, which, not exposing the patient’s life to 
risk, cannot be comprised in a discussion on the difficulties 
and dangers of the operation ; but which are, nevertheless, 
productive of great annoyance, and even of misery, to those 
who are, unfortunately, the subjects of them. These will be 
enumerated here as accidents concurrent and consecutive. 
Taking them in the order of their occurrence :— 
1. The first accident which may be met with is that of 
wounding the rectum. It may occur if the incision is placed 
too low down in the region, within an inch above the anus, 
especially if the knife is entered close to the raphe, from which, 
in this situation, it ought to be from three to four eighths of 
an inch distant. Otherwise it wall not happen, if the knife be 
held with a moderate degree of obliquity, and proper care be 
taken to guard the position with the left hand, unless the 
bowel is unusually capacious, as in some elderly subjects ; or is 
distended with faeces, as may happen when the preliminary 
purge or enema has not acted before the patient is placed on 
the table. The accident may take place in the first, or in the 
second incision, or while withdrawing the knife, if the operator 
enlarges the opening in that act. No doubt also it is more 
likely to happen if the operator makes a deep thrust at his first 
incision, with the view of reaching the staff at once ; but if the 
1 This case was recorded in Med. Times, Nov. 19, 1859. REMOVAL OF PORTIONS OF PROSTATE. 
101 
first incision is carried only through the skin into the cellular 
interval, and the finger be used to separate the tissues and feel for 
the staff, before the knife is again employed, the risk of injury 
to the bowel is less. In any case, however, when an incision 
into the bowel has been made, and it is only small, no notice 
need be taken of it; if it is considerable, most authorities have 
advised that the opening should be freely enlarged through the 
margin of the bowel and sphincter. But the necessity for this 
proceeding is by no means proved. Probably, the best method 
is to leave the parts untouched, and to reserve division of the 
sphincter until the necessity of it appears from the non-cica- 
trisation of the wound, as such cases have been known to 
recover soundly when not interfered with.1 At worst, usually, 
a small urethro-rectal fistula remains, which may be much 
diminished, or even wholly obliterated, by the introduction of 
a wdre heated by the galvanic current, the bladder being first 
emptied and a vaginal duckbill speculum placed in the rectum. 
I believe no operator can perform lateral lithotomy on many 
elderly patients, in whom the rectum is sometimes enormously 
capacious, and may become distended by flatus or otherwise at 
any moment, without sometimes making an opening into the 
bowel. I have had three cases myself among my numerous 
lithotomies, at upwards of sixty years of age, and think it right 
to state this fact. Sometimes sloughing of the thin septum 
between the wound and the rectum will take place, and an 
opening show itself ten or fourteen days subsequently. Of this 
I have certainly seen two examples. 
2. The removal of a portion of the prostate gland by lace- 
ration, or otherwise, is not a very uncommon accident with 
elderly patients. It may occur in two very different ways: 
first, it sometimes, but rarely, happens that the section of 
the prostate divides, or exposes freely, one of those small 
rounded tumours which so frequently exist embedded in the 
1 Mr. South states that he has seen only two cases of wound in the rectum, 
both of which healed well without any incision.— Chelius' Surgery, vol. ii. 
p. 606, Lond. 1847. Samuel Cooper says he saw it ‘in three or four cases, 
but no serious consequences were the result.’—Surg. Diet. 7th ed. p. 035. 
Mr. Key only once witnessed this accident, and no bad result occurred. Dr. 
Gross gives a decided opinion against interference.— Urinary Organs, 2nd ed. 
p. 500. 102 
CALCULI REMAINING UNEXTRACTED. 
suostance oi tne organ, especially in elderly patients ; under 
which circumstances the tumour becomes very easily enucleated. 
Secondly, when an outgrowth, more or less projecting or 
pedunculated, exists at the neck of the bladder, springing from 
the prostate into the vesical cavity, it may be caught between 
the blades of the'forceps when seizing the stone, and be torn 
off in the act of removing it. I have myself witnessed this 
accident three times, and twice have removed such a tumour 
myself, and in no one of the cases did it appear to endanger 
life.1 Dr. Keith informs me that he has met with it nine or 
ten times, and he is not aware that material injury resulted in 
any instance. Mr. Key made a similar observation.2 Civiale 
states that he has frequently removed them thus.3 Neverthe- 
less, it appears to have sometimes prolonged the recovery by 
retarding the healing of the wound. On the other hand, the 
patient has been known to pass urine more freely than before, 
but whether this has been due entirely to the removal of the 
stone, or whether in part also to the loss of an obstruction, it 
is not possible to decide. However, there can be no doubt that 
the accidental removal of these growths should be avoided, 
and with this object the left, index-finger, when exploring the 
bladder, and subsequently when acting as guide to the forceps 
or adjusting the position of the stone, should ascertain also, if 
possible, the presence of prostatic growth, and guard it from 
inclusion or laceration, when the operator is dealing with a 
patient of advanced age. If, when such a growth exists, he 
determines to get rid of it, as is sometimes done, it is better to 
do so with probe-pointed scissors than by tearing it off, or even 
than by excising it with the scalpel. 
3. It is sometimes discovered within a few days after the 
operation that one or more calculi, or fragments of calculus, 
remain unextracted. This is a serious accident and ought very 
rarely to happen, although, from unavoidable circumstances, it 
may occur to the most experienced operators. The course to 
1 I had the opportunity of exhibiting, at the Pathological Society of London, 
three tumours of this kind, weighing five scruples, removed from a patient the 
subject of two large stones, who recovered.—Path. Trans, vol. xiii. p. 155. 
2 ‘ Remarks on the Lateral Operation of Lithotomy,’ Guy's Hospital 
Reports, 1837, p. 23. 
3 La Lithotritie rt la Taille. Paris, 1870, p. 455. CALCULOUS INCRUSTATION: SECONDARY HAEMORRHAGE. 
103 
be adopted must depend, in some measure, on the condition of 
the patient. When only small fragments are present, they will 
frequently pass spontaneously by the wound. If otherwise, and 
the patient is in course of recovery, and his prospects are good, 
the first step is to ascertain precisely the size of the fragments 
or calculus remaining. This may be done by a lithotrite, and, 
if not large, the fragment or calculus can be crushed and 
removed at once. If it is of medium, or rather large size, it is 
quite easy within a fortnight of the original operation, to dilate 
the wound, and remove the foreign body with the forceps. I 
have done this once only in a case of my own, and assisted a 
brother surgeon once in similar circumstances. Each case was 
operated on the second time about nine or ten days after 
the first, and each made a good though a slower recovery than 
usual. 
Calculous incrustation, always phosphatic, and coating the 
wound after lithotomy, is sometimes very troublesome. It 
occurs between the seventh and fourteenth day after, or there- 
about. When slight, a few hip-baths, or washing with warm 
or acidulated wTater, will remove it. Once or twice I have 
found it so thick and so extensively deposited, as to be obliged 
to remove it by the forceps. In one case only it coated the 
whole track of the wound, from the perineum to the neck of 
the bladder, and from the internal extremity a small calculus 
was formed in the bladder itself, and wras crushed by me before 
the end of the fourth week. The wmmd was some months in 
healing, but did so at last, and the patient is at this moment 
in excellent health. 
4. Secondary haemorrhage. Haemorrhage occurring at, or 
immediately after, the operation, is an accident liable to occa- 
sion considerable hazard; it has, therefore, been considered in 
describing the steps of Lateral Lithotomy (see pages 37, 38). 
But it is sometimes secondary, taking place at a period of seven 
to ten, or even fifteen days after the event, and then it must 
be regarded as an accident which no foresight could have pre- 
vented, Four cases have occurred in my own practice, in two 
with a fatal result, and in circumstances which, had it not 
happened, there was every reason to expect a successful issue 
to the case. One was a case of Medio-bilateral Lithotomy. 104 
FISTULA FOLLOWING OPERATION. 
The other occurred in a gentleman aged 55, quite suddenly 
and unexpectedly, on the twelfth day after a lateral operation. 
The remedies must depend on the character and 
of the flow. If controllable by the ligature, no means is so 
safe and certain ; but at this stage such a result is not to be 
expected, since the external wound has generally by this time 
become small. The finger should be introduced, to ascertain 
whether by pressure with its point the source of bleeding can 
be stopped; if so, a piece of lint attached to a probe, or stick, 
and dipped in a solution of the perchloride of iron, should be 
applied to the spot. Sometimes the actual cautery has been 
found effectual. At the same time local cold applications 
should be made to the perineum and adjacent region. Mr. 
South records several of these cases in which pressure with the 
finger on the pudic artery for several hours was necessary in 
order to save life. Were a case to occur to me now, I should 
open up the wound and at once insert the air tampon, described 
page 19, and I do not doubt it would suffice to arrest the 
haemorrhage. 
5. Occasionally the wound which follows the operation heals 
very slowly, and results in the persistence of a fistulous track 
from the prostatic urethra to the perineum. This is an ex- 
ceptional occurrence, and most operators occasionally meet 
with such cases. The fistulous opening depends sometimes on 
the deposit of phosphatic matter on the raw surfaces of the 
wound from the urine ; a condition already referred to. The 
deposit may become permanent at the upper extremity of the 
passage; in other words, may form a calculus there, which, 
until removed, will assuredly maintain the patency of the 
fistula. If, then, we have ascertained that no foreign matter 
exists in the track, the whole internal surface of the fistula 
should be lightly touched with the actual cautery in the form 
of a heated wire, or with the galvanic cautery, or with a probe 
coated with nitrate of silver. After this the patient, having 
previously learned to do it with facility, should withdraw all 
his water on every occasion for three or four weeks by catheter, 
provided he can accomplish it easily, so as to prevent any flow 
through the fistulous channel. By a perseverance in this plan 
success may be obtained in several, perhaps in most, cases. It SEXUAL IMPOTENCE. 
105 
has been recommended to allow a catheter to remain in the 
urethra and bladder for some days, with the view of withdraw- 
ing all the urine in this manner. But this mode of treatment 
is not successful. Urine soon trickles by the side of the instru- 
ment and so enters the fistula; and the urethra itself becomes 
irritated, and much purulent discharge is secreted from its 
mucous membrane, conditions very unfavourable to the healing 
of any fistula. On these grounds, and from the observation of 
its effect in numerous cases of urethral fistula, I very much 
prefer the employment of the catheter by the patient on every 
occasion of his requiring to pass water. There are still a few 
cases met with, which it must be confessed appear to be wholly 
intractable, and these for the most part probably owe their 
character to the existence of disease in the prostate gland. 
6. A result of the lateral operation, which very seldom 
occurs, is sexual impotence. This condition has been attributed 
to the division of the seminal duct which lies nearest to the 
line of incision. There is good reason, I think, to doubt the 
correctness of this supposition. First, the line of incision 
ought never to intersect the duct even on the side operated 
on; the knife must be carried almost vertically downward in 
order to endanger it; indeed, if it be employed with even a less 
degree of obliquity than has been previously advised, the vessel 
will still be safe. Secondly, the duct of the other side must in 
any case remain intact, for it is difficult to conceive the possi- 
bility of an operator dividing both ; and if one is left uninjured 
it will be superfluous to state that sexual impotence following 
the operation is not the result of the surgeon’s knife. The 
real cause of this happily exceedingly rare sequence to the 
operation is rather to be sought in some morbid change affect- 
ing both the seminal ducts, and which may be produced by the 
lesion of Lithotomy as it now and then is by other lesions. 
When prostatitis has terminated in chronic prostatic abscess (I 
do not refer to periprostatic, so often mistaken for it), and this 
has involved in destruction all, or nearly all, the structure of 
the gland, the ducts sometimes become obliterated or sealed by 
plastic effusion, and loss of sexual function results. The 
vesiculae seminales may then be found exhibiting the same 
condition, having become the seat of abscess, their structures 106 
being injured or atrophied. This condition I have seen, not 
only following abscess, but also as the result of tubercle in the 
prostate and vesiculae. When, therefore, loss of virile power 
follows Lateral Lithotomy, I believe it is generally due either 
to sloughing from violence, or to inflammatory action in and 
around the ducts and vesiculse seminales, destroying the func- 
tion of these organs as conduits for spermatic fluid; and not 
to the mechanical division of one or both of them by the knife. 
The fact is an extremely difficult one to verify: long-continued 
and patient watchfulness for the opportunity of dissecting 
cases can alone determine precisely the actual lesion which has 
destroyed the function in question. 
7. Incontinence of urine occasionally follows the operation. 
It occurs more frequently in patients below the age of puberty 
than in adults. Apart from those rare instances of extremely 
large stone in which the neck of the bladder has been exten- 
sively damaged, no very clear explanation of the cause can be 
afforded, although speculative statements respecting it have 
been frequently made. Nor, perhaps, is it possible to offer any 
therapeutical considerations relative to it, differing from those 
which are available for incontinence occurring in ordinary cases, 
the numerous and varied modes of dealing with which need 
not be recapitulated here ; the following fact, however, is wTorth 
notice:—A very successful case of Lateral Lithotomy for large 
stone, which I performed in 1869, was followed by this un- 
pleasant consequence for many months. The patient was 
•otherwise in perfect health. Scarcely venturing to hope for 
good result, I cauterised the neck of the bladder in the summer 
-of the present year, 1870, since which there has been almost 
no incontinence. The effect was as complete as it was un- 
expected. 
8. A very unfortunate accident remains to be noticed, which 
is occasionally, but by no means frequently, encountered : viz. 
inability to discover any stone in the bladder when the opera- 
tion has been performed. 
In the first place, the stone may not be found because it is 
so small as to be washed out with the first gush of urine from 
the bladder. I have seen lithotomy performed for a stone no 
larger than an apple-pip, and no small embarrassment arising in 
/ 
INCONTINENCE OF URINE. LITHOTOMY WITHOUT A STONE IN THE BLADDER. 
107 
consequence of the occurrence named. It has happened, not 
very unfrequently, that after a long and fruitless search in the 
bladder, a very small concretion has been found on the floor, or 
in the receptacle placed to receive the blood and urine, or em- 
bedded in a clot, or even adhering to some part of the operator’s 
dress. But this ought not to happen, mainly because cases in 
which the calculus is so minute should not be subjected to 
Lithotomy at all. We shall see hereafter in the final applica- 
tion, in Chapter XIY., howT necessary it is, before performing 
any operation, to ascertain the size of the stone, that we may 
select an operation which is adapted to it. 
Again, an operation may prove fruitless because the stone is 
fixed in a cyst of the bladder, and cannot be detached from its 
place. This is very rare ; because if the presence of a stone can 
clearly be verified by means of the sound, it is generally suffi- 
ciently free in the bladder, although it may be partially en- 
cysted, to be removed by some means. See the management 
of encysted calculi at page 95. More rarely still are the follow- 
ing conditions met with. A bladder is sacculated, and one of 
its sacs is large, and communicates by a considerable opening 
with the original cavity. The latter state is rare, such openings 
being almost always small. But the patient is also the subject 
of calculus. The stone is usually in the bladder proper, where 
it is readily struck by the sound, but occasionally escapes into 
the sac, where there is no possibility of reaching it. Here, as 
in the preceding case, if its presence cannot be made out satis- 
factorily wuth the sound at the time of operation, no incision 
should be made.1 Lastly, no stone may be found at the opera- 
tion, because none has ever existed. The surgeon may have 
repeatedly sounded his patient, may have satisfied himself and 
others that he is the subject of calculus, and yet no stone what- 
ever may have been present. Thus, the existence of a polypoid 
tumour in the bladder, probably with some calculous deposit 
adhering to its surface, has deceived the surgeon. Such a case 
1 li may be as well to say that there is a material distinction between the 
terms * cyst ’ and * sac ’ as used here. By cyst I mean a cavity in the walls of 
the bladder, fitting to, and embracing closely, the stone which is always 
lodged in it; by sac, one of those large dilatations of one or more of the 
vesical coats, found independently of stone, but in which one may sometimes 
be lodged. 108 
LITHOTOMY WITHOUT A STONE. 
was many years ago cut for stone ; the preparation is now in 
the Museum of St. Thomas’s Hospital.1 
Again, it has happened that a rugose and hardened condition 
of the muscular fibres of a hypertrophied bladder has misled the 
surgeon, when sounding, into the belief that he has struck a 
stone. Still, nothing like the clear and ringing sound of a 
calculus can be elicited from such a source. The bony walls 
of the pelvis particularly, according to some authorities, may 
furnish similarly erroneous impressions to the operator. But in 
both these circumstances, the tactile impression and the audible 
sound are dull and heavy, not so clear and defined as the metallic 
click of a stone. Yet the fact exists that highly experienced 
and able surgeons have been misled by one or other of these 
causes.2 Few have the courage and the honour to enlighten 
their brethren by publication of the case after an experience of 
this kind. Mr. Paget, of Leicester, has very recently offered a 
noble exception to this remark, in furnishing the particulars of 
an instance in which he operated without discovering stone. 
In his case, that of a child, the click, although heard by several, 
was not satisfactorily distinct on any of the occasions of sound- 
ing which had taken place, while the symptoms were exceed- 
ingly severe. The operator, however, desired to relieve the 
sufferer if it were possible, hoping that a partially encysted 
stone might be the cause. Death occurred after two days, and 
at the post-mortem examination no calculous matter was found 
in the bladder, but the ureters were enormously dilated. On 
repeating the act of sounding, the click was reproduced, and it 
was discovered to be due to the point of the sound impinging 
upon the iliac portion of the brim of the pelvis, the edge of 
which was unusually thin and sharp.3 This case, in some 
measure, confirms the opinion of Mr. Gutteridge, of Birming- 
ham, who had, with a like admirable candour, previously 
published the fact that he had 4 operated in three cases, wherein 
the most confident assurance the sense of touch was capable of 
giving was had respecting the existence of a stone,’ and had, 
1 South’s Chelius, vol. ii. p. 551, 
2 Cheselden, Roux, Dupuytren, and Crosse have operated and failed to find 
the stone. 
3 British Med, Journal, Dec. 14, 1861. SPECULATIONS AS TO CAUSE OF DECEPTION, 
109 
nevertheless, found none. The patients lived, but by subse- 
quent inquiry and experiment on the dead body, Mr. Grutteridge 
came to the conclusion that the deception is due to the sound 
striking some part of 4 the bony fabric of the pelvis itself; ’ and 
he defines the precise spot to be the spine of the ischium, a 
part rarely touched, except when, the suspected stone not being 
at first found, a prolonged and extended search is made; and 
he adds, 4 the sound or staff being brought to the ischiatic ring, 
on either the right or the left side, and kept pressed there, will 
procure a sensation like that caused by touching a large rough 
stone.’1 
After experience and statements like these it may appear 
somewhat hardy to say that I am unwilling to relinquish my 
belief in the possibility of distinguishing between the click of 
a stone, and a sound produced in the manner described. I 
have repeated the experiment on the dead body several times, 
and I am quite unable to elicit a note, or to perceive a resist- 
ance by striking the sound against any portion of the bony 
walls of the pelvis, which is at all comparable with the results 
obtained by striking any kind of foreign body I have ever 
encountered in the bladder. The question is one of great 
interest, and is well worthy of further examination. Un- 
doubtedly a certain very small number of patients who are not 
the subjects of calculus, have been submitted to the incisions 
of Lithotomy, under the impression that they were so. But I 
believe that this happens less frequently now than in former 
times. As the art of diagnosis becomes more cultivated, and 
the means of exercising it are improved, the number of these 
cases will be diminished. With our present means and know- 
ledge, I venture to believe the mistake ought not to occur. 
1 A Memoir on the subject, published by Mr. Gutteridge, Sept. 1860. no 
CHAPTER VII. 
THE RESULTS OF LITHOTOMY. 
My own Inquiry, embracing 1827 Hospital Cases by numerous English Opera- 
tors.—Complete Analyses of them.—Affords a True Result of Lateral 
Method before Lithotrity was general.—Results of Cheselden's Practice.— 
And Martineau’s.—Now that both Crushing and Cutting Operations are 
employed, results must be different,—Fergusson’s Cases.—Keith’s.—The 
Author’s.—Results of other forms of Lithotomy. 
An inquiry into the results of Lithotomy will in the future he 
a pursuit of a different character from that which it has been 
in the past, and will yield different conclusions from those 
which have hitherto been attained by it. It is much less 
easy to estimate its capabilities now than it was formerly ; for 
when the Lateral Operation alone was applied to all patients 
with stone, its results were calculable by enumerating the 
cases, their ages, and the ultimate fact, whether recovery or 
death. 
Several years ago I made a laborious and extended inquiry 
relative to that operation in this country; and it is a matter of 
no little satisfaction that the matter was accomplished then, 
as the opportunity will probably never recur. The crushing 
operation has been found too successful for Lateral Lithotomy 
to become again the invariable and only resource for calculous 
patients, as it was in old time. Before Lithotrity was much 
employed in Great Britain, I had the means of ascertaining the 
capabilities of Cheselden’s method, in those districts where it 
was the only operation practised; and I think I am entitled to 
say that, by adopting a more rigid system of inquiry than had 
ever been pursued before, I obtained nearly 2,000 cases of 
perfectly authenticated examples in the following manner, re- Ill 
RESULTS OF LATERAL OPERATION. 
jecting a large number of proffered data, because they were 
unaccompanied by all the facts which I considered necessary, or 
had occurred in circumstances which appeared to impair their 
value as evidence. 
I required the whole of the hospital experience of a district, 
a written note of every patient, including his age and the 
result of the operation, and during a long term of years, 
corresponding with which the Lateral Operation alone should 
have been employed. On account of imperfect records, many 
hundreds of cases were rejected, since well-ascertained facts 
alone could be serviceable. Thus, also, in many reports which 
I received, the operators selected their best cases for Lithotrity, 
others for the Median Operation: on this account I did not 
include Mr. Teale’s valuable and well-known experience. Others, 
again—and this will apply also to the gentleman just alluded to 
—were men of so great celebrity in their districts, that the 
worst and oldest examples of the complaint were attracted 
from afar, and contributed to make such an experience by no 
means a fair and average product of the neighbourhood. I was 
therefore compelled to exclude Mr. Crichton’s long and valuable 
list in my possession, because it contained a most unusual 
proportion of aged patients. But the most considerable sacri- 
fice of this kind which I have made is the exclusion of Dr. 
Keith’s large and admirable experience, and on the same 
ground. 
The experience of the Glasgow Infirmary, numbering 152 
cases, is not employed in this department of the inquiry, 
because a large proportion had been operated on by the 
method of Dr. Buchanan. So, also, that of the Bristol Eoyal 
Infirmary, kindly afforded me by Mr. Pritchard, simply because 
it was not possible to ascertain correctly the ages of all the 
patients submitted to operation. The same remark applies to 
some of the metropolitan hospitals, to which access has been 
kindly afforded. 
Such care is essentially necessary in order to obtain valid 
numerical results. My table, then, is composed as follows:— 
The experience of the Norfolk and Norwich Hospital, in- 
cluding the 669 cases published by Mr. Crosse, in his well- 
known and valuable work, and 124 more cases immediately 112 
LATERAL OPERATION IN PUBLIC HOSPITALS. 
following these, during a subsequent period, and not interfered 
with by other modes of practice. For these I am indebted to 
my friend, Mr. Cadge, of Norwich. 
The records of the Eadcliffe Infirmary, Oxford, up to the 
present time, for which I am indebted to Mr. E. L. Hussey, of 
Oxford. The entire experience of University College Hos- 
pital, London, from an early date until very recently, for 
wThich my best thanks are due to each and all of my esteemed 
colleagues. 
A detailed account of all the cases met with at the Leices- 
ter Infirmary, obtained for me by my friend Mr. Thomas Paget. 
The experience of the Leeds Infirmary, for which I was in- 
debted to my friend, the late Mr. Nunneley. That of the 
Birmingham General Hospital for the last ten years, kindly 
placed at my disposal by Mr. 0. Pemberton. The records of 
Guy’s Hospital, carefully prepared by Mr. Thomas Bryant, who 
most readily permitted me to make any use whatever of them. 
The experience of the surgeons of St. Thomas’s Hospital, for 
which my thanks are due to Mr. Solly, Mr. Le Gros Clark, and 
for valuable aid in my inquiries to my friend Dr. Bristowe.1 
I am also a debtor for much kindness and pains to Dr. G. 
M. Humphry, of Cambridge, in affording me the experience at 
Addenbrooke’s Hospital; an additional number of 183, inclu- 
ding 13 deaths,’ a result which is so much better than any 
other, viz. 1 in 13 cases, that I am compelled to mention 
and register it separately as well as collectively. Once for all, 
let me say that, respecting every one of these cases, I have 
received, and now possess, exact particulars in writing from the 
most competent person to furnish it: those cases only excepted 
which have been referred to as already published by Crosse and 
South. 
The sum total, with Cambridge, is 1827 cases of Lateral 
Lithotomy, including 229 deaths, or 1 in 7-977, almost ex- 
actly 1 in 8. Without Cambridge it is 1644 cases, with 216 
deaths, or one in 7*62, in round numbers 7-|. 
The separate results are as follows:— 
1 A portion of the St. Thomas’s cases are the more recent ones (those in 
which all particulars were present), belonging to the well-known Table pub- 
lished by Mr. South, in his edition of Chelius' Surgery, vol. ii. p, 635. RESULTS OF LATERAL LITHOTOMY. 
113 
Norwich (Crosse) . . 669 cases, with 91 deaths, about 1 in cases. 
Since that time .124 ,, 15 „ 1 in 8£ „ 
Oxford 110 „ 14 1 in 8 „ 
Leicester 90 „ 8 „ 1 in 11 „ 
Leeds 29 „ 4 „ 1 in 7J „ 
Birmingham . . . 102 „ 10 „ 1 in 10 „ 
Guy’s Hospital . . . 230 „ 33 „ 1 in 7 „ 
St. Thomas’s do. . . 200 ,, .29 „ 1 in 7 „ 
University Coll. do. . 90 „ 12 „ 1 in 75 „ 
1644 216 
Cambridge .... 183 „ 13 „ 1 in 14 „ 
1827 229 
It must be remembered that these ratios of death alone 
furnish no certain index of the success which has followed the 
operation at different institutions. Before all things, indeed, 
it is necessary to know also the relative proportions of young 
and aged patients included in the number, since the rate of 
mortality differs so greatly at the different extremes of life, an 
element so constantly lost sight of in discussing the mortality 
following Lithotomy. Taking the whole number of 1827 cases, 
no less than half of them occurred in patients under the age of 
thirteen years. Applying this rule to any of the separate 
reports, we have an easy and tolerably accurate mode of testing 
the relative proportions in question. In metropolitan hospitals, 
to which many patients from the country are sent up, these 
being almost always adults, the proportion of aged patients 
is larger than that in the provincial hospitals. Thus in the 
records of University College Hospital, instead of half the 
number of patients being below thirteen years, those below 
that age formed only two-fifths of the total, from the unusually 
large proportion of elderly cases. In the Norwich Hospital the 
proportion of adults is also larger than the average, while that 
of Cambridge has a little more than the common proportion of 
children. The metropolitan hospital of Cfuy’s has, however, 
also an unusually large proportion of young cases. 
But for any such inquiry it is necessary to deal with the 
question of age much more carefully and minutely. We have 
to examine the proportion of fatal cases after the lateral opera- 
tion as occurring at several different periods of life. And I 
have dealt with this subject in a manner somewhat differing 114 
RESULTS OF LATERAL LITHOTOMY 
from that usually pursued. Thus it was soon obvious, in study- 
ing my figures, that little was to be gained by adopting the 
usual method of classifying the results of operation during 
periods of life artifically fixed as from 1 to 10 years, 10 to 
20, 20 to 30, and so on, the product of which is extremely 
deceptive. It was necessary to examine every year separately, 
then to group the years, and to observe wdiat natural indica- 
tions the facts presented. The following plan, after many 
trials, appeared to me best adapted to afford the simplest and 
truest aspect of the subject at a single glance. 
During the years Cases. Deaths. 
inclusive. } 473, including 33, or 1 in cases. 
inclusive. } 377> ” 46, about 1 in 28* . „ 
12 ti 16, | . 
inclusive. J 178, ” 19’ ” 1 m ” 
17 to 29, ) . 
inclusive. ( ” 22’ ” 1 “ H " 
30 to 38, ] _ . , lrt. 
inclusive. ) 75’ ” 7’ ” 1 m 102 ” 
39 to 48, 10o, „ 17, „ 1 in 6 „ 
inclusive 
inclusive } ” 40’ » 1 in '• 
UlusL0; } 233- 63- »iin 3* - 
71 to 81, 
inclusive 38’ ” 12’ ” 1 m 3(5 ” 
1827 229 
In studying this table, we see what Lateral Lithotomy is 
capable of effecting at various ages At the earliest ages—the 
first year only excepted—one death occurs in about fourteen 
cases, the rate of mortality falling to one only in twenty-three 
cases between six and eleven years. As we pass from twelve 
to sixteen years, the death-rate rises, for during the period 
when puberty is declaring itself, as sexual activity becomes 
developed, we find the increased susceptibilities thus aroused 
raising the mortality to one in nine and a half; and from 
thence to the thirtieth year, being until then about one 115 
AT DIFFERENT AGES. 
in seven cases. As manhood becomes established and the 
strength increases, the death-rate diminishes to one in ten 
and a half between the thirtieth and the thirty-eighth year. 
But daring the succeeding ten years, organic morbid changes 
beginning to set in, and the influence of continued depraved 
habits to tell on the constitution, the rate rises to one in six. 
These causes become more active, and at the same time the 
powers of life diminish, as age progresses from fifty to seventy 
years, the rate rising to one in four and three-quarters between 
forty-eight and fifty-eight, and gradually to one in three and 
three-quarters between fifty-eight and seventy, and finally to 
one in little more than three between seventy and eighty. 
Now let us revert to the two great groups, separated from 
each other by the event of puberty. The great group of 
infancy and boyhood, ceasing as adolescence begins, say at six- 
teen years, and comprising more than half the entire number, 
were operated on with a mortality of 1 in cases. Sub- 
tracting all these, we shall now learn its product in relation to 
adults. Regarding this great group as composed of all ages 
above 16 years,—and it matters little to the result whether we 
commence at that age or at 20 years,—we find just 800 indi- 
viduals left. Among these were 161 deaths, giving a mean of 
rather more than one death to every five cases. This, indeed, 
there can be no question, is a good average result of the opera- 
tion as applied to average adult males only, eliminating the dis- 
turbing influence of the large number of cases under puberty ; 
and it may be said here that this is the total to which the 
results of Lithotrity are to be brought, for purposes of com- 
parison, since that operation is applicable to adults alone. 
A reference to the experience of some past operators may 
be briefly mentioned since it furnishes matter of interest in 
connection with the present inquiry. The first trustworthy 
record we possess is that supplied by Cheselden himself, and it 
presents his entire experience. That famous surgeon at the 
close of his career, reported as follows. Telling us first that 
‘ of his private practice he kept no account,’ he states that 
‘ he cut 213 cases at St. Thomas’s Hospital,’ pertinently adding, 
4 but what is of most consequence to be known is the ages of 
ihose who recovered and those who died.’ Of these 213 cases. 116 
MORTALITY FROM LITHOTOMY VARIES 
no less than 135 were under ten years of age and 3 died ; 62 
more were between 10 and 20 years, and of these 4 died. 
Only 46 were above 20 years of age, of these 13 died,l 
Long after this comes Martineau’s (of Norwich) remarkable 
and exceptional series of successful cases, viz. 84 operations 
with 2 deaths ; this number did not represent his entire ex- 
perience, which I have learned on good authority at Norwich 
was by no means equal in result to the portion published, his 
success being indeed, as regards the total, not above the usual 
average. Of those 84 cases, however, 6 wrere females, and 36 
of the others were under 20 years of age ; leaving 42 cases 
of twTenty years old and upwards, among which were the two 
deaths.2 
I have already said that we can no longer examine Litho- 
tomy under the conditions of the past. At the present time, 
almost all the cases of small stone, and those occurring among 
the healthy patients, at all events, are submitted to Lithotrity. 
For some past time, and in the future, Lithotomy in adults 
must be regarded as an operation almost exclusively applicable 
to unusually large stones, often in patients with bad health. 
Instead of looking for one death in four or five cases, which I 
have shown to be a good result among average adults, we shall 
find a much larger proportion of fatal consequences. This 
again will be modified by the habit of the operator in selecting 
patients for the two methods. If he divides his cases pretty 
equally between the two operations, Lithotomy and Lithotrity, 
he will have a much smaller proportion of deaths from Litho- 
tomy, than if he applies the crushing operation to four cases 
out of five. If he takes this latter proportion, he will have 
made Lithotrity responsible for some difficult and unhealthy 
cases, but four out of five will have escaped the knife. His 
Lithotomy will in this case be performed on selected had cases, 
and the mortality will necessarily be high. His Lithotrity will 
have a higher death rate per cent., but the very strong proba- 
bility is that there will be a smaller percentage of deaths on 
the sum total of his stone cases. Thus it is clear that the 
mode of selecting, and the ratio of apportioning, patients for 
1 Cheseldcn's Anatomy, &c. 5th ed., London, 1740, p. 333. 
2 Trans, of the Boy. Med. and Chir. Soc. vol. xi. p. 402. ACCORDING TO CASES SELECTED. 
117 
the two operations, must be known before the results can be 
exactly judged. 
In illustration of this subject, the experience of Sir William 
Fergusson may be cited, as reported by himself in his lectures 
at the Royal College of Surgeons in 1865. The total number 
of his cases at that time was 271. Of these, 219 were adults 
(but certainly some were females), and 110 of them were 
treated by Lithotomy, with thirty-three deaths; while 109 were 
treated by Lithotrity, with twelve deaths; total, 219 cases with 
forty-five deaths, a mortality of adults treated by both methods 
of 20 per cent., or one death in every five cases. The remain- 
ing fifty-two cases were in children, with two deaths; an 
illustration, as the operator points out, of the need to report 
them separately. I wrote to Mr. Henry Smith, who was so 
intimately associated with Fergusson, for any information he 
might possess relating to his subsequent experience. He 
replies that he does not possess any, and believes ‘ that his 
additional cases would not amount to very much.’ 
Another valuable experience is that of the late Dr. Keith, of 
Aberdeen, so long the respected and successful surgeon to the 
Royal Infirmary there. At the close of his career, he placed 
at my disposal very complete records of all his cases of opera- 
tion for the stone. These had been kept with scrupulous 
care and accuracy, and I had the opportunity of seeing the 
calculi themselves at Aberdeen. The total number of all ages 
was 304 cases, from which must be deducted three cases in 
women, and twenty-three cases of youths and children; among 
wdiom there wTas one death only. Of the 278 male adults re- 
maining, 160. were operated on by Lateral Lithotomy, and 
among them were thirty-eight deaths, or one in over four cases. 
Then 118 cases were operated on by Lithotrity, and among them 
were seven deaths, or one in every sixteen and a half or seventeen 
cases. Taken collectively, in the 278 adult cases treated by 
both operations, there were forty-five deaths or a total mortality 
of eighteen per cent., or one death in every six and a half 
cases. 
It will be observed that his proportion of Lithotrity to 
Lithotomy was still smaller than that of Sir William Fergusson. 
In both cases the predominance of the cutting operation was due 118 
author’s series; five hundred cases. 
to the fact, that at the outset of the career of each of these 
distinguished surgeons, Lithotrity had scarcely been accepted 
in this country, and was rarely attempted. 
I can now offer as a contribution to this subject the result 
of my own experience up to the end of the year 1876, and 
comprehending every one of the adult male cases I had 
operated upon up to that date, a total of 500 cases. I pre- 
sented a complete summary of these, together with the stones 
themselves, to the Royal Medical and Chirurgical Society of 
London, in the spring of 1878.1 Of these 500 cases 422 
were operations by Lithotrity, and seventy-eight were by Litho- 
tomy; the relative proportions were, therefore, two cut for 
every eleven crushed, or one cut in every six and a half cases. 
The mean age of the 500 cases is no less than sixty-one and a 
half years ; the youngest being twenty years of age, the oldest 
eighty-four years; it should be added that there is one only of 
twenty years of age, and only twelve patients in the entire list 
are below thirty years. 
The proportion of patients allotted to the two operations 
respectively is, it will be seen, very different to that which 
the preceding operators named had adopted. Throughout the 
series the smaller and middle-sized stones and the more pro- 
mising cases were reserved for Lithotrity, while, as a necessary 
consequence, Lithotomy has been employed only for exceptionally 
large and difficult cases. As, certainly, during my life I have 
never rejected five cases, if, indeed, so many, as unfit for any 
operation, it follows that many difficult and almost hopeless 
cases were to be found amongst those on whom the cutting 
operation was performed. The number of deaths was as 
follows :—In the seventy-eight cases of Lithotomy, there were 
twenty-nine deaths, or about one in two and three-quarter 
cases. In the 422 cases of Lithotrity there were thirty-two 
deaths, or one death in rather more than thirteen cases. 
Taken collectively, in the 500 adult cases treated by both 
operations, there were sixty-one deaths, or a total mortality of 
twelve per cent., or one death in eight and a half cases. 
To the late Mr. Allarton I have been indebted for the record 
of 139 cases of Median Lithotomy at all ages, with thirteen 
1 Trans. Buy. Med. Chir. Soc., 1878, vol. Ixi, RESULTS OF OTHER OPERATIONS. 
119 
deaths, or one in eleven cases. Not to forestall future observa- 
tions, it is necessary to note that this operation, being usually 
reserved for stones known or believed not to be very large, we 
are entitled to claim from it a result better than that of Lateral 
Lithotomy. This does not include the Norwich cases of the 
Median Operation, which my friend Mr. Cadge informs me 
amount to between forty and fifty within about four years, and 
the mortality from which has been about the same as by the 
lateral method. But it is only fair to state that there was 
rather a full proportion of unpromising cases among them. 
Dr. Buchanan reported upwards of sixty cases of his opera- 
tion, performed by several surgeons, with, as nearly as possible, 
the same result as that exhibited by Mr. Allarton’s table. 
From the history of the Bilateral Operation, we know that 
in the hands of Dupuytren and his contemporaries, eighty-five 
male cases were cut, with nineteen deaths, or about one in 
four and a half cases. In other hands it is said to have been 
more successful. 
Of the Medio-bilateral Operation we have no large experience 
to examine. I have performed it in a few cases, believing, at 
one time, that it might present some advantages over Lateral 
Lithotomy, but I do not find this to be the case, so far as I can 
judge. I used it as an exceptional proceeding for large stones 
not amenable to Lithotrity, and always in elderly and infirm 
men. The result which my experience afforded me, and which 
I was not prepared for, was that the haemorrhage was often 
unusually large and troublesome to repress. Besides this, the 
rectum was easily wounded from its necessarily close proximity 
to the incision, for a large stone, not always perhaps by the 
knife, but by the removal of the stone tearing the thin septum 
between the wound and the bowel. On these grounds I have 
discontinued the operation, having performed it last in January, 
1868, and have since substituted the Lateral Operation. 
From the history of the Recto-vesical Operation, we learn 
that a nearly equal number of cases gave a result of about one 
death in five; and a similar proportion of the patients recover- 
ing were the subjects of fistula subsequently. 
The Suprapubic Operation has given results said by some 
to be about one death in four cases. Dr. Murray Humphry, RESULTS OF SUPRAPUBIC OPERATION. 
120 
of Addenbrooke’s Hospital, Cambridge, performed it success- 
fully for a boy of fourteen years. He collected from authentic 
sources 104 cases, of which thirty-one were fatal, equal to one 
death in three and a third cases. Of course it is to be recollected 
that this, as well as the preceding operation, is rarely performed 
for other than very large stones, and mostly in adults. He 
remarks, also, that ‘ the dangers of the high operation do not 
increase in so great a ratio with the size of the stone ’ as in the 
lateral operation.1 
1 ‘ Case of High Operation,’ Trans. Prov. Med. Ass. 1850, vol. xvii. p. 103. PART II. 
LITHOTEITY. 
CHAPTER VIII. 
LITHOTRITY.-—INTRODUCTORY. 
General Observations relative to its Rise and Progress.—The Importance of 
Treatment preliminary to the Operation,—Its Nature, General and Local. 
I propose in this, the second portion of my work, to illustrate 
concisely the principles and practice of modern Lithotrity. 
By this term, since custom has popularised it, all those 
processes may be denoted by which the stone is broken up, 
crushed, and powdered in the bladder, and by which the debris 
are removed through the natural canal of the urethra without 
the use of the knife. 
Lithotrity is the product of rapid growth. Sixty years ago 
it was but a theory. Forty-five years ago it had barely made 
good its claim to be admitted into the list of recognised surgi- 
cal operations. Each succeeding ten years has witnessed great 
improvement in its applications, and its increased capabilities 
for good. 
The Lithotrity of to-day is not the Lithotrity of even ten 
years ago, but a safer and a better operation—an operation 
which now is founded on principles, and regulated by well- 
defined laws deduced from a large experience; no longer con- 
sisting, as in its infancy, in the mere experimental application 
of a crushing instrument to any calculus which, being con- 122 
RISE AND PROGRESS OF LITHOTRITY. 
sidered neither too hard nor too big, might be located in a 
fairly healthy bladder. 
It is, therefore, the Lithotrity of to-day, its principles, and 
the practice logically deduced from them, which it will be my 
aim to expound and to illustrate here. 
There is reason to believe that calculous matter has been 
occasionally removed by Lithotrity at various early dates, but 
no attempt seems to have been made to apply the principle, 
generally or systematically, until a.d. 1813, when Grruithuisen, 
a surgeon in Bavaria, proposed a plan for seizing and reducing 
to powder, by drilling, a stone in the bladder. Subsequently, 
in 1819, Elderton, a Scotch surgeon, published a somewhat 
similar proposal. Meantime, in 1817, Civiale, of Paris, de- 
signed his earliest instruments; and was closely followed by 
Leroy d’Etiolles and Amussat, in the production of other 
instruments for the same purpose. It appears, however, that 
the first successful operations were undertaken in 1824, the 
honour of which belongs to Civiale, who performed them before 
a committee of the French Academy. Improvements in the 
method and in the instruments were subsequently made by 
Weiss, Heurteloup, L’Estrange, Costello, Charriere, and others, 
as well as by Civiale himself, whose experience in the applica- 
tion of Lithotrity must be regarded as exceeding that of any 
other operator. It is his method which, during my earlier 
operations, was closely followed and practised by myself; my 
own experience, however, now very large, led me to modify the 
character and action of the lithotrite, and the method, to 
a certain extent, has necessarily somewhat changed with it. 
With this, as well as after large opportunities of observing the 
practice of other operators, I do not hesitate to say that the 
operation has become more rapid and safer still than any pre- 
viously practised. Still more recently, the proposal of Professor 
Bigelow to crush more completely, and to remove all debris by 
larger evacuating catheters—a mode of operating still on its 
trial—bids fair in competent hands to render Lithotrity more 
largely applicable, and perhaps more successful, than heretofore. 
The most modern and improved methods of performing the 
operation will therefore be described in detail in the next and 
succeeding chapters. 123 
PRELIMINARY TREATMENT NECESSARY. 
Treatment preliminary to the Operation of Lithotrity. 
—There is one topic in connection with Lithotrity which I do 
not propose to consider at length here; the practical manage- 
ment of the operation itself being the main object in view. 
But it is impossible to pass it by altogether. I refer to the 
preparatory treatment which should precede, in some instances, 
the application of operative measures. 
Among the calculous patients admitted into hospitals in 
the Metropolis, most show signs of general deterioration of the 
health; the result of pain, loss of rest, and other depressing 
influences of their malady. Much may often be done to im- 
prove their condition before deciding on, or proceeding to, 
the operation. Others, however, and especially some patients 
from country districts, present much more promising signs, 
even although they may have been for a considerable period 
the subjects of stone. Nevertheless, it is unwise to admit even 
these cases to operation after a rest of only three or four days, 
and the conventional aperient. It is an error, I believe, to 
operate on country patients, whether in private or in public 
practice, immediately after their arrival in London. However 
healthy the condition of such a case, it sometimes happens, if 
operative proceedings are at once undertaken, that the patient 
soon afterwards becomes the subject of fever and exhaustion, 
and he may even fall a victim to the attack. 
A period of acclimatisation must be passed through by 
most of them, during which the system is not in a condition 
calculated to support favourably a capital operation. Soon 
after the arrival of a country patient in London, he occasionally 
becomes feverish, digestion is deranged, and sleep disturbed. 
Generally, a dose or two of mild aperient, a few days’ rest and 
more than ordinary care in diet, restore him to his usual condi- 
tion. Many persons, enjoying excellent health, suffer in this 
way in a change from country to town residence. The change 
involves altered diet, altered habits, and the presence of 
numerous sources of excitement, disregarded by the native, 
perhaps unknown to him, but strongly impressing, and often 
disagreeably, the sensorium of the stranger. When to these 
are added the numerous sources of anxiety and discomfort 
which a patient experiences when he is anticipating the crisis 124 
PRELIMINARY TREATMENT FOR PATIENTS 
which is to free him from it, but not without some risk to life, 
it is not surprising that some nervous derangement should 
sometimes manifest itself by troublesome symptoms. 
Apart from these considerations, but little reflection may 
suffice to convince us, that in most cases it is unwise to operate 
on a bladder which is the subject of unchecked chronic inflam- 
mation, a condition not infrequent, although often absent, in 
calculous cases. When it does exist, incautious interference 
may set up acute cystitis and lead to mischief in the kidneys, 
and a fatal issue. Hence we should endeavour to allay the 
irritation of the bladder, to tranquillise the nervous system dis- 
turbed by local pains and broken rest, improve the diges- 
tive organs, and increase the general strength. If we can 
accomplish these objects, although at the sacrifice of a little 
time, prior to operation, we have a right to expect, other 
things being ordinarily favourable, the ultimate recovery of 
the patient. 
We shall enjoin, then, for a few days, rest in the recumbent 
posture ; and, according to the necessities of the patient, atten- 
tion to the secretions, regulated diet, local bathing, possibly, in 
some few cases, washing out the bladder; and, if necessary, the 
use of opiates or other sedatives. 
Demulcent drinks, decoctions of roots and leaves exercis- 
ing specific effects on the bladder, may be also useful. Among 
them, I know none, in these particular circumstances, so valu- 
able as a decoction of the underground stem of Triticum 
repens; a pint to be taken in divided doses daily. 
One element of the preliminary treatment, especially abroad, 
is the systematic employment of bougies, so as to accustom the 
urethra to the contact of a full-sized metallic instrument. 
Especially if the patient has not been the subject of catheterism 
previously, first a soft elastic bougie of middle size, and then 
metallic ones, is passed through the urethra every other day or 
so, increasing the size on each occasion. A little warm water 
is injected into the bladder if much pus or mucus is present, 
and the urine is alkaline ; or water containing a small propor- 
tion of nitric acid, or of acetate of lead, especially if phosphates 
are found in the deposit. 
Hut this preparation by instrument is really necessary only ABOUT TO UNDERGO LITHOTRITY. 
125 
in exceptional cases. When the urethra is not quite ample, 
it may be dilated with advantage; or the external meatus may 
be divided, so that the lithotrite or a large evacuating catheter 
may pass easily. 
Most commonly, if the patient is in fair condition, the 
removal of his stone, especially if it can be accomplished at a 
single sitting, will be the best means of diminishing local 
inflammation, and of inaugurating a new and tranquil state of 
the bladder, in which it will rapidly regain its healthy tone. 
Nevertheless, it is desirable to have favourable conditions 
present if possible ; they are not essential to success, which 
happily is often achieved in their absence. Such conditions 
are 
1. A capacious and not very tender urethra. 
2. A bladder capable of retaining 3 or 4 ounces of urine. 
3. Absence of the ordinary signs of renal disease; and fair 
general health. 126 
CHAPTER IX, 
THE OBJECTS OF LITHOTRITY, AND THE PRINCIPLES ON WHICH 
INSTRUMENTS SHOULD BE CONSTRUCTED IN ORDER TO ATTAIN 
THEM. 
Objects of Lithotrity defined.—Principles which guide its Practice.—All evil 
Results arise from mechanical Lesion.—Lithotrites constructed to avoid 
producing Injury.—Three Classes of Lithotrites : Fenestrated Blades ; 
Plain Blades; and Intermediate.—The Mechanical Power employed;• the 
Wheel and Screw.—French and English Models.—The Cylindrical Handle, 
—Size, Materials. &c. 
What is the precise object of Lithotrity ? is a question which 
must be proposed and definitely answered at the outset of any 
consideration of this subject. The object of Lithotrity has 
been generally held, until late years, to be the reduction of the 
stone to the form of debris, sufficiently small to be expelled by 
the patient’s natural efforts during the act of micturition. 
Of late, the artificial removal of debris has also been 
employed, and increasingly so; and the object of Lithotrity, 
according to some surgeons, and including the present writer, 
may now be defined, as, first, to reduce a stone to fragments 
sufficiently small to pass through an evacuating catheter which 
can be introduced into the bladder without injury to the 
passages ; and, secondly, so to remove the fragments without 
unnecessary delay. 
In the performance of the necessary manipulations to effect 
this object, it will be obvious that any evils connected with the 
practice of the operation are traceable to mechanical lesion of 
some kind, mostly tending to excite more or less inflammation 
of the bladder or urethra; the direct agents in producing it 
being instrumental interference, or the presence of sharp or 
angular fragments. > L1TH0TR1TY: PRINCIPLES OF THE OPERATION. 
127 
Therefore it must be our aim, first, to reduce the stone 
to fragments in the most efficient manner without injury to 
the passages; and secondly, to take care that the sharp and 
angular fragments cause as little injury as possible to the 
bladder afterwards by residence therein, removing them, there- 
fore, always when possible ; and, finally, to accomplish these 
objects by the smallest amount of instrumental interference. 
These principles are to be constantly kept in view; they 
will guide us materially in the selection of instruments, as 
well as in numerous details connected with the operative treat- 
ment. 
The subject of instruments will first engage our attention. 
The mode of applying them will follow: and here it may be 
well to remark that the practice of systematic, methodical 
Lithotrity—and such alone can be relied on for success—consists 
not only in the conformity of its proceedings to two or three 
general principles, but in attention to numerous details, the 
value of which experience has established. Each of these may 
be minute in itself, indeed, apparently insignificant at first 
sight to some minds; but each becomes important when the 
result of their aggregated influence is regarded. I feel, then, 
that no apology is due for the attempt to present a circumstan- 
tial exposition of these details, especially as I know of no pub- 
lished source where it can be found. Of one thing I am certain, 
they will not be deemed unimportant, or without value, by 
those who have a practical acquaintance with the difficulties 
and the risks which attend Lithotrity when pursued in igno- 
rance of rules and without a method. 
Instruments for Crushing Stone in the Cavity of the 
Bladder: Lithotrites.—The subject of instruments is a most 
important one, and deserves a careful consideration from every 
student who wishes to practise Lithotrity with success. There 
is much more to be gained by a knowledge of the minutiae of 
the mechanical arrangements adopted in the construction of 
the lithotrite than is generally supposed. 
It should be remarked at the outset, that every point relat- 
ing to the form, weight, size, and construction of a modern 
lithotrite has been arrived at through long years of experience 
and careful attention to the necessities of hundreds of cases, 128 
CONSTRUCTION OF A LITHOTRITE. 
and after the occurrence of numerous contingencies, not antici- 
pated at first, but now provided for. No study of Lithotrity, 
whether it be pursued on the body or without 
it, is of much value, apart from a prelimin- 
ary knowledge of the mechanical principles 
on which lithotrites are, or should be, con- 
structed. 
In order to save misunderstanding and 
circumlocution, it may be premised here 
that all lithotrites will be regarded as 
possessing the following principal parts: 
The blades (when acting together often 
called ‘ jaws’), the shaft, the sliding-rod, and 
the handle (fig. 51). The blades are two in 
number ; one distal (from the handle), im- 
movable, continuous with the shaft, called 
‘ the female bladethe other, proximal, 
movable, continuous with the sliding-rod, 
and called i the male blade.’ The shaft is 
perfectly straight, and forms the longest 
portion of the instrument, corresponding to 
the average length of the urethra and two 
or three inches over. The sliding-rod is re- 
ceived into a longitudinal channel, occupy- 
ing the entire length of the shaft; it bears 
at one end the male blade, at the other it 
is acted upon by the mechanical power em- 
ployed ; and on its upper surface, near to 
this end, is marked a scale showing to what 
extent the blades are separated, when hidden 
in the bladder from the surgeon’s eye. The 
handle not only serves the purpose which its 
name implies, but contains, or has affixed to 
it, the mechanical power which is destined to 
move the male blade. 
Up to a recent period, lithotrites were 
regarded as naturally occupying two distinct 
classes, arising out of the nature of the 
work required to be accomplished by the 
Fig. 61, 
A French Lithotrite 
of the well-known ‘ Chan* 
ri6re,’ model, a, female 
blade; 6, male blade; 
c, c, shaft; d, sliding- 
rod, ending in the male 
blade ; e, handle. DIFFERENT KINDS OF L1THOTR1TES. 
129 
crushing part, or the blades ; while the modes of applying the 
necessary force, which will be considered hereafter, might be 
the same, or might vary, in either class. 
Class I. Lithotrites with the female blade open or fenes- 
trated ; or instruments for breaking the stone into large 
fragments ; which they, the instruments, are incapable of remov- 
ing from the bladder. 
Class II. Lithotrites with no opening in the female blade ; 
or instruments for reducing the stone into small fragments or 
o o 
debris ; and which these instruments are capable of removing 
from the bladder. 
But a good modern aspirator being unquestionably superior 
in most hands for the purpose of removing fragments or debris 
to the flat-bladed lithotrite, the latter, although still required, 
is less used than formerly. A safe and efficient lithotrite for 
reducing the stone to a condition in which it is easily remov- 
able by aspirator and evacuating catheter, is what is now de- 
manded. And as it must be fitted to work in the bladder during 
some minutes before being withdrawn, it is essential that it 
should be so constructed that the blades cannot be choked with 
debris, and so rendered unable to close; a condition which may 
sometimes occur with the ordinary flat-bladed lithotrite, if 
worked for some time without withdrawing it to be cleared. 
Hence I have adopted, after several experiments, some powerful, 
but not large lithotrites, on a principle of construction which 
is intermediate between these two classes, and avoiding the 
objectionable points of each ; the female blade slightly fenes- 
trated, the male blade partly wedge-shaped : its description will 
follow that of the others. I have also very recently improved 
the flat-bladed lithotrite, so that it now is much less liable to 
choke than formerly. 
But before considering these separately, it will be well first 
to advert briefly to certain principles of constructing the blades 
which apply equally to all classes. 
1. The blades and the shaft form an angle with each other 
which is always somewhat greater than a right angle. But the 
greater the angle, the greater is the sacrifice of power, and 
vice versa; power acting through blades whose 
inclination from the shaft is more than 120°. On the other 130 
CONSTRUCTION OF THE BLADES OF A LITHOTRITE. 
hand, the greater the angle the more easily the instrument 
passes through the urethra. 
2. The wider the blades the easier is it to catch a stone or 
fragment, and the less likely is either when caught to slip 
from the grasp of the instrument. But power acts disadvan- 
through wide blades: a narrow male blade forces its 
way through a mass which could not be penetrated by a wide 
one ; on the other hand, the grasp of a small fragment is much 
less certain to be secure when one, and especially when both 
blades are narrow, than with two wide ones. 
3. The surface of the male blade which is opposed to the 
female blade is roughened, in order to render the grasp more 
sure, and because pressure between roughened surfaces tends to 
separate cohering particles ; between smooth surfaces it favours 
their forming into a mass. If the object is to break a hard 
stone, the male blade may have a toothed surface, that each 
of the several projections may exert a wedge-like action on the 
resisting mass. But if the male blade has an acute angular 
or wedge-like form, although it will act most powerfully and 
efficiently on a large and hard stone, it is, nevertheless, an 
objectionable instrument, because, as may easily be proved 
by experiment, the divided fragments fly off at right angles 
with great force, and endanger the walls of the bladder, as I 
have long ago verified. Hence the male blade must not be too 
narrow in any case, although it should be somewhat angular for 
large stones, in degree proportioned to their size. 
Fig. 52. 
Class I. The lithotrite with an open or fenestrated female 
blade (figs. 52 and 53). 
Fenestrated female blade, with large teeth : a large and powerful Lithotrite. FLAT-BLADED LITII0TR1TES. 
131 
The peculiar function of the unfenestrated instrument is to 
reduce a stone into fragments, and not to produce fine debris. It 
is adapted only for very hard stones, and for those which are 
of really large size; but its employment requires care, because 
the edges of the blades are necessarily angular, and may be 
Fm. 33. 
Fenestrated female blade, with small teeth ; rather less powerful than preceding. 
sharp; because these edges meet each other accurately, and the 
mucous membrane may therefore be readily included between 
them.1 The jaws are also longer than those of other instru- 
ments, and can, therefore, be less readily and less safely turned, 
or in any way manipulated, in the vesical cavity. 
Class II. The lithotrite with plain or entire blades. (See 
figs. 54 and 55.) 
The larger and stronger kind may be used to crush uric 
acid stones of medium size, say nearly all up to about an inch 
in diameter, and larger ones if phosphatic; but the special 
function of this class is to reduce calculous matter, whether 
existing as such stones, or as fragments produced by fenestrated 
instruments, to a granulated condition. 
A well-constructed lithotrite, with plain blades, for the 
purpose of crushing stones of small and medium size, has a 
wide female blade, and a narrower male one, so that the force 
applied through the latter may act efficiently by its narrow 
surface, and not be diminished by distribution over a large one. 
A comparison of fig. 54 with fig. 55 will exemplify this remark. 
The narrow male blade of fig. 54 will readily make its way 
through a small stone or fragment lodged against the female 
blade, the width of which aids in retaining the fragment in 
1 Although always made with sharp and accurately fitting edges, there is 
no reason why these should not be bevelled; the accident would then be less 
liable to happen. 132 
MODIFICATIONS OF THE BLADES : 
position ; while the male blade of fig. 55, nearly as wide as the 
female blade to which it is opposed, will granulate small frag- 
ments admirably, but will be inefficient against a hard mass 
of more than half an inch in diameter. Moreover, were an 
Fig. 54. 
Litliotrite with plain blades, but the male blade narrow. 
Fia. 65. 
attempt so to use it successful, the jaws of the instrument 
might become packed so tightly with detritus, as to render its 
dislodgment somewhat difficult. 
An instrument of this class may be rendered somewhat 
Lithotrite with plain blades, but the male blade wide. 
Fig. 56. 
Lithotrite with male blade very slightly wedge-shaped. 
more powerful still by making the male blade slightly convex 
or angular, or projecting in the centre. I have long used this NATURE OF THEIR ACTION. 
133 
slight modification with advantage, when a stone has been a 
little larger or harder than usual. (See fig. 56.) 
The occurrence of this condition, viz. 4 packing ’ or choking 
with debris, is provided against in the lithotrite with a narrow 
male blade, from the jaws of which it can be generally dislodged 
at the will of the operator, by a method which will be explained 
when we arrive at the subject of manipulation. But it is 
important that the female blade should not be too hollow or 
deeply recessed, especially at the angle, or that part wThere the 
blade joins the shaft, since complete dislodgment of debris 
from this spot is difficult, and its presence here interferes with 
the perfect action of the instrument. It is a fault too commonly 
met with in instruments made both here and abroad. In any 
case there should be an opening at the angle, as large as the 
instrument will safely admit , for the exit of debris. 
The crushing instrument of this class is a very safe and 
efficient lithotrite where it is applicable, and is possessed of 
considerable power and strength, although not equal in this 
latter respect to those of the first class. The margins of the 
jaws are not sharp, but well bevelled; moreover, it is scarcely 
possible, from its construction, to seize or nip a piece of mucous 
membrane between the edges of the male and female blades, a 
considerable interval existing between them (the edges only) 
when the blades are closed. This instrument will also perform 
the office of the old 4 scoop,’ when required, as well as any other 
instrument made. Its blades being flat, much debris may be 
contained between them without unduly enlarging the calibre ; 
their capacity in this respect is remarkable. Further, the 
blades are shorter than those of the powerful fenestrated 
instruments, and will therefore not easily retain their hold on 
a stone which is much too large for their power; it will be 
obvious that the shorter the blades, the more readily will a 
large stone slip from their grasp as the screw power is applied ; 
so that they are to a certain extent able to reject a stone much 
beyond their capacity to crush. Lastly, it may be remarked 
that the construction of this instrument, when properly made, 
provides that if, by any mischance, its power is overtaxed, and 
fracture of the instrument at some spot is inevitable, this must 
take place at the angle of the male blade (that is, its union 134 
NEW LITHOTRITES WITH KEEL-SHAPED BLADE. 
with the sliding rod), so that the instrument can be withdrawn, 
and only a very small portion, not too large to traverse the 
urethra, will be left in the bladder. There is no more fear of 
this occurrence, however, if used with prudence, than with any 
other instrument; still, it is as well to be aware that this 
admirable provision exists against possible accident. 
Class III. A new lithotrite, differing from any example of 
those described under Class I. and II., is one which I have 
recently designed and employed. It equals any fenestrated litho- 
trite in power, and at the same time avoids the disadvantages of 
that instrument already pointed out. 
The difference in this new lithotrite consists in making the 
lower part of the male blade keel-shaped, or like the prow of 
Fig. 57. 
The male blade, showing that it is almost vertical in profile, and the prow-shaped arm of 
the lower part, gradually becoming flattened above. Transverse sections of the blade, A, to the 
upper part; B, at the middle ; and C, near the base, show this form. 
Fig. 58. 
'epresonts the male and female blades and tbe opening winch is filled by tbe projection of 
the lower part of the former when the lithotrite is closed. 
a ship, while the upper part is still flattened; so that the 
instrument may execute powerful cutting and crushing actions 
simultaneously. The male blade is also placed at almost a THE MECHANICAL POWER TO BE EMPLOYED. 
135 
right angle with the shaft, and thus acts at great advantage in 
comparison with a blade diagonally placed. At the same time, 
the female blade retains its curve, enabling the instrument to 
be introduced with as much facility as heretofore. Lastly, I 
have thickened the sides of the latter, and enlarged the opening 
to admit the prow of the male blade to enter it and drive out 
any debris which, with the increased amount of work now 
required, might otherwise lodge and impact the blades. (See 
figs. 57 and 58.) 
I have extended the same principle to a lighter, and flat- 
bladed lithotrite also ; suitable for crushing smaller stones and 
large fragments, making it much stronger and less liable to 
block than other flat-bladed instruments. 
Thus much for that portion of the lithotrite which transmits 
the applied force, by direct contact, to the stone itself. The 
next subject for consideration is that portion of the instrument 
by which the force is accumulated and applied. 
The screw is now the only mechanical power adopted for 
this purpose; but force can also be transmitted by direct 
manual pressure, and by percussion. 
The conditions necessary to the construction of this portion 
of a good lithotrite are—first, powTer in abundance ; second, 
power which can be quickly applied, and in small or large 
quantity at the will of the operator; third, power which can 
be disengaged and re-applied with ease and rapidity ; lastly, 
all these conditions to be fulfilled, and to be made effective in 
small compass and without the necessity for harsh movements 
capable of communicating injurious concussion to the bladder 
or urethra. 
In reference to the rule that a good lithotrite should 
possess an abundance of power, it is necessary to remark, that 
the leverage by which the screw is turned should always cor- 
respond with the strength of the blades, in relation to the work 
submitted to them ; and should also be apportioned to the 
muscular strength of the operator. If the surgeon has a 
powerful hand, the instrument-maker will not increase the 
diameter of the wheel-shaped handle above an average size ; if 
he is deficient in muscular power, the handle ought to be larger. 
The screw is a form of mechanical powTer which admits of 136 
THE SCREW AND ITS MODIFICATIONS. 
great pressure being gradually, evenly, and continuously applied. 
But the production of rapid impulse and percussion are also 
with practice both compatible with the action of the screw. 
One great drawback in the original screw instruments was the 
loss of time expended by unscrewing, in order to open the jaws 
of the lithotrite which have been closed in the act of crushing. 
No matter how often the screw is turned home for the latter 
purpose, so often must it be deliberately unscrewed before the 
jaws can be opened again for a fresh search. The abolition 
of unnecessary time and movement is so much clear gain to the 
process, since there is necessarily a correspondingly diminished 
chance of producing disturbance of the bladder. It was long a 
desideratum to produce a lithotrite in which the screw should 
remain as the mechanical power, and yet no unscrewing be 
necessary, in which, also, rapid impulse and percussion could 
be applied. After many attempts, this was first successfully 
supplied by the late M. Charriere, the well-known surgical 
mechanist of Paris, in the very ingeniously devised lithotrite, 
commonly distinguished by his name. Its action provides 
that, after the male blade has been screwed home, it can be 
withdrawn instantly to any extent without unscrewing. The 
movement may be described as follows :—The male blade having 
been screwed home on a fragment, the operator makes a quarter 
turn of a movable disc in the handle (fig. 59), when the screw 
power is instantly detached from the sliding rod and male blade, 
which may now be withdrawn to the full extent, or moved 
Fig. 59. 
backwards and forwards in any way, for the purpose of finding 
a fragment; when this has been seized, a reversed quarter 
turn of the disc is made, the screw power is attached, and the 
The handle of Charriere’s Lithotrite, showing scale, &c. 137 
LITIIOTRITE WITH THE CYLINDRICAL HANDLE. 
fragment is crushed by screwing home. Supposing, however, 
that the calculus 'does not readily yield to screw pressure, and 
there is reason to believe that percussion may be useful, the 
screw power is again detached without risking the grasp of the 
fragment, and a smart tap or two made on the end of the 
lithotrite communicates direct its effect through 
the male blade. Or, simple manual pressure may 
be substituted, if preferred. The attainment of 
these objects by this lithotrite constitutes a great 
advance on instruments of the pre-existing con- 
struction. Subsequently, attempts to improve 
this action were made by Weiss, Collin and 
others. By far the most simple and efficient 
method is that of Weiss, in which the sliding 
action is exchanged for that of the screw, and vice 
versa, by merely touching a button in the handle. 
My own design, also of a handle of cylindrical 
form, has been associated with this, and enables 
the operator to employ the lithotrite with greater 
ease, dexterity and nicety, than can be attained 
with any previously existing lithotrite. It is the 
power of employing this instrument with the 
lightest possible hold by the finger and thumb, 
in any direction, which imparts its peculiar 
facility for the detection of small fragments. 
This will be especially showm when that subject 
comes in due course for consideration; but I may 
say here, that it is perfectly easy for a practised 
hand to elicit an audible note from a fragment of 
calculus in the bladder, the size of which frag- 
Fig. 60. 
A, Wheel-shaped end of sliding? shaft, held in the operator’s right hand, 
which directs the movements of the male blade b. 
n, The screw. 
d, The button which throws the screw into gear or releases it, as desired, 
c, The cylindrical handle attached by outer shaft to the female blade F. 
Fig. GO. The author’s Lithotrite with cylindrical handle. 
ment is not larger than a split pea. This I have demonstrated 
too often on the patient, not only in my clinical lectures here, 
but in public in Paris, for the smallest doubt to exist of the 138 
SIZE AND MATERIAL OF LITHOTRITES. 
fact. It is one, however, the importance of which cannot be 
over-stated in relation to the success of Lithotrity. The same 
cylindrical handle, moreover, enables the operator to hold the 
instrument with a firm and steady grasp when this is required. 
On account, then, of these qualities, which have now brought it 
into very general use, both here and throughout Europe, it 
will be assumed to be the lithotrite employed in the directions 
hereafter given, unless a special statement to the contrary is 
made. 
Other methods of applying power by the wheel, rack and 
pinion, the screw, by percussion, &c., have been employed, but 
having become obsolete, belong now only to the history of 
Lithotrity, and will not be regarded as within the scope of 
our consideration. 
Lithotrites vary in size, according to the purposes for which 
they are required. Powerful adult lithotrites may measure in 
the shaft about 10 or 11 of the English catheter scale, and 
about 13 to 16, as the mean of the two diameters (lateral, and 
from before backwards) of their blades Lithotrites of moderate 
average power may be equal to 9 or 10 in the shaft, and 12 or 13 
in the blades; small ones, 7 or 8 in the shaft, and 10 or 11 in 
the blades. For boys, 6 or 7 in the shaft, and 9 or 10 in the 
blades; and the smallest of all, 4 or 5 in the shaft, and about 
7 or *l\ in the blades. The two last are not frequently required. 
All the parts of a lithotrite should work very smoothly and 
easily, so that the slightest contact with a small fragment can 
be instantly perceived, a result wholly impossible if the sliding 
rod does not work with perfect ease and freedom. All litho- 
trites intended to deal with hard or large stones should be cut 
from the solid steel; the best and strongest instruments for this 
purpose are those of English makers. For reducing fragments 
and small stones, this costly mode of construction may be un- 
necessary ; the shaft is then forged, or formed from a tube which 
is drawn into shape, instead of being cut from the solid metal. 
Other instruments used in Lithotrity. 
These will be simply enumerated here. Their description will 
be given hereafter, when their practical application is considered. 
Aspirators and evacuating catheters. Injecting apparatus. 
Urethral forceps. Urethral lithoclasts. 139 
CHAPTEK X. 
LITHOTRITY.—THE SYSTEMATIC APPLICATION OF IT IN THE 
VARIOUS STAGES OF THE OPERATION. 
Position of the Patient; ordinary and exceptional.—State of the Bladder; 
Injections.—Introducing the Lithotrite.—Finding the Stone; different 
Methods.—Practical Directions for seizing and crushing the Stone.—Method 
of Procedure, by Several Sittings, or by One only: the former to be first 
considered.—Removal of Fragments ; importance of removing every por- 
tion.—Value of the Aspirator for this purpose; Evacuating Catheters.— 
Treatment following the sitting.—Impaction of Fragments.—Removal of 
Foreign Bodies.—Fever; Cystitis ; Orchitis; Haemorrhage ; Chronic Reten- 
tion of Urine.—Use of Ether, &c.—Lithotrity in Children.—Recapitulation 
of Maxims. 
I shall now proceed to describe each one of the separate 
proceedings which are necessary in effecting a single perform- 
ance of Lithotrity. And in future each application of these 
proceedings will be denoted by the word 4 sitting,’ as equivalent 
to the French word 4 seance; ’ and the word 4 operation ’ will be 
applied to the sum total of sittings, when more than one are 
necessary to relieve the patient of his stone. 
At the outset it is necessary to consider— 
First, the position of the patient during the performance of 
Lithotrity. 
Two positions may be described as necessary in Litho- 
trity : an ordinary position, and an exceptional or extraordinary. 
The latter is, however, suitable to many of the cases to which 
Lithotrity is applicable. 
In the ordinary position, a patient lies easily, on his back 
upon a couch ; which, for the convenience of the operator, 
should be higher than a common sofa, else he must stoop and 
be otherwise much constrained in his movements. It should 
be at least thirty inches high ; firm and steady. The ordinary 140 
THE FIRST POSITION OF THE PATIENT IN LITHOTR1TY. 
bed is the best so that the patient need not be moved, provided 
he is placed on a firm mattress, and that the pelvis does not 
sink, a position fatal to good practice ; he should be brought 
with his right side close to the edge of the bed. The pelvis is 
to be raised above the level of the shoulders, which must 
remain on the same plane as the rest of the trunk, the head 
only being supported by a pillow. A firm cushion, about two 
Fig. 61. 
TLe first or ordinary position. Common screw Lithotrite, witli a stone rather above 
middle size. 
or three inches thick, should be placed under the pelvis; an 
excellent substitute, to be found in any bedroom, is a common 
pillow rolled up tightly in a towel, which is then fastened by 
pins. 
The thighs are to be separated a little, so that there is a 
clear interval of a foot or more between the knees, and each 
knee may be supported, or not, on a small pillow, but leaving 
the space between the legs clear for the operator. 
The position thus described constitutes that which is ne- 
cessary for all ordinary cases; and when the patient is so placed, 
the stone generally lies a little behind the neck of the bladder, AN EXCEPTIONAL POSITION WHEN PROSTATE IS ENLARGED. 
and may be easily found and acted on by the lithotrite, pro- 
vided the bladder and prostate are normal. 
In the exceptional position, the pelvis is raised from four to 
six inches above the level of the shoulders; a firm cushion of 
sufficient thickness is placed beneath the pelvis, so as to sup- 
port the sacrum and tubera ischii. The thighs are slightly 
Second position : prostate enlarged ; stone removed by this position to the back of the 
bladder. 
raised; they must not incline from the pubes downwards, or 
the position of the pelvis will be interfered with. The abdomen, 
on the contrary, inclines backwards from the pubic symphysis. 
The stone now lies towards the posterior wall of the bladder, 
at a little distance from its neck, varying in proportion to the WHY THE EXCEPTIONAL POSITION IS REQUIRED. 
degree of elevation of the pelvis. This position is generally 
desirable when there is an enlarged prostate, behind which a 
stone is frequently concealed; it is so often when the patient 
is very stout, and the abdomen protuberant, and in search- 
ing for last fragments, or for a small stone, in any case where 
its presence is suspected, and there has been want of success 
in a previous search by the ordinary position. 
Fig. 63. 
The first or ordinary position : enlarged prostate ; stone not easily seized in this position. 
In those few cases in which it may be decided to perform 
Lithotrity for children, the pelvis should also be a little elevated, 
otherwise the stone will lie close to the neck of the bladder; 
the position of this viscus in children rendering that the natural 
situation for it in the ordinary recumbent posture. 
The object of determining the position in Lithotrity is 
important; namely, to prevent the stone from lying close to 
the neck of the bladder, which it almost certainly does if the CONDITION OF THE BLADDER BEFORE OPERATING. 
pelvis sinks a little below the horizontal line of the body. The 
centre of the cavity and space beneath it, form the area of 
operation. The neck, which is sensitive, easily injured, and 
ready to take on inflammatory action, is to be kept free from 
all unnecessary mechanical irritation: an important principle, 
hereafter to be considered in its place, which is never to be lost 
sight of in the conduct of Lithotrity. The elevated position of 
the pelvis also enables the operator to reverse the lithotrite 
with facility ; since, in order to do so, it is almost always neces- 
sary to depress the handle. 
2. The state of the bladder prior to commencing Lithotrity. 
Injections. 
It is desirable for the safe and successful performance of 
Lithotrity that the urethra should possess a calibre of at least 
average size, and that the bladder should be capable of con- 
taining a moderate amount of fluid. It used to be held that if 
it could not hold four ounces, the area for working the blades is 
too small, unless the object be to use a small instrument upon 
small fragments, in which case two or three ounces might be 
sufficient. A quantity much exceeding eight ounces makes 
the area of operation too large, in which condition a small 
stone or a fragment may elude our search readily. The plan 
commonly adopted was, to withdraw the urine by catheter before 
operating, and to inject five or six ounces of warm water. 
A little experience sufficed to teach me, howrever, that 
all this was quite unnecessary ; and for several years I have 
never made any preliminary injections, nor even desired the 
patient to retain his urine before the hour fixed for operating. 
Indeed, his very attempt to do so w’ould often defeat the 
object ; added to which, some nervous anxiety beforehand 
would often compel him to pass water immediately before or at 
the surgeon’s arrival. 
Perhaps three or four ounces may as a rule be always pre- 
sent with advantage, especially for young operators. Never- 
theless, I am bound to say that, with instruments constructed 
on the principles laid down, no mischief can be done by proper 
manipulation in a bladder which is empty or nearly so ; and, 
for myself, I as frequently operate in that condition as not. 
By not insisting on this preliminary injection of water, much CONDITION OF THE BLADDER DESIRABLE FOR LITHOTRITY. 
unnecessary manipulation and the consequent pain and irrita- 
tion are saved to the patient. The introduction of the lithotrite 
commences the sitting, the duration of which is thus con- 
siderably shortened. 
If the patient cannot retain his water more than twenty or 
thirty minutes, he may require some little preparation by way 
of rest, &c., a rare necessity; for if an attempt is made to 
compel the bladder to retain a larger quantity than it tolerates 
comfortably, uncontrollable contractions of it are produced, 
pain is occasioned, and the organ is placed in an unfavourable 
condition for Lithotrity. It is useless to contend with the 
bladder ; and any contest engaged in will certainly end in the 
discomfiture of the operator. The organ must be coaxed into 
obedience, not forced. At the same time it is no less certain 
that the only method of subduing irritation very frequently is, 
to crush the stone, especially fragments ; but experience only 
can determine the cases in which we should ‘ prepare ’ the 
patient, and those in which we should operate forthwith. With 
the powerful appliances of modern Lithotrity, the latter alter- 
native is, I believe, now much more commonly presented than 
the former. 
That condition of the coats of the bladder which is most 
favourable to Lithotrity is one of healthy tonicity, a condition 
in which the organ contracts upon its contents sufficiently to 
form a reservoir of tolerably regular form. An abnormal irri- 
tability, or disposition to contract, is objectionable on the one 
hand; a flabby, unexcitable state of the coats is unfavourable, 
although in a less degree, on the other. It is so, because the 
stone is apt to be partially enveloped, it may be, hidden in 
loose folds of the bladder; because the viscus, in place of 
forming, by its inherent tonicity, a somewhat ovoid figure, is 
influenced rather by the pressure of surrounding viscera, and 
may take any irregular form which they determine. Such a 
condition may, perhaps, be temporarily improved by the stimu- 
lus of injection. The urine is withdrawn, a known quantity of 
water is injected, and if it is much cooler than the blood, say 
at 70° or 60°, the stimulus to slight contraction is usually 
increased. The want of tonicity in a bladder presents a state 
of things which resembles the condition of the bladder in the MODE OF INTRODUCING A LITHOTRITE. 
145 
dead subject. Useful as the practice of Lithotrity is on the 
subject, in relation to the manipulation of instruments, it should 
be remembered that the condition of the bladder is different 
from that which exists in the healthy living body. In the 
dead body the stone does not lie at the neck of the bladder, 
but falls anywhere in the flaccid viscus, which position, and the 
pressure of adjacent viscera, render the lowest. By depressing 
the jaws of the lithotrite into the bas fond, the stone of course 
rolls into it. But this result is by no means a matter of course 
in the living. When tonicity is active, there is often a constant 
tendency in the muscles of the bladder to roll a large stone 
towards the neck, a fact of importance, and the result of this 
action, though much modified by the position of the body, is 
by no means altogether counteracted by it. 
3. The mode of introducing a lithotrite. 
This varies materially from that by which a catheter is 
passed into the bladder, and it is important that the difference 
should be explained and observed. The difficulty frequently 
encountered in introducing the lithotrite is generally due to 
ignorance or neglect of the distinction existing between the two 
operations. 
In catheterism, a smooth continuous curve or sweep is made 
from the external meatus into the bladder. Throughout the 
entire movement, the instrument describes a series of con- 
tinuous curves ; the shaft of a silver catheter, at first horizontal 
(supposing the patient to be recumbent), is gradually moved 
upwards to the perpendicular, and downwards to the horizontal 
again, in a direction precisely opposite to the first position. 
In passing a lithotrite, the continuous sweep will not be 
successful in carrying it into the bladder; the terminal angular- 
part constituted by the blades would thus be brought into 
hazardous contact with the upper part of the urethra before 
the pubic arch is passed. On the contrary, the shaft of the 
lithotrite must be maintained in one position for a considerable 
part of its course. This will appear in describing the movement 
in detail. 
The operator places himself on the right side of the patient, 
and stands with his back turned partly towards the head of the 
couch, his left side being to the patient’s right. Having INSTRUCTIONS IN DETAIL FOR PASSING A LITHOTRITE. 
warmed and well oiled the lithotrite, he holds it lightly with 
his right hand, in a horizontal position, the blades pointing 
downwards, and raises the penis with his left; and as he in- 
troduces the blades into the urethra, the left draws gently the 
penis over the angular end of the instrument, which descends 
in this manner down to the bulbous portion of the urethra, the 
shaft rising gradually towards the perpendicular. Having 
arrived there, it is not now to be depressed as in catheterism, 
since this movement raises the point of the blades against the 
roof of the urethra in front of the deep fascia above the narrow 
orifice of the membranous portion, while the large capacity of 
the bulbous urethra favours the malposition described, and, if 
force is used to overcome the difficulty, laceration will probably 
take place. This, indeed, is the accident which, more commonly 
than any other, happens in the hands of beginners, or with 
those who are not aware of the proper course to be pursued. 
In order to pass the blades easily and safely through the narrow 
membranous portion, it is necessary to maintain the lithotrite 
a few seconds at or near the perpendicular, permitting it to 
progress slowly in that position. This proceeding is accom- 
plished by permitting a part of the weight only'of the instru- 
ment to act as the propelling power, while the penis is drawn 
upwards a little, in the same, that is the vertical, direction. In 
this position the blades slide through the bulbous portion, enter 
and traverse the membranous portion, and arrive at the prostate. 
Then, and not before, the operator gradually depresses the 
instrument towards the patient's thighs; the blades rise up 
through the prostatic portion into the bladder, a movement 
which is rendered more easy if a very slight lateral rotary 
motion is given to the instrument at this part of its progress. 
At the same time the fingers of the left hand may be gently 
pressed on the pubic symphysis to relax the suspensory ligament 
of the penis; at all events the disagreeable sensation of strain 
upon it experienced by the patient at this moment is relieved 
by so doing, and the movement onwards of the instrument is 
facilitated, especially if the shaft has to be much depressed to 
surmount any obstacle at the neck of the bladder. In ordinary, 
that is, normal, conditions, the shaft of the lithotrite at the 
entry into the bladder forms an oblique line and an angle of FINDING AND SEIZING THE STONE. 
147 
about 20° to 30° with the horizon; and this it continues, as it 
slides easily and freely down upon the trigone to the posterior 
wall of the viscus. It will be obvious that the urethra now 
entirely loses its curve, being occupied throughout by the 
straight shaft of the lithotrite. 
The angle which the blades form with the shaft varies, as 
has been already seen; in some the blades describe a curve 
from the shaft to their points. The more angular, however, 
the union between the blades and shaft, and the smaller the 
angle so described by their axes respectively, the more necessity 
is there for following the directions just given. 
For those who prefer it, the instrument may be passed on 
the patient’s left side, as in catheterism ; but, if so, the operator 
must afterwards go round to the right side to perform the 
operation of crushing. It is, however, equally if not more 
convenient to introduce it on the right side, in which case time 
and movement are economised to a slight extent. 
4. To find and seize the stone.—This is a very important 
subject, about which there has been no little discussion, since 
practical men have been divided in their opinions respecting 
the course to be followed. 
It will be supposed here that the lithotrite last described 
(fig. 60) has been easily introduced, and that its blades have 
passed into about the centre of the vesical cavity. The proper 
method of holding the instrument is the first step to be con- 
sidered, since the facility with which the operation is performed 
will much depend on the system of manipulation adopted. 
The surgeon should be completely familiarised with the litho- 
trite, and with the best position and action for his hands upon 
it, long before he ventures to operate in the living bladder, so 
that he may instinctively hold and manage the instrument 
according to the rules laid down, and has not to recall them to 
his memory at that moment. Without doubt, the best method 
with the existing lithotrites has been ascertained by practice 
and observation; viz. that which enables the operator (bearing 
in mind our guiding principles) to exert the largest amount of 
influence on the stone, with the smallest amount of disturbance 
to the bladder. Even supposing this were not the case, it 
would be advantageous to the operator to practise one method MODE OF SEARCHING AND CRUSHING THE STONE 
as the rule, and so acquire a facility in the use of the lithotrite, 
which practice by a uniform method alone can impart; but it 
is doubly so in the circumstances just stated. 
First, the manner of holding and employing the lithotrite 
when the blades have arrived in the cavity of the bladder. 
The left hand being above the instrument, the cylindrical 
handle is at first lightly held between the thumb and three 
fingers, the little finger being free, so that a slight rotary 
movement of the instrument can easily be made on its axis, 
when necessary. The wheel-shaped end of the sliding rod, 
which terminates in the male blade, is then held between the 
thumb, index, and second fingers of the right hand (see fig. 64), 
Fig. 64. 
Mode of employing the Lithotrite with cylindrical handle in searching. The left hand holds 
the cylinder lightly, while the right opens and closes. 
so that it can be drawn out, and pressed in, at pleasure; corre- 
sponding to which movements, of course, the blades at the 
other extremity are opened and closed. 
If a stone or a fragment be seized, the fingers are to remain 
on the wheel with slight pressure to keep the stone between 
the blades, and the thumb is to be extended to draw upwards 
the button, which act suffices to change the sliding into the 
screwing action. If the stone or fragment is small, the fingers 
of the left hand remain in their place; if it is large, and 
especial steadiness be required, the cylindrical handle is grasped 
in the palm of the left hand, and perfect immobility is ensured 
(see fig. 65). A turn of the wheel now* screws home the male 
blade, and crushes what has been caught. WITH THE MODERN LITHOTRITE. 
In order to reverse the blades in searching for fragments, 
it is only necessary first to depress the cylindrical handle, and 
then to rotate it between the thumb and fingers of the left 
Fig. 65. 
The instrument firmly grasped in the left hand, while the right crushes by screwing home. 
hand, the wheel remaining unmoved in the right hand. In- 
deed, the most complete and exhaustive series of changes in 
position of the blades is attained in this instrument by 
rotation with the left hand, while, at the same instant, the 
right hand is opening and closing the blades in search. 
The manner of employing the French instrument may next 
be described. 
The handle is to be held between the thumb and fingers of 
the left hand, the thumb applied to a knob attached to the 
Flg. 66. 
Position of the hands in searching with the French Lithotrite. 
disc, the index finger to the other knob attached on the farther 
side; the second and middle fingers are applied to the handle RULES FOR FINDING THE STONE, 
close to the index finger; the little finger may be free or ap- 
plied ; where ease of movement is wanted, as in searching, it is 
free; where steadiness and immobility, as in crushing, it is 
applied. The pulp of the thumb is brought into contact with 
the knob, the last or distal phalangeal joints of the fingers are 
the parts which come into contact with the opposite side of the 
handle (fig. 66). Held lightly, but firmly, in this manner, the 
thumb and index command and control easily the movements 
of the instrument, and can incline the blades right or left, with 
very little movement of the hand itself, and, a fortiori, without 
any change or shifting of its hold on the instrument. 
The right hand is free to open and close the blades, to turn 
the movable disc which converts the sliding into a screw action, 
and vice versa, and to screw home the male blade for the pur- 
pose of crushing the stone. The position is represented in the 
adjacent drawing (fig. 66). 
Next, What is the first proceeding in order to find and to 
seize the stone ? 
It is not at all necessary at the present day to describe 
various systems, so called, of seizing the stone, related as Some 
of these have been to forms of the lithotrite now obsolete. 
Nothing can be more simple than the process to be followed ; 
and difficulties, if any are met with in the endeavour to 
accomplish it, usually arise more from the belief on the part of 
inexperienced operators, that some peculiarly dexterous move- 
ments are necessary, than from any other cause. 
Quiet and deliberate movement, with simplicity in action, 
and gentle handling, comprehend all that is essential to ensure 
a good operation, apart from that education of the sense of 
touch which experience alone can impart. 
Firstly: quiet and rather slow movements of the jaws of 
the lithotrite in searching the bladder are desirable, because 
rapid movements produce currents in the urine which keep the 
stone more or less in motion; so that it is less easily seized 
than wdien the surrounding fluid is in a state of rest. We are 
apt to overlook the fact that the specific gravity of the stone is 
much less considerable when placed in urine than in air, and 
that slight currents in the denser fluid act on its position with 
considerable energy. AND FOR SEIZING IT EFFICIENTLY. 
151 
Secondly: in respect to the action necessary, and gentle 
handling, the following details respecting them are given as 
the result of my own experience. 
Let us suppose that the blades of the lithotrite have entered 
the cavity of the bladder, and that the instrument slides easily 
and smoothly down the trigone, which in the living and healthy 
organ is an inclined plane, although quite otherwise in the 
atonied and in the dead bladder. 
In many cases the instrument in thus passing grazes the 
stone, and the slightest lateral movement of the blades, right 
or left, will determine on which side it lies. Whether however 
the stone is felt or not, when the blades have passed gently 
down in the middle line until a very slight check to their 
movement is perceived, the lithotrite should rest there for 
three or four seconds, and then the male blade should be slowly 
withdrawn, without moving any other part of the instrument, 
towards the neck of the bladder, until a very slight check is 
perceived in that direction, followed by another three or four 
seconds rest for currents to subside. Now the operator should 
quietly press back the male blade, without changing the position 
of the lithotrite, and almost certainly the stone will be seized. 
In other words : open; pause; close—that is all. It is neces- 
sary always to remember, when withdrawing the male blade, 
that it is never to be drawn out roughly, since in this action 
the sensitive neck of the bladder may easily be irritated. 
But suppose no stone is thus found, the operator is again to 
withdraw the male blade as before an inch or more in the middle 
line, to incline the blades to the right side about 45°, and then 
to close them, without altering the axis of the shaft, or other- 
wise disturbing the central position of the instrument. If still 
no stone is felt, he turns them, opened, to the left in a similar 
manner, and then closes them. Observe, that the blades are 
always to be opened before they are turned, for this reason : 
if the turn is first made and the blades are subsequently opened, 
the chance is that the male blade as it is withdrawn will move 
the stone away ; whereas if the blades are inclined while open, 
the stone, if there, is almost certainly seized. This is one 
of the many apparently minute but important points of which 
systematic Lithotrity is made up. To return : it is very rare SEARCHING IN VARIOUS WAYS 
that the stone will elude the search thus far; but if it does, 
depress the handle of the lithotrite an inch or so, an act which 
raises the blades slightly from the floor of the bladder, and turn 
them another 45° to the left, bringing in fact the blades hori- 
zontal to the left; close; if unsuccessful, turn them gently to 
horizontal on th,e right, and close. These five positions (vertical, 
right and left incline, right and left horizontal) explore the 
bladder fully, middle, right, and left, and will almost certainly 
find any stone of moderate size in a healthy bladder. The 
object is at the same time strictly to avoid communicating any 
jerk to the instrument or to the bladder. In all these move- 
ments, if properly executed, there has been barely contact of 
the lithotrite with the vesical Avails, at all events no pressure, 
nothing to provoke undue pain, or cause contractions of the 
bladder. If, however, there is an enlarged prostate, causing an 
eminence at the neck of the bladder, a depression behind it, or 
the stone is very small, or we are exploring for some fragment, 
at the close of the case, which is suspected to have eluded 
previous search, and, also, in some cases where none of these 
conditions exist, the blades are to be reversed so as to point 
doAvnwards to the floor, and the object sought may then often 
be secured with ease. If seeking for a small stone or for frag- 
ments, we may employ a lithotrite with short blades, which can 
therefore be reversed with greater ease than one Avith long 
blades. 
In order to do this properly in the normal bladder, the 
handle of the lithotrite is depressed another inch or more 
between the patient’s thighs, so that the shaft of the instru- 
ment, instead of being directed obliquely a little upwards, is 
level Avith, or points belowq the horizon ; the blades, supposed 
to have been already brought to the horizontal, as before de- 
scribed, are cautiously brought round to the reversed vertical 
position, and the floor first lightly swept, wdth closed blades, in 
the manner of a sound in searching for stone. Then, if the 
handle is sufficiently depressed, the blades may be carefully 
opened and closed two or three times, in slightly varied direc- 
tions, but without injuring the floor of the bladder; after which 
an exhaustive examination of its cavity ought to have been ac- 
complished (fig. 67). It sometimes happens, when the prostate WHEN THE STONE IS NOT KEADILY FOUND. 
is considerably enlarged, and a stone or fragments have to be 
sought behind it, that the lithotrite is reversed without depress- 
ing the handle. 
As a rule, all these movements are to be executed at or 
Pig. 67. 
Searching for fragments with reversed blades in healthy bladder. 
beyond the centre of the vesical cavity, the proper area for 
operating, without hurry, rapid movement, or any other which 
partakes of the nature of a jerk or concussion, and, if in a fairly 
healthy bladder, without causing more than a very slight degree 
of pain to the patient. Nevertheless, there are many cases in 
which the special spot for searching with reversed blades is close 
behind the neck of the bladder. With the cylindrical handle 
this is quite easy and safe; the mode of using it will be shown 
in considering the removal of small fragments. The operator’s 
eye is also to be so familiar with the scale marked on the 
sliding-rod, that he knows at a glance the exact interval which 
it indicates as existing between the blades in the bladder. 
It is essential to good practice, while manipulating the 
lithotrite, to maintain the axis of the instrument, as far as 
possible, always in the same direction. The blades only are to 
be moved; the shaft should occupy the same inclination, unless 154 
DIRECTIONS IN USING THE LITHOTRITE. 
when this is intentionally altered. In screwing home the male 
blade, the operator is very apt to move the lithotrite also, at 
each turn of the screw, unless he is conscious of the care neces- 
sary to avoid this evil. All lateral movements, all vibration 
and concussion, necessarily tell on the neck of the bladder and 
prostatic urethra, where the instrument is most closely embraced, 
Fig. 68. 
Second position : enlarged prostate. Lithotrite reversed to seize a large stone. 
and its mobility is most limited. To that part of the lithotrite 
which occupies the anterior portion of the urethra much freedom 
of lateral movement is permitted, and in the bladder the instru- 
ment is free, although in a less degree; but the axis, or fixed 
point, as regards lateral movement, is at the part indicated, 
which is also the most sensitive spot of the entire passage. NATURAL SITUATION OF A LARGE CALCULUS. 
155 
Hence the aim of the operator should be to produce in this 
situation no motion of the lithotrite except that on its own 
axis. Few of the details of the operation require more practice 
to master than this. 
A rule has been laid down with reference to the situation 
of the calculus in the bladder. It is said that the larger the 
stone, the more certain is it to be found lying near to the neck 
of the bladder in the ordinary recumbent position, while a small 
one is usually detected at the back of the trigone. Without at 
all assenting to the accuracy of this remark, at all events in 
relation to the small stone, which is often close to the vesical 
orifice, it may be said here that the act of seizing a large stone 
in this position requires consideration. In this case, the litho- 
trite is not necessarily to be pushed onwards to the bottom of 
the bladder ; it is sometimes better to incline the blades from 
the side on which the stone is felt, then to push on the female 
portion of the instrument only, by itself, as far as it will go, 
maintaining the male blade at the neck of the bladder ; it is 
now only necessary to incline towards the stone, and it will be 
seized almost certainly at once. But if the operator commences 
by pushing on the whole instrument, and then withdraws the 
male blade according to the ordinary custom, this blade is apt 
to be drawn against the large stone, which it therefore fails 
to catch, and presses it back against the neck of the bladder, 
producing pain, irritation, and perhaps bleeding. As a general 
rule, I think it may be said, that by far the most common cause 
of failure to seize a stone arises from its close proximity to the 
neck of the bladder (whatever position is given to the patient), 
and from the male blade being drawn up against it, at each 
opening of the lithotrite, in the manner just described. In 
these circumstances, the operator feels the contact of the stone 
without suspecting its precise locality, each time he withdraws 
the blade, and is apt to feel embarrassed on failing to seize it 
when he closes immediately after. In these cases it is essential 
to draw the male blade gently, but closely, to the neck of the 
bladder, and to slide the blade between the neck and the stone 
which lies in contact with it. 
The rules already laid down for finding and seizing apply 
more or less to all lithotrites, as far as the rules can be applied RULES FOR CRUSHING STONE WHEN SEIZED. 
with less perfect instruments, this general rule applying in- 
variably to all; viz. the more powerful the lithotrite, that is, 
the larger and longer are its blades, the less readily are we 
to adopt the horizontal, and still less the reversed, positions of 
the blades; the more fluid also is it necessary to have in the 
bladder. As large and fenestrated blades are used chiefly for 
the initial act of breaking up a large stone into fragments, it is 
obvious also that there is less occasion for the horizontal and 
reversed movements, since a large stone may almost certainly 
be seized by the right or left incline. 
5. The manner of crushing the stone when seized.—Sup- 
posing that a hard stone of an inch and a half in diameter is 
in the grasp of a powerful lithotrite, the screw is to be gradually 
turned at first, to make the blades bite, since a sharp turn at 
this moment is likely to drive the stone out either right or left. 
As the power is increased, which is still to be done slowly, the 
resistance is felt to relax, sometimes by degrees, sometimes 
suddenly with a crack, and the stone is broken usually into 
four or five large pieces, besides some small debris. This being 
done, the male blade is again drawn out, taking care not to 
shift the situation, or alter the axis of the lithotrite, and, 
almost certainly, one of the large fragments will be picked up. 
It is then only necessary to screw home, release the screw, and 
open as before. This process may be repeated two or three 
times, if the instrument is worked at the same spot, and the 
patient maintains his position. Since the area within which 
the larger fragments fall is very limited in extent, and remains 
unchanged if these conditions are complied with, there is no 
difficulty whatever in finding the fragments readily, provided 
the operator is content to work in the centre of the bladder, 
above its most depending part, as determined by the position of 
the patient, and not to change the place either designedly or 
unwittingly. .The large and heavy pieces fall invariably in the 
same place, and may be picked up again and again, if this 
simple rule of keeping the blades in one place is adhered to. 
Having now broken up the stone, and, say, crushed two or 
three times the largest fragments, enough has been done for 
the first sitting, supposing that we are proceeding according to 
the system hitherto generally pursued. I shall, however, in the TREATMENT AFTER A SITTING. 
157 
following chapter enter upon the consideration of ‘ Lithotrity 
completed at a Single Sitting,’ a method which in my opinion 
possesses advantages destining it to supersede, to a considerable 
extent the old system of employing for a stone of medium or 
large size some four or five separate sittings. Nevertheless it 
is necessary, at present, to consider the latter before discussing 
the new mode. 
After a sitting, the patient should at once be warmly 
wrapped up; a hot bottle put to his feet; while a hot napkin, 
or a flannel wrung out of boiling water, applied to the perineum 
and hypogastrium, has a soothing effect, and diminishes any 
want to make water which maybe present, and which it is best 
to discourage for a short time. During the first twenty-four 
hours, at least, after a first sitting of the kind described, the 
patient should pass his water as he lies on his back: the large 
angular fragments are in this way prevented from being driven 
forcibly against the neck of the bladder. It is because these 
characters are more marked after the first fracture of the stone 
than after later sittings, that it is desirable, as a rule, to take 
every precaution against irritation, local and general, after the 
first crushing or two. Pursuing this plan, the bladder need 
not be largely injected at or after the first sitting ; in the 
first place, because it is on this occasion particularly desirable to 
avoid unnecessary irritation ; and, secondly, because the first 
object being mainly to make fragments, no great amount of 
small debris capable of removal would probably be found. 
6. The crushing and removal of fragments.—Supposing 
that, thanks greatly to management and care, no signs of local 
irritation, and no bleeding, or only a trace of it, have appeared, 
and no fever has occurred, it is desirable very soon to deal with 
the fragments. After a period of from two or three days, 
according to circumstances, we should, unless the stone has 
proved so hard or so large as to require another application of 
the powerful instrument, commence the second sitting by in- 
troducing a lithotrite with strong plain blades, of which the 
male is narrower than the female blade (fig. 54). As the frag- 
ments are now large, and, probably, several in number, simply 
opening and closing in the first position, or in the right or left- 
incline, will almost certainly secure one at each attempt, and THE REMOVAL OF FRAGMENTS AND DEBRIS. 
enable us to crush it into smaller fragments, making at the 
same time a fair proportion of fine debris, a good deal of which 
generally becomes impacted between the blades of the lithotrite. 
Much of this impacted material may be brought away in this 
manner, if the urethra is capacious; if not, it is desirable to 
diminish the quantity before removing the instrument, inas- 
much as, being powder, it is sure to come away easily enough 
during the subsequent injection ; and there can be no necessity 
to irritate the bladder or urethra by withdrawing the blades 
largely impacted. By adopting the following manoeuvre, al- 
most all this debris may be removed from the instrument at 
will. The blades are to be carried to the centre of the bladder, 
the cylindrical handle is grasped firmly by the left hand (see fig. 
65), while the right screws the male blade as near home as it 
will go, and then makes numerous alternate turns of the screw, 
one turn out and one in, somewhat rapidly: this movement 
will work the impacted debris out of the female blade on each 
side of the narrow male blade. This proceeding is practicable 
with a flat-bladed lithotrite in which the male blade is narrower 
than the female, and it is one of the important purposes con- 
templated by the construction described, and forms one of the 
advantages of the instrument. The patient is now to rest 
quietly, making water in the recumbent position, as before, 
certainly during twenty-four hours, so that any sharp frag- 
ments remaining may lie quietly in their place undisturbed by 
movements. 
It is quite possible to remove by the flat-bladed lithotrite a 
large proportion, or even the whole, of the calculous debris, 
instead of permitting it to come away by any other means. 
As much as will pass easily between the blades should be 
brought away, but not more. The removal of large portions 
thus is not to be advised, as a ride, and for the following 
reasons. First, nothing is gained by so removing it; all the 
debris which can be impacted between the blades of an instru- 
ment being in a state of powder, or nearly so, can be removed 
by some form of evacuating catheter, with an exhausting elastic 
bottle. Secondly, the risk of over-distending and scratching 
the urethra, together with the serious consequences which such 
accidents often entail, is increased by this proceeding. Thirdly, OF SUBSEQUENT SITTINGS. 
159 
the impaction of fragments in the urethra is subsequently much 
more likely to take place, if may laceration of the canal has 
been occasioned by withdrawing debris. Indeed, troublesome 
impaction of fragments does not very often occur unless the 
urethra has been previously injured in some way. But all the 
fine debris and smaller fragments may be removed at the 
close of this sitting by the ordinary apparatus of Clover, or 
by one of the numerous modifications and improvements of 
his original idea, now known as aspirators; and presently to 
be described. 
The succeeding sitting or sittings may usually follow at an 
interval of from two to three days, unless difficulties have 
arisen ; and the kind of instrument employed must depend on 
the size of the fragments we have to deal with, and these, of 
course, will depend on the original size and texture of the 
stone. If there are now many small fragments remaining in 
the bladder, but too large to pass, it will be advisable to employ 
the lithotrite with a wide male blade (fig. 55), but constructed 
in all other respects similarly to that last used. With such an 
instrument it is scarcely possible to fail of picking up small 
fragments on each time of opening and closing, and on each 
crushing these wdll be granulated by the action of its flat blades; 
while not only the right and left incline, but the right and left 
horizontal positions, will be advantageously available in its use. 
When the fragments are small, it is not necessary always to screw 
up the male blade in order to crush them ; it suffices simply to 
press it closely home by manual power, a method adopted by 
some. The screw, however, is smoother in its action, admits of 
no jerk or concussion, and I prefer it on this account. If a 
fragment falls between the blades which the scale upon the 
sliding-rod indicates to be too large for the power of this in- 
strument, it has only to be rejected, and smaller ones found 
and crushed. In a few minutes much granulated matter will 
have been made by the application of this instrument to the 
smaller fragments, and this, or, indeed, probably all which 
remains of the calculus, may be removed by aspirator, if not 
at the third, at least by the fourth sitting. 
7. Removal of the last fragments.—This is an extremely 
important crisis in the operation, and one which if is important SEARCHING FOR A LAST FRAGMENT. 
not to neglect. It sometimes demands more skill and nicer 
manipulative power than any other part of it. 
Supposing that after three or four sittings, or more if the 
size of the calculus has demanded them, it has become obvious 
that very little calculous matter remains in the bladder, we 
have now to take care that the last fragments are entirely 
removed. As long as any remain, there will almost invariably 
be some pain in passing water, especially at the close of the act, 
while the urine may be cloudy and often tinged with blood, and 
quick movements of the body give pain. As long as these 
symptoms persist we may suspect that some portions still re- 
main behind, and these must be found. The best method of 
proceeding is to introduce, as before, the lithotrite with plain 
blades, taking care to have only a small quantity of water in 
the bladder, at most one or two ounces. The best form for the 
purpose is that in which both the blades are short and wide, 
and their ends not in any degree tending to a point. The form 
represented by fig. 69 is greatly preferable for this purpose to 
Pig. 69. 
Lithotrite with short and wide plain blades for small fragments. 
that of fig. 54, p. 132. If by the ordinary positions of the in- 
strument we encounter no fragment, the handle must be a 
little depressed between the patient’s thighs, as directed for the 
reversed positions at pages 152-3, and these positions of the 
blades employed. It will now be seen why the pointed blades 
are objectionable, as being more likely to irritate the floor of the 
bladder, and less likely to catch the fragment. A careful 
search in the reversed vertical position will generally discover 
its object; if not, the patient’s pelvis is to be raised about 
four inches, that is, to the exceptional position, when with care 
and perseverance the fragments -will be caught and crushed. CYLINDRICAL HANDLE USEFUL FOR LAST FRAGMENTS. 
161 
This sitting requires sometimes a little longer time than usual; 
it should never extend, however, beyond five minutes. 
I have before alluded to the facility which the cylindrical 
handle affords for the most delicate sounding, or searching 
for these tiny fragments; and also to the ease with wrhich a 
practised hand may demonstrate the practicability of producing 
an audible ‘ click ’ from a fragment no larger than a pepper- 
corn. A gentle but very rapid half-turn of the instrument 
between the finger and thumb will give a blow sufficient to 
produce a click, which three or four persons standing over the 
patient may hear. I have often afforded the proof of this 
by first producing the 6 click ’ in question, and then instantly 
seizing and removing the little fragment unbroken, since it is 
mostly too small to produce any inconvenience in its transit 
through the urethra, and placing it in the hand of the by- 
stander, who is usually surprised to see how minute a body 
may thus be detected and removed. 
It is at this period of the case that the cylindrical handle 
of the lithotrite becomes of great value. Supposing the instru- 
ment to have been placed in the bladder, and that the blades 
are in the reversed position, these should be brought up close 
to the neck of the bladder, by withdrawing the lithotrite until 
they are felt to rest lightly against the internal meatus. Now, 
holding the handle between the index finger and thumb, 
several gentle but quick semi-rotations of the instrument on its 
axis should be made in perfect silence, and if any fragment is 
there, a slight click is easily obtained, or the contact felt. All 
that it is necessary to do, is to open at this spot the blades of 
the lithotrite, by pushing the female blade towards the centre 
of the bladder, for about half an inch or so, and then, on clos- 
ing, almost certainly the fragment is included. You then turn 
upwards the blades and crush. 
It has been supposed to be sometimes useful to employ an 
instrument of similar form to the preceding, but with a small 
channel traversing the male blade, and entire length of the 
sliding rod. In this way, without removing the instrument 
from the bladder, we may add to or diminish the fluid contents 
of the bladder, and thus search for the fragment under different 
conditions of the viscus. I succeeded recently with an exceed- CIVIALE’S TR1LABE FOR LAST FRAGMENTS 
ingly troublesome fragment which had eluded me at two some- 
what prolonged sittings previously, by using this instrument in 
the following manner:—The patient was seventy-five years old, 
had a very large prostate and a greatly diseased bladder, with 
phosphatic calculus, all of which had been removed except 
this small bit. I introduced the hollow lithotrite, the patient 
standing and leaning forward, opened the blades about an inch, 
and then allowed the urine to flow out altogether, through the 
hollow male blade: on closing the blades (that is, drawing 
doivn the female blade upon the male, not raising the male 
blade, an important distinction), I found and crushed the 
missing fragment. At this time, however, I did not possess my 
present lithotrite, which has rendered any resort to the instru- 
ment in question unnecessary. 
There was another resource which was a favourite one with 
Civiale, to find a last fragment not yet expelled, viz. the employ 
ment of the 4 trilabe,’ or 4 pince a trois branches,’ one of the 
earliest instruments designed in the history of Lithotrity. It 
(see fig. 70) consists of a cylindrical sheath, containing a stem, 
Fig 70. 
A. The Trilabe, open, as in the cavity of the bladder b. The axis which perforates the 
centre of the instrument, its roughened head occupying the centre of the space between the open 
blades. Here it is shown separately from the rest of the instrument. 
having three branches at its vesical end, which expand on 
pushing them outwards, and approach each other closely on 
being drawn in: in the centre is a fourth branch with a rough 
head, which can be rotated or otherwise moved independently 
of the rest. Civiale had an inventor’s penchant for this instru- 
ment, and although for everyone else it had long been obsolete, 
he was fond of showing it and using it occasionally. This feeling 
shows itself even in his posthumous work on Lithotrity, in which 
it is still referred to with obvious satisfaction.1 His directions 
for its employment may be expressed as follows. To search 
1 Op. cit. p. 103. VALUE OF ASPIRATOR FOR LAST FRAGMENTS. 
for a final fragment, introduce this instrument into the bladder, 
which should contain about five or six ounces of water; ex- 
pand the branches a little, and rotate them once or twice by 
way of searching: meantime the urine slowly runs off through 
the instrument until the three blades are surrounded on all 
sides by the walls of the bladder, a cavity of a pyramidal form 
existing between them. Into this cavity the fragment is almost 
certainly brought: it may be felt for there by the central 
branch. The branches are now slowly withdrawn into the stem, 
the cavity slowly contracts in size, and the fragment is found in 
its centre, and will be crushed either by them as they finally 
close, or by rotating the central one. 
Nevertheless, while it is a rule in searching for minute 
fragments at the end of a case to employ a small and light 
instrument with a small quantity only of urine present, there 
are some very rare cases in which there is reason to believe a 
fragment or two may still remain behind, although none has 
been so detected. It may be from peculiar configuration of 
the prostate, or that in some bladders the interstices are so 
numerous from fasciculated muscular coats, that small fragments 
become engaged in them, and evade all search by that means. 
In these circumstances the plan now to be considered is mostly 
successful. 
The increased use which I have made during the last eight 
or ten years of the evacuating catheter and Clover’s apparatus, 
has convinced me that an aspirator forms the best means of 
removing ‘ last fragments.’ In employing it at the end of a 
case, the presence of a fragment is almost invariably revealed 
by the very audible sound which is produced, through contact 
between the fragment and the end of the instrument, as the 
water rushes out and dashes against it the bit of calculus, 
towards the close of the current. This contact is not only 
heard by the operator, but felt by the hand which supports the 
catheter. If the fragment fails to issue, he introduces a litho- 
trite into the empty bladder, and with care may almost certainly 
crush it at once. The evacuating catheter is then re-introduced 
and the debris washed out. If after several pressures on the 
elastic bottle and expulsions of water, nothing more is heard or 
felt, almost certainly he may conclude that all calculous matter 164 
EVACUATING CATHETERS. 
has been removed. This instrument, or some other allied form 
of aspirator, has entirely superseded all evacuating catheters 
worked by the syringe, all double-current catheters, or other 
ingeniously contrived mechanical devices with an internal 
endless screw, &c., &c., for giving 
exit to fragments produced by li- 
thotrity. 
Evacuating catheters should 
generally be made of silver, and as 
large as the urethra will admit, with 
a large oval orifice near to the end; 
one should have an opening on the 
convex, and another on the concave 
aspect of the curve; they may also 
be placed laterally (fig. 71, 72). 
There may be a flexible gum-elastie 
or metal-jointed stylet, perfectly 
filling the interior, at all events 
at the lower end where the open- 
ing is situated, that the instru- 
ment may pass smoothly into the 
bladder (fig. 72, a). It may be pro- 
vided with a stop-cock or not (b), 
but this is mostly unnecessary. 
When the evacuating catheter 
is about to be withdrawn, it should 
not be forgotten that a fragment 
may be engaged in the orifice and 
be protruding from it, an occurrence 
by no means unfrequent. This is 
made obvious by the light resist- 
ance experienced when the fragment 
touches the neck of the bladder, 
and the patient will probably feel a 
little pain. If the resistance is very 
slight, it is only necessary to withdraw the catheter slowly and 
gently and no harm will result ; by humouring it, and giving 
plenty of time, injury may generally be avoided, and no pain 
will be occasioned. If, on the contrary, the resistance is 
Fig. 71. 
Fig. 72. 
Fig. 71. Evacuating Sound, with 
lateral apertures, a and b, stopcock 
and nozzle for injecting. 
Fig. 72. Ditto, mounted on metal- 
jointed stylet, a, stylet removed. clover’s apparatus. 
165 
obvious, a jointed metal stylet (fig. 72, a), which fits the 
catheter, being pushed home, the fragment will either be 
crushed or disengaged, probably the former. 
The aspirator of Clover, which I have referred to above, 
consists of a ten-ounce india-rubber bottle, into the neck of 
which is fitted a glass cylinder with 
a perforation at the end, the size 
of a No. 14 catheter, or larger, to- 
gether with a series of evacuating 
catheters. These are of various 
forms and sizes, each made to fit the 
glass cylinder, into which they pro- 
ject one inch. They should be as 
large as the urethra will admit, 
made of thin silver, and may be pro- 
vided with gum-elastic stylets. In 
some cases, the best kind is that 
which is cut transversely at the 
distal end. 
Fig. 73. 
Fragments are sometimes more 
easily drawn into this catheter than 
into those which have lateral aper- 
tures, since the route they must 
take in the latter is more tortuous. 
There is very little difficulty in pass- 
ing such an instrument if the stylet 
is furnished with a conical silver 
end, projecting half an inch beyond 
the end of the catheter. 
a. India-rubber bottle, b. Glass 
receiver, c. Tube projecting into 
receiver, d. Aperture of tube to 
fit evacuating catheter. 
Aspirator of Clover. 
One of the best forms is that 
with an oval opening at the side, which should extend half 
through the thickness of the instrument, so that the diameter 
of the opening is equal to that of the catheter itself. In 
other cases, the opening may be placed either on the concave 
or convex side of the instrument. 
In employing the apparatus, let the following instructions 
be followed :—Having passed the catheter, remove the stylet, 
and let the urine escape, then attach the india-rubber bottle 
previously filled with warm water. Compress the elastic bottle 166 
TREATMENT AFTER THE SITTING, 
till the resistance of the bladder is felt, then gently press on 
the catheter so that its internal opening may approach the 
lowest part of the bladder; allow the elastic bottle to expand as 
long as the water comes freely away, but if the stream diminishes 
or stops, reverse the current by pressing the bottle, and if this 
will not effect a free outflow, inject a little more water, and 
move the end of the catheter a little towards the centre of the 
bladder. If the calculus has been sufficiently broken up, several 
pieces will come away at once, but when they are rather large, 
they are apt to block up the tube, and the current must be 
changed frequently to enable them to come away. The frag- 
ments having passed through the catheter, fall into the glass 
vessel, and cannot return when the current is sent inward. As 
soon as the outward current is seen to slacken, press the bottle 
to force back the obstruction, for whether the diminished stream 
depends upon too many pieces, or one large piece, or from con- 
tact with a mucous membrane, it is useless to try to empty the 
bladder further, for no fragments will be removed by a languid 
outflow. The inward current should be slow, the outward 
current should be rapid, and the process may be repeated ten 
or twelve times at a sitting. 
Treatment following the Sitting.—Much might be said 
in reference to this subject, if every accident possible to occur 
were to be considered and provided against. Those of the most 
importance will be considered here: some have been already 
slightly alluded to. 
The principal aim of modern Lithotrity, as by this time 
will have become obvious, is to crush the stone without risk, 
not only of danger from the operation itself, but from the 
occurrence of serious difficulties afterwards : for many of these 
the manner of performing the operation is answerable. For- 
merly, a case was rarely conducted to its termination without 
some grave troubles from the impaction of fragments in the 
urethra. Nowq this is a rare occurrence. Fragments are 
rarely impacted unless they are sharp and angular, or the walls 
of the urethra have been lacerated. If care is taken that the 
patient passes his water, at every act of micturition if possible, 
in the supine position, for a day or two after each of the first 
two or three sittings ; and if the operator is fairly successful in IMPACTION OF FRAGMENTS. 
167 
pulverising or granulating the stone subsequently, not much 
risk of trouble will arise on this head. After a short sojourn in 
the bladder the angular fragments become water-worn, their 
points and edges are rubbed down, and they pass without diffi- 
culty. 
Impaction of fragments.—Supposing, however, a fragment 
to have become arrested in the urethra, and the patient to be 
able, nevertheless, to relieve his bladder in a diminished stream, 
the pressure of the urine usually brings it forward in a few 
hours to the orifice, or near to it. If not, an attempt may be 
made to remove it, and with a well-made urethral forceps this 
may be accomplished almost at any depth. The long stems of 
the forceps should be slightly curved so as to cross each other ; in 
this way an instrument may be constructed seven inches, or 
more, in length (not including the rings), the blades of which 
will open sufficiently to seize a fragment two or three eighths 
of an inch in diameter, without overstretching the meatus 
Fig. 74. 
The long urethral Forceps described. They are drawn of exactly half the length of the 
original. 
externus. A drawing of one, made for me by Messrs. Weiss 
and Son, is annexed (fig. 74). They are inches long, and 
will pass to the neck of the bladder in most individuals. 
Furthermore, the ends of the blades should not be pointed, 
should not meet each other, and should be slightly scoop- 
shaped. With this instrument I have extracted large fragments 
with great ease. All that is necessary for this purpose is to 
commence with a fair firm hold on the fragment, and then to 
give plenty of time to the withdrawal, extracting as slowly and 
gently as possible. In this way it is remarkable how large 
and sharp a fragment may be safely removed, whereas by force 
the urethra is lacerated, and the extraction is rendered much 
more difficult. Sometimes it is necessary to return to the 
bladder a fragment situated in the prostatic or membranous RExMOVAL OF IMPACTED FRAGMENTS 
portions; but all on this side the last-named spot should cer- 
tainly be extracted. To effect the former object, a large gum- 
elastic bougie usually suffices ; if not, a large silver catheter, 
the end of which is cut off, and the opening accurately fitted 
with an olive-shaped knob attached to a stylet, is passed down 
until the fragment is reached; the stylet is then withdrawn, 
the rim of the opening at the end of the catheter surrounds 
the fragment, and will remove it safely into the cavity on 
making pressure : sometimes a stream of water forcibly injected 
will displace it more readily than the instrument. Some 
operators prefer to extract with a small three-bladed forceps 
(‘pince a trois branches’) (fig. 70, p. 162). The small ure- 
thral lithotrite (fig. 75) is used by others, but the simplest 
Fig. 75. 
A small urethral Litliotrite, the female blade of which can be depressed by turning the disc 
A to the left. After insinuating it beyond the fragment, it can be raised by turning the disc to 
the right, when, by means of the male blade, the fragment can be crushed, b, female blade 
depressed, c, the blades closed. 
instrument, and in my opinion the most efficient, since it is 
much more immediately under the guidance of the hand than 
those which are more complicated, is the long urethral forceps 
described above. The employment of small crushing instru- 
ments in the urethra requires great care and extreme delicacy 
of manipulation, or more harm than good may be done; and 
should not be resorted to unless the forceps have really failed. 
A long scoop, well constructed, is a very useful aid ; and is in 
some circumstances the most efficient means which can be 
employed (fig. 76). 
It is said to be necessary occasionally, but very rarely, to 
cut down upon an impacted fragment, either in the perineum 
or near to the meatus externus. If it remains there, obstruct- 
ing micturition, or if it is lodged in the soft parts surrounding 
the urethra, which is apt to happen in or about the mem- 
branous portion, causing much disturbance, or threatening 
abscess, it might be removed by incision. Up to the present REMOVAL OF FOREIGN BODIES. 
169 
time (1880) I have never had occasion to do this; although 
occasionally I have had to divide the inferior angle of the ex- 
ternal meatus to set free an unusually large piece, which was 
arrested there. The meatus is sometimes preternaturally small, 
and requires to be divided; if so, this should be done at the 
outset of the case. 
On the other hand, although I have thought it right to 
retain these practical directions in relation to fragments, it 
will be clear to the reader that if the principle of clearing out 
the bladder at a single sitting can be re- 
alised in practice, there can be no trouble 
in relation to impacted fragments. 
Removal of foreign bodies.—With the 
proceedings for removing fragments of 
stone, the removal of foreign bodies intro- 
duced into the bladder is closely allied. 
Few of these can be crushed; almost all 
must be removed either entire, or after 
division into one or two pieces when neces- 
sary. It is more common to meet with 
them in the female than in the male 
bladder; always excepting, for the latter 
sex, fragments of bougies and catheters 
which, especially when made of that treach- 
erous material the gutta-percha of com- 
merce, are liable to break, and thus to 
occasion this accident. Pieces of stick, 
straw, and sealing-wax are occasionally in- 
troduced. I removed a considerable portion 
of the last-named successfully by lithotomy 
some years ago, not finding by experiment 
that sealing-wax was very friable at the temperature of the 
body, and so not performing lithotrity. Nevertheless, a similar 
case has been so dealt with in Paris since, and with good results. 
For the removal of many of the foreign bodies referred to, 
the French makers have designed several ingenious instruments. 
Figs. 77 and 78 represent those which are adapted for laying 
hold of a portion of bougie, flexible and inflexible, respectively, 
and bringing it away safely. The instrument (fig. 77) is intro- 
Fig. 7G. 
A scoop of the natural 
size. 170 
REMOVAL OF FOREIGN BODIES. 
duced into the bladder with its extremity in the condition 
shown at a; a hook is then made to issue from it and search for 
the flexible bougie by moving the handle B; the bougie being 
seized, it is forced into a position which coincides with that of 
Fig. 77. 
Fig. 78. 
the long axis of the instrument, as seen at h, which ensures its 
safe withdrawal. Fig. 78 is another instrument which similarly 
deals with a portion of metallic catheter or bougie. Figs. 79 
and 80 represent instruments ingeniously contrived for a similar REMOVAL OF HAIR PINS FROM THE BLADDER. 
171 
purpose in relation to the female bladder, particularly for the re- 
moval of hair pins, or other pieces of wire, so that it is scarcely 
foreign to the purpose to mention them, especially as it is by no 
means impossible that they might be useful for the other sex. 
Fig. 79 acts by seizing, folding, and drawing a wire into a straight 
tube. Fig. 80 removes them without folding, but by simply seiz- 
ing and adjusting them to the long axis of the instrument.' 
I have removed a hair pin from the male bladder in a man 
aged 65 years, whom I saw in consultation -with Mr. K. W. 
Dunn, by seizing the end of the pin with the blades of a litho- 
trite and slowly withdrawing it, so that the pin issued as an 
almost straight wire, five inches long. No bad symptom 
followed, and the patient went about as usual the next day.1 
This is practicable only with slender and flexible hair pins; but 
some are made of stout wire which cannot be readily unbent,2 
and which, indeed, are too powerful for the instrument de- 
lineated as fig. 79, which was made in Paris, as I once tested 
in the case of a female patient. Messrs. Weiss, on that occa- 
sion, constructed a fac-simile of that instrument, but much 
more powerful, and with this I could draw any hair pin into 
the tube of exit. The girl supplied me with a hair pin similar 
to that which she had passed into her bladder, and thus I was 
enabled to discover the character of the foreign body to be dealt 
with, and to learn by experiment that the French instrument 
was quite powerless to remove it. 
Complications occurring in the course of the operation.— 
It is not my intention to dwell at length on complications 
frequently arising in connection with Lithotrity, which require 
treatment on those general principles which it must be assumed 
are well understood by anyone likely to practise the operation. 
Some remarks only will be made on those affections wdiich 
directly result from operations performed on the calculous sub- 
ject. They may be enumerated as follows:—Fever, inflamma- 
1 Lancet, Nov. 28, 1863. 
2 A common pin was removed from a young man in three portions by Litho- 
trity. It was the nucleus to a phosphatic stone. Cat. of Calculi, Royal 
College of Surgeons, Pt. I. pi. xii. fig. 14. In the Museum, H.a. 14. 
There are several examples of pins, bodkins, &c., forming the nuclei of 
stones in the bladder of women, in the Royal College of Surgeons. See H.a. 1, 
H.a. 2, H.a. 7, H.a. 11, and pp. 127-130 of Pt. II. of Cat. of Calculi. COMPLICATIONS OCCURRING DURING LITHOTR1TY. 
tion of the bladder or of the prostate, orchitis, haemorrhage, 
and retention of urine. With regard to the influence which 
I'm. 79. 
Fig. 80. 
certain complications, affecting the patient prior to operation, 
should have in determining what method of relieving him is to 
be adopted—such as extreme age, debility, renal disease, diseased FEVER 
173 
bladder, enlarged prostate, stricture of the urethra, peculiarities 
in the stone itself—that will be discussed in Chapter XIV., 
which is devoted to a consideration of the numerous circum- 
stances which should guide the judgment in relation to each 
individual case which comes before us. 
Fever.—It is by no means uncommon, although it is excep- 
tional, that a sitting is followed by a rigor, rapidly succeeded 
by hot and dry skin, and subsequently by sweating. At the 
same time there are thirst, an accelerated pulse, and augmented 
temperature. Pains in the head or back, or in all parts of the 
body, not unfrequently occur also. This is commonly known 
as an attack of fever, or of 4 urethral fever; ’ this peculiar group 
of symptoms being probably often associated with some lesion, 
however slight, of the urethra. The attack varies greatly in 
intensity ; it may commence in the faintest chill, or in a rigor 
of great severity, the subsequent phenomena generally corre- 
sponding to the initial one. In nine cases out of ten it is not of 
serious import: it renders the patient temporarily weak, and 
prolongs the treatment by rendering some postponement of 
the next sitting desirable. Having occurred once, it should be 
anticipated at the next crushing by keeping the patient warm 
at the time, wrapping him up well, and afterwards applying hot 
bottles to the feet, and giving some warm drink, as hot tea, or 
a little wine and water, if preferred. A moderate dose of opium 
is, perhaps, the most useful prophylactic; quinine appears to 
have little influence in preventing the attack. A drop of the 
tincture of aconite given at the time, and repeated in two or 
three hours, has been said to prevent rigors; but I cannot 
endorse the observation, for it is very difficult to judge of the 
effect of any single agent in these circumstances. That one in 
which I have the greatest faith, as a preventive, is the surgeon’s 
ability to operate with ease, gentleness, and rapidity, so as to 
injure the urethra as little as possible. 
Inflammation of the bladder, prostate, or testicle.—When 
the attack is very severe, it may announce the onset of some 
local affection, as of cystitis, or of renal implication, or in- 
flammation of the testicle, although it may still be only severe 
constitutional disturbance resulting from the operation, and not 
related to any local inflammation ; in this case the fever is 174 
INFLAMMATION OF BLADDER AND TESTICLE. 
more likely to continue or become intermitting. If pain above 
the pubes, or at the neck of the bladder, and frequent desires 
to make wTater are experienced; or, on the other hand, should 
severe pains in the loins and sickness occur,—counter-irritation 
to the suprapubic region, or to the loins, respectively, is of ser- 
vice. I know of no better form for these cases than the repeated 
application of hot linseed poultices, sprinkled with mustard. 
Hot hip-baths, demulcent drinks, small but frequent doses of 
liquor potassae, diaphoretic regimen, and mild nutriment, form 
the main elements of treatment; opium, if necessary, to relieve 
pain. The decoction of Triticum repens, from a pint to a pint 
and a half daily, is particularly useful. When the cystitis be- 
comes more chronic, and much pus and mucus are mixed with 
the urine, the bladder may sometimes be washed out daily, and 
another crushing performed as soon as possible, since pulveris- 
ing some of the larger fragments may ameliorate the condition 
of the bladder sooner than any other treatment. In orchitis, 
which rarely occurs, fomentation and rest are necessary, and 
the use of a lotion, one part tincture of opium, three parts 
liquor of the subacetate of lead, and four parts water. I know- 
nothing which relieves so speedily as this combination. Of 
course, the next sitting must be postponed until it is better, 
and be a short one, and more than usual care be taken in mani- 
pulating. 
Hcemorrhage.—This rarely occurs ; a little bleeding some- 
times follows the application of instruments, and may even 
continue for a day or two—but this is exceptional. I once saw 
severe haemorrhage occur from the bladder, not from the urethra, 
probably from peculiarity of constitution, after a short sitting 
conducted with great care ; the bleeding continued in spite of 
all treatment until the patient’s death, which occurred in the 
course of a week. At the autopsy no sign of injury was dis- 
covered by the most rigorous examination, either in the tissues 
of the bladder or in the prostate ; but the whole mucous mem- 
brane was greatly congested. The patient had been in the 
habit, while the subject of stone, of losing blood freely from 
the bladder after exercise even of a very moderate kind. The 
usual treatment of vesical haemorrhage should be adopted in 
these cases, consisting in rest, elevation of the pelvis, cold, with HAEMORRHAGE and retention of urine. 
175 
or without ice, ice in small pieces in the rectum, even injections 
of ice-water, or iced solution of matico, if the manipulation 
does not excite fresh bleeding. The tying-in of a soft vul- 
canised catheter may or may not be advantageous, which 
experiment alone can determine. As a rule, all mechanical 
expedients are to be postponed, until absolute quiet and cold 
have proved inadequate to obtain subsidence of the haemor- 
rhage ; since it is so much more easy to excite fresh bleeding 
by mechanical means than to check it; and further attempts 
to deal with the stone should be postponed until the symptoms 
have ceased, when the course to be pursued is a question for 
very grave consideration. The subject of haemorrhage in all 
its bearings is a very large one, and has been treated fully else- 
where. A brief synopsis will suffice here.1 In a case recently 
under my care, the disposition to bleed manifested itself after 
the first sitting or two, but it gradually got less as the end of 
the treatment approached, and the bladder appeared to regain 
a healthier tone. It was sufficient, however, at the outset to 
occasion anxiety, but the case terminated admirably well. 
Chronic retention of urine.—There is one condition which 
must always be closely looked for after Lithotrity, especially in 
elderly subjects. It is the occurrence of retention of urine after 
a sitting. It may occur very insidiously, occasioning great 
discomfort and even constitutional symptoms, before either the 
patient or the surgeon is aware of the cause. The bladder 
appears to be temporarily atonied ; it becomes full and the 
surplus runs over, and as the urine appears in the ordinary 
quantity of health, the distension of the bladder is easily over- 
looked. It is not due to impaction of fragments in the neck 
of the bladder, but apparently in part to defective power in 
the organ, resulting from the operation; and in part to swell- 
ing of the urethra, or of the prostate beneath it; mostly, but 
not alwTays, the natural power is speedily regained, but, until it 
is so, the catheter must be introduced twice a day, or more 
frequently if necessary, as in all cases where this condition 
exists from other causes. 
As to the time during wdiich the recumbent position shoidd 
be retained after each sitting, and to the amount of confine- 
1 Diseases oj the Frost ate. By the Author. Bond. 1868, p. 206, et seq. 176 
IISP: OF ANESTHETIC AGENTS. 
ment within doors subsequently, it is impossible to lay down 
any rules wdiich can be applicable to all cases. In each it must 
depend on the liability to local and constitutional irritability 
which each case exhibits. While in some cases, where the 
stone is small and the patient has good health and little local 
excitability, strict confinement to the house is not desirable, in 
others it has been necessary for a period of some weeks. Often, 
however, air and some very gentle exercise can be taken be- 
tween each sitting, with advantage to the patient. 
Anesthesia.—There is a point of some importance indirectly 
connected with the operation of Lithotrity on which difference 
of opinion exists. 
I refer to the use of ether or chloroform during the sitting; 
and shall very briefly consider how the condition of anaesthesia 
affects the operation, because it is quite evident, from the 
manner in which the preference to perform Lithotrity without 
chloroform has been viewed by some, that the grounds for that 
preference have been misapprehended. 
First, then, let it be premised that there is no reason why 
the patient should not escape any degree of pain and uneasiness 
which attend the crushing of a stone if he be very nervous or 
susceptible. In these circumstances, it is no doubt better on 
the whole that he should be spared the excitement and the 
shock, which might be considerable in his temperament. 
But the pain arising from Lithotrity, properly performed, is 
really not severe. It is uneasiness rather than pain; and when 
a sitting is no longer than one or two minutes, the demand oh 
a patient’s fortitude it not very considerable. 
Now the only advantage in not employing ether with which 
I am acquainted may be thus explained. There are certain 
circumstances, over which wTe have no control, and of which 
we have little knowledge, that render calculous subjects more 
sensitive on some days than others. Ordinarily the patient 
may bear the sitting without a murmur, and after it is over 
state that he has had little to complain of. But on commenc- 
ing to perform it on another day, although the operator pro- 
ceeds with the same care and facility as usual, the patient 
complains much as soon as the lithotrite has entered the 
bladder: its slightest movements aggravate the pain, and any LITHOTRITY IN CHILDREN. 
177 
attempt to proceed evidently causes him much suffering. In 
such circumstances nature’s plain indication should be followed, 
the instrument should be withdrawn at once, and the sitting 
postponed to another day. The knowledge of this condition 
constitutes all the advantage, whatever it may be worth, which 
is to be gained by the absence of ansesthesia. Each case, in 
relation to this matter, must be judged by its own peculiar 
requirements. My own practice has been, for the last seven 
years, to use ether in almost every case ; it is very rare indeed 
that I do not do so. At the same time, a very brief sitting 
ought not to occasion much suffering; and if the surgeon 
operates without an anaesthetic, watching for any sign of un- 
easiness on the part of his patient, he acquires almost unconsci- 
ously a mode of manipulating which is delicate, careful, and 
extremely unlikely to irritate the bladder. 
Lithotrity in Children.—Lithotrity can be applied to 
patients of any age; but there are some difficulties in its 
employment in the cases of children which those of adults do 
not generally present. Regarding Lithotrity in the abstract, 
without reference to age, let us call to mind what are the con- 
ditions most favourable to success. 
First. A fairly capacious urethra. 
Secondly. A bladder displaying moderate tonicity, but not 
excessively irritable. 
Now, neither of these two conditions exists in children, 
and their absence is the source of most of the difficulties in 
question. 
1. The urethra of the child, say from three to seven, or 
eight, years, is exceedingly small, and it is during this period 
of life that half the cases below puberty occur. To crush a 
stone at this age it is, therefore, necessary to employ a very 
small lithotrite. Hence, none but small stones are amenable 
to its action, unless the sittings are numerous. For, in a 
small lithotrite, the blades must necessarily be short, otherwise 
they are liable to break; and short blades are incompetent to 
grasp any but small masses. If used to break down piecemeal 
a stone of an inch diameter, the time consumed is considerable. 
Hence in Paris, where oaly Lithotrity has been largely em- 
ployed for children, ten, twelve, or more, sittings are common, 178 
LITH0TR1TY IN CHILDREN. 
and each sitting requires at least double the time which is 
necessary for an adult, from circumstances next to be alluded 
to. A case is on record there of a child nine years old, who, 
in the most able hands, was the subject of no less than seventy 
sittings. 
2. The pyriform shape of the bladder, and its situation in the 
abdomen rather than in the pelvis, are unfavourable. There 
is no fixed area for operating as in the adult; no spot where 
the stone may almost certainly be found; no depression behind 
the prostate; and the viscus is often much distended and 
capacious; hence, there is extra expenditure of time in seeking 
the stone. 
The form and situation of the bladder also favour the de- 
termination of fragments to the neck, when the patient is 
recumbent in the ordinary position. The organ is extremely 
excitable, contracting vigorously and continuously with very 
slight irritation. Hence, impaction of fragments in the urethra 
readily takes place after the stone has been crushed. It is 
common to encounter much difficulty from this cause ; obsti- 
nate retention of urine not unfrequently resulting, which has 
sometimes to be relieved by cutting down on the fragment, and 
removing it through the perineum. 
Furthermore, these young patients possess none of that 
self-command which so often conduces to the success of the 
proceeding in the adult; and chloroform must always be em- 
ployed in their cases. 
Incontinence of urine after Lithotrity in children is not a 
very uncommon result, although it generally disappears spon- 
taneously in course of time. 
If it is decided to operate in any given case, the urethra 
should be dilated on three or four occasions previously, the 
pelvis should be well elevated ; and if the stone, when caught, 
proves to be no larger than a pea, it should be efficiently 
crushed at a single sitting, care being taken to granulate it 
thoroughly. Providing it is thus small, the proceeding is 
generally successful. The child should be confined strictly to 
bed, have plenty of demulcent drink, an opiate if much strain- 
ing follows, and warm baths. In cases of my own, in which 
the stone was quite small, I have crushed it at a single sitting. LITH0TR1TY IN CHILDREN. 
179 
Such a result must be regarded as a simpler and safer proceed- 
ing, probably, than Lithotomy. But where more than two or 
three sittings are necessary, the advantage of Lithotrity appears 
to be very doubtful. The instrument I used, in that and in 
other cases, is one without a screw; the crushing power being 
obtained by simple pressure in the palm of the hand; and 
this is ample for the small concretions to which it is applicable. 
Fig. 81 represents the instrument, and fig. 82 the mode of 
applying it. But the usual form may equally be employed. 
Boys, from nine to thirteen, are somewhat more promising 
Fig. 81. 
Fig. 82. 
I’]10- A small Lithotrite without screw, for young children. Its size is about No. 5. 
h iCx. 82. The transverse bar is the base of support against which pressure by the hand crushes 
the stone. 
subjects, but in them the same sources of difficulty exist, 
though in a less marked degree. 
Dr. Guersant, of Paris, surgeon to the Children’s Hospital, 
reported twenty-one cases of children, on whom he practised 
Lithotrity, in which there were six deaths; ‘ two,’ he states, 
‘ from the operation, and four from intercurrent diseases.’ 
Besides these, three others were subsequently cut. Lithotomy 
in children, following unsuccessful Lithotrity, does not appear 
t° be a promising operation: every one of the three died. It RECAPITULATION OF PRACTICAL MAXIMS 
need hardly be added that English Lithotomy affords results 
incomparably better than these. The deaths to recoveries 
between the first and the fifth year are only one to thirteen, 
and between the sixth and the eleventh year, only one to 
twenty-two and a half. (See Table, p. 114.) 
I shall close this chapter by recapitulating briefly a few of 
those practical maxims which have been regarded, in this and 
the preceding chapters, as among the most important to guide 
the practitioner of Lithotrity. 
1. It is occasionally desirable that the urethra be accus- 
tomed to instruments before operating, so that the lithotrite, 
which it is necessary to employ, can be passed without causing 
much uneasiness, or any bleeding (pp. 123-5). 
2. Always operate, whenever this is possible, without pre- 
viously disturbing the bladder by injecting or sounding (p. 143). 
3. Having determined the position of the patient accord- 
ing to the necessities of the case, slowly introduce the lithotrite, 
and take care that the blades reach or pass beyond the centre 
of the bladder before the male blade is withdrawn. 
4. Execute every movement deliberately, occasionally with 
a slight pause between each (pp. 150-3); open and close, incline, 
or rotate, slowly, without any jerk whatever; and all without 
bringing the blades into rough contact, as far as it is possible, 
with the walls of the bladder. 
5. Maintain the long axis of the instrument in the median 
line of the body and the blades at or near the centre of' the 
bladder, this being the area for operating mostly to be chosen. 
In screwing home the male blade to crush, it is especially 
necessary to keep the instrument steady, to avoid much vibra- 
tion of it, or much lateral movement of the blades from its 
axis at each turn; a small deviation at the handle produces a 
large one at the blades. 
6. The position of a large stone is often very near the neck 
of the bladder. But the position of the stone varies much in 
different cases. When it is difficult to find or seize, the 
reason usually is, that the stone lies close to the neck of the 
bladder, so that the male blade, when drawn out, impinges upon RELATING TO THE OPERATION OF L1THOTR1TY. 
181 
the stone, instead of including it within the grasp of the in- 
strument. It is necessary then to insinuate carefully, by a 
lateral movement, the male blade between the stone and the 
neck of the bladder (p. 155). 
7. When the stone is caught, especially if in a large or 
powerful lithotrite, rotate the instrument a little on its axis 
before screwing up firmly or crushing, to make certain that 
nothing is included besides the stone. 
8. Having broken a stone or a large fragment, the operator 
may pick up and crush piece after piece consecutively, without 
further searching, if he is only careful to work the lithotrite 
exactly at the same spot—the patient of course not shifting 
his position—since fragments fall immediately beneath the 
blades of the instrument, and rest there (p. 156). 
9. Never withdraw a lithotrite overloaded with calculous 
debris; a moderate quantity will come away between the plain 
blades; but if an impediment is felt at the neck of the bladder 
on withdrawing, return to the centre of the cavity and unload 
them. This can always be done with a properly constructed 
lithotrite (p. 158). 
10. After a sitting it is generally desirable that the patient 
should have a hot fomentation to the pubic region, remain in 
the horizontal position, and pass his water in that position if 
he can. If his bladder has not been emptied of calculous debris, 
he should remain tolerably quiet until it has passed, which 
usually happens within two or three days of the sitting. 
11. The aspirator is now the most serviceable instrument 
for removing all debris; and is at the same time the most 
efficient, as a rule, for revealing the existence of a last frag- 
ment, as well as for taking it away. CHAPTER XI. 
LITHOTRITY AT A SINGLE SITTING. 
Caution in Procedure, the marked characteristic of the early Lithotritists. 
—Introduction of Anaesthesia shortened the process.—Bigelow’s proposal 
to remove all the Stone at one Sitting.—Cases referred to.—Modifications 
in Lithotrites necessary, and improvement in the Aspirator.—Rules for 
employing it.—Risks inherent in the Single Sitting Method, especially with 
unnecessarily large Instruments.—Illustrative Cases. 
In the early stages by which Lithotrity was developed, and 
especially in the hands of its chief originator and advocate, 
Civiale, the highest importance was attached, and doubtless 
rightly so, to the exercise of extreme caution in relation to all 
instrumental interference with the bladder and the urethra. 
The principle pursued by almost all surgeons who adopted 
the new operation of crushing, at that time, constrained them 
to proceed little by little, to feel their way cautiously, and 
accomplish as much progress as they could, but always subject 
to one important condition—namely, that the operator should 
do no mischief to the organs by any undue manipulation on his 
part. This was the practice long before anaesthesia was allied 
with surgery, and the lithotritist made it part of his business 
to watch the patient closely during the proceeding to ascertain 
whether he w'as distressed by it, and to modify it according to 
his sensibility and power of endurance. So much had this 
become a natural condition of the operation that, long after the 
use of ether and chloroform had become indispensable in all 
other operations, Lithotrity was performed by many without an 
anaesthetic agent. Hence, as we have already seen, it was the 
aim of the operator to cultivate a light and gentle, but quick, 
hand, to do as much as possible in a short space of time, but 
also as gently and delicately as he could. Thus several sittings, PROPOSAL TO REMOVE ALL DEBRIS AT ONE SITTING. 
183 
varying in number from three or four to ten or twelve, were 
commonly necessary according to the size of the stone. 
In time, however, ansesthesia became adopted also for 
Lithotrity, and since employing it myself I have gradually 
diminished the number of sittings, and removed more debris 
on each occasion, so that from one sitting to four or five became 
at length as productive as the numbers before named. This 
progress was naturally in part the result of familiarity with the 
instruments and their use, acquired by many years of practice. 
I also employed more and more, during the last eight or ten 
years, for the same purpose, the aspirator of Clover, and 
especially when the presence of irritation or inflammation made 
the removal of all the fragments particularly desirable. At the 
same time I have been in the habit of saying to younger men, 
who, as so many have done, accompanied me to my operations 
for the sake of studying the process, 4 Do not attempt on first 
beginning to do as much as you see that I venture myself to 
do.’ Such, at all events, was my practice until about two 
years ago; and in Paris the mode of operating then was, as 
I think, for the most part, it still is, based on the original 
4 cautious ’ style, or many-sitting system. 
In 1878 Professor Bigelow, of Harvard, U.S., having tried 
the experiment in a few cases, proposed, as a general rule, that 
the stone should, if possible, be all crushed at one sitting, and 
removed entirely by a large aspirator and evacuating catheters, 
no matter how prolonged the time which might be necessary in 
order to accomplish the task. He believed that less damage 
would really accrue to the bladder and associated organs by a 
long, and even somewhat hazardous, sitting, provided the viscus 
was emptied of the debris, than by the old process of taking 
away a little and often, but leaving always hard and broken 
fragments in the cavity, to produce continued and sometimes 
serious irritation there during much of the period necessary 
for repeated sittings.1 
1 Litholapaxy, or rapid Lithotrity with Evacuation. By H. J. Bigelow, M.D. 
New York, 1878. It seems to me unnecessary, if not inconsiderate in relation 
to the origin of the old and well understood term ‘ Lithotrity,’ to invent a 
new, and not very euphonious one, to designate this proceeding, ‘ Litholapaxy ‘ 
(from Aldus, a stone, and Aa7ra|is, evacuation) implying, as it does, that the TO REMOVE STONE WHEN LARGE AT ONE SITTING 
This was a bold, and I think it may be considered a happy, 
idea. My mind wras already prepared by past experience to 
receive it favourably, although the means Bigelow employed in 
the shape of instruments, especially the lithotrites he proposed 
to use for the purpose, are unnecessarily large and clumsy; and 
I at once tried the plan, and have to a very great extent carried 
it out during the past twelve months. Having tested it to the 
extent of 35 cases, I do not hesitate to regard it as, on the 
whole, in competent hands, successful. Let the stone as to 
size be within the limit of the surgeon’s powers, and let all be 
removed, or at all events the greater part of it, at the first 
trial. In attempting this, he should commence by crushing 
freely with a light but strong lithotrite, removing debris by 
the aspirator-current afterwards. This done, the lithotrite is 
again introduced, if necessary, to deal with the remainder, and 
is again followed by the aspirator. If the rattle of fragments 
in the bladder against the end of the evacuating catheter still 
exists after its use, the lithotrite is to be again introduced to 
break them down, and another employment of the aspirator 
will perhaps complete the task. If only a few small pieces still 
remain, it is better perhaps to leave them than to subject the 
parts to repeated manipulations in order to remove some tiny 
portion. Such will do no harm, and may be removed at a 
second sitting. 
By this method, instead of limiting the sitting to a term of 
two or three minutes, it may extend from five or seven to 
twenty-five or thirty minutes, although a watchful caution must 
control the period as it becomes extended to the longer term 
named. The longest sitting I have as yet found necessary 
is twenty-five minutes, during which I removed 329 grains 
of a hard uric acid stone from a gentleman of seventy-eight 
years of age. Three days after I removed 192 grains more in 
thirteen minutes, completing the case, and the result was quite 
successful; and when I last heard of him, he was enjoying 
evacuation of the fragments is a new practice. Nothing can be more contrary 
to fact, since evacuation has throughout been an essential part of the process, 
gradually becoming more in vogue the last few years, and the evacuating 
instrument itself, and the method of using it, are in principle precisely what 
they were before, only a larger catheter is now employed. Bigelow uses No. 
18 or 20 English scale, instead of 13 or 14 which I have always used. DEMANDS LARGER LITHOTRITES AND ASPIRATORS. 
greatly improved health at the seaside. This and all the other 
cases referred to have been seen by many of my brethren both 
in town and country. It is worthy of remark that at present 
not one of the thirty-five cases has been fatal, but this number is 
insufficient to prove anything, as I once had an unbroken series 
of forty-eight cases by the old system without a death. All 
experienced operators know how large must be the numbers in 
order to furnish tabular results of a trustworthy nature. In 
reference to the time occupied in operating, I find I have 
hitherto removed on the average from 150 grains to 200 grains 
in ten minutes, of hard calculus (uric-acid or oxalate of lime). 
Of course, when the stone is friable, as in the case of phos- 
phatic formations, a larger quantity may be removed in a given 
time. 
For the purpose of this mode of operating, I have modified 
my instruments somewhat. I have designed especially for the 
purpose one lithotrite stronger than before, making the male 
blade more wedge-shaped, or rather like the prow of a ship, in 
part angular, in part more bluff or obtuse; this male blade pro- 
trudes through a small opening at the bottom of the female blade, 
so as to make blocking up impossible. (See fig. 57, page 134). 
And the original aspirator of Clover, the principle of which is 
maintained in its entirety, I have considerably modified in a 
manner so that my new form of it offers three advantageous 
conditions: first, there is no possibility of air entering it; 
secondly, it ensures the shortest possible route into it from the 
bladder; and thirdly, it has a globular trap at the bottom, into 
which the fragments enter, but which they cannot leave. 
The annexed woodcuts and following explanations will de- 
monstrate the mechanism and action of the new aspirator. The 
apparatus consists of a stout india-rubber bottle (fig. 83, a). On 
the upper part is a tap (b), and above it a small funnel through 
which to fill the bottle. At the lower end is a tube, and 
attached to it are the lower tap (c) and the glass receiver. 
The tap is constructed thus :•—Through the tube is fixed an- 
other metallic tube with a large opening on the under side, 
towards the receiver. The tube projects a short distance at D 
(figs. 83, 84, 85), to receive the end of the evacuating catheter 
placed in the bladder. The tap (c) is contained in the interior 186 
THE AUTHOR’S ASPIRATOR. 
of this tube, and is hollow ; it is provided with a large opening 
in one of its sides, so that when once the tap is in situ, this 
opening faces that of the fixed tube containing it, and the end 
faces the opening D (figs. 83, 84, 85), which fits the evacuating 
Fig. 83. 
Fig. 84. 
catheter. Next there is a spherical glass receiver (figs. 83, 84, 
85, e) ; the metallic tube to which the receiver is fastened goes 
down into it about two-thirds of an inch. The spherical re- 
ceiver is about two and a quarter inches in diameter. When 
the operator compresses the india-rubber bottle, the fragments PRINCIPLES OF CONSTRUCTION AND ACTION. 
187 
enter, fall downwards through the tube, and cannot mount 
again into the apparatus, in consequence of the projection of 
the tube into the glass receiver. The apparatus acts thus :— 
The evacuating catheter being in the bladder, the tube at d 
(figs. 83 and 84) is easily adapted. If the tap is now turned, 
as in fig. 84 (c), communication is established between the 
bladder and the apparatus. If, on the contrary, the same tap 
is turned as at fig. 85 (c), all communication is closed, and the 
apparatus can be removed without spilling a drop of water. 
Nothing is easier than to fill the instrument. The upper tap 
b (fig. 83) is opened, the lower tap (c) closed, and water poured 
in by the funnel at the top. The water fills it directly and 
drives the air completely out; the upper tap (b) is then closed, 
and the instrument is ready for use. 
The change in the situation and form of the lower tap shortens 
the distance many inches for the fragments to traverse, which 
thus reach the receiver by the shortest possible route. The cur- 
rent having less distance to travel, has a more powerful action on 
the fragments, consequently the aspiration is more perfectly 
made that it has hitherto been. The entry of air into the blad- 
der is impossible, since the current leaves the lower part of the 
apparatus, and the air bubbles, if any, must rise to the upper 
part. In consequence, also, of its small size and portability, this 
instrument can be very easily adapted to an evacuating catheter, 
without necessitating any change in the position of the patient 
to be operated on. Further, for those who prefer a portion of 
flexible tube between the aspirator and the evacuating catheter, 
a portion is provided; two inches thus interposed, at D, will 
ensure freedom from any jar to the bladder in using the instru- 
ment, and will only lengthen the route pro tanto. For my- 
self, I prefer the absolutely direct and shortest route; having 
no more fear of hurting the bladder with the inflexible evacua- 
ting catheter than I have with the inflexible lithotrite. 
This apparatus is to be used as follows:—The largest 
evacuating catheter the urethra will admit is to be passed, 
and if it be necessary, as sometimes happens, to enlarge a little 
the external meatus, it should be done at once. No. 15 or 
16 may mostly be used ; if a larger can be admitted without 
violence, so much the better. The catheter may have a large 188 
opening near its extremity, either in the cavity or on either 
side, in which latter case a flexible stylet should fill the interior 
of the instrument; on reaching the bladder all the urine is 
withdrawn and the aspirator is attached, either directly, or by 
means of a short piece of india-rubber tube fitting outside both 
metal tubes. The catheter is held steadily, or its position may 
be modified, by the left hand of the operator, who holds the 
india-rubber bottle in his right: and with it makes pressure, 
forcing a current of warm water into the bladder. The pressure 
is then to cease, suddenly, when a strong current flows into the 
aspirator, carrying outwards the fragments, which fall at once 
into the glass trap below. This process is repeated several 
times, according to the amount of debris observed to quit the 
bladder and enter the trap. 
If the patient is breathing heavily under the influence of 
ether, it is desirable to inject during the act of his expiration, 
and let the fluid flow outwards into the aspirator during his 
inspiration, which act assists the evacuation of the bladder. 
After a large crushing, the end of the evacuating catheter 
should not rest on the floor of the bladder, as it is then likely 
to be choked with debris. But after most of the fragments 
have been removed it is advantageous to lower the end of the 
catheter, in order to catch the last fragments. 
If the outflow of the current is felt to be suddenly checked, 
and the aspirator ceases to distend, the operator may be almost 
certain that a fragment of a rounded or cubical form, or a small 
calculus, nearly fitting the interior of the catheter, blocks the 
passage and prevents further egress. The piece must be ex- 
pelled by making smart pressure on the india-rubber bottle, 
after which the action of the aspirator will probably be re- 
sumed. 
If after crushing all the stone, so far as the operator is able 
to judge, and removing the debris largely, nothing is heard or 
felt in contact with the end of the evacuating catheters, not- 
withstanding that three or four successive pressures have been 
made, there is ground for believing that all the fragments may 
now have been removed. Perhaps there can be no better proof 
that the bladder has been emptied, than is afforded by the fact, 
that a succession of outward and inward currents through the 
DIRECTIONS FOR USING THE ASPIRATOR. LARGE AND UNWIELDY INSTRUMENTS RARELY NECESSARY. 
aspirator reveal no sign of the presence of a fragment, either to 
the operator’s hand or ear. 
Thus far I have spoken of 4 Lithotrity at a Single Sitting ’ 
with the favour which my present experience of it, about to he 
detailed below, warrants me in doing. But no estimate would 
be a just one which did not point out certain sources of danger, 
not present in ordinary Lithotrity, which attend Bigelow’s 
method, and which have perhaps been somewhat overlooked by 
some of those who have enjoyed less considerable opportunities 
than myself of studying the subject. 
First, there is no kind of question, that the instruments 
which Bigelow" uses, and which have been employed here—that 
is, both lithotrites and evacuating catheters—are unnecessarily 
large, and are, moreover, too large to be safely passed into the 
bladder by ordinary hands; and especially since instruments 
wThich are two or three sizes smaller will execute the work 
required to be done. To handle safely such large lithotrites 
and evacuating catheters, a more skilful and experienced master 
in the use of instruments for the urethra and bladder is required, 
than for the manipulation of instruments which are smaller in 
size. 
Secondly: the fact seems to be quite overlooked here—which 
is not surprising since it appears not to be taken into account 
by Mr. Bigelow himself—that large instruments are wholly 
unnecessary for at least three-fourths of the stones which occur 
in 'practice : while, if stones are found early, as they ought to 
be almost always, such instruments will never be wanted at all. 
The smaller and light handy lithotrites which are now used 
throughout Europe, amply suffice to crush all small and medium 
sized stones at a single sitting. To accomplish this purpose, 
all that is further necessary is a more powerful aspirator and a 
somewhat larger evacuating catheter than before; say a No. 
16 (English scale), instead of a 13 or 14. With these a uric 
acid stone up to an ounce in weight can be readily removed at 
a single sitting. Nevertheless I have known Bigelow’s enormous 
lithotrites to be employed here to crush a little stone (which 
one of my smallest lithotrites would dispose of in three or four 
minutes at the most, and almost certainly without causing 
irritation), and the debris removed by a catheter of No. 18 190 
INCREASED AMOUNT OF CRUSHING DEMANDS INCREASED SKILL. 
(English) size ! an application of apparatus which would arouse 
a smile by its incongruity, were it not that the result has been, 
to my own knowledge, so disastrous. These large machines, if 
necessary at all—and I do not hesitate to say that they are 
unnecessary and undesirable—are only to be applied to the 
purpose of attacking calculi of rare and extraordinary size; to 
use them for small calculi denotes an absence of common tact 
and judgment which it is difficult to understand. 
Let it be observed that for the cases given below—and all, 
large and small, are recorded just as they consecutively appeared 
in my practice—in no one instance have I used any other instru- 
ment than my own lithotrites, one of these being made stronger 
and more penetrating than before, together with the aspirator 
already described. 
Finally, there can be no question whatever that the extra 
work necessary to be performed at a single sitting especially 
demands a practised hand to do it safely. The operation by 
one sitting, if the stone is hard and weighs 400 or 500 grains, 
requires more skill and experience to accomplish it safely and 
successfully, than the old operation by several sittings. This 
given, the results of the new method will be better than the 
old, because the irritation caused by fragments retained in the 
bladder from sitting to sitting is saved to the patient; but it is 
saved only at the cost of manipulation which is more severe 
and prolonged than before. If this is attempted by hands 
which are not experienced, or, at all events, not well trained 
and skilful, the balance of probability in relation to injury in- 
flicted will almost certainly be larger, and will tell against the 
patient; and will not be in his favour, as under the old but 
slower system might safely be anticipated. 
Cases of Calculus, of all Sizes, eecently removed by Litho- 
trite and Aspirator at a Single Sitting, or as nearly at 
one Sitting as possible. 
Case 1.—A gentleman aged 54. December 16, 1878. Oxalate and 
phosphate, weighing 97 grains ; in 9 minutes. Sent to me by Mr. 
Spencer Wells, who was present at the operation. Occasionally forms 
phosphates and washes out the bladder to remove them. 
Case 2.—A gentleman aged 66. December 16, 1878. A uric acid CASES OF L1THOTRITY AT A SINGLE SITTING. 
calculus, weight 84 grains,removed at one sitting; in 7 minutes. He 
had some fever and impaired health for several weeks, but ultimately 
recovered; had no more symptoms, and is now in good health. Seen 
with Dr. Taylor, of Camberwell. 
Case 3.—A gentleman aged 43. December 21, 1878. Oxalate of 
lime, small, in one sitting, 42 grains; no fever or other untoward 
symptoms after, and quite well at present time. Mr. Spencer Wells 
was present at the operation. 
Case 4.—A gentleman aged 72. December 22, 1878. I had 
crushed a calculus five and a half years before, and he had been free 
from symptoms until about twelve months ago. I removed now, in 
one sitting, a phosphaticcalculus, weight 154 grains, in 8 minutes; a 
slow but sound recovery. He draws all his urine by catheter; Dr. 
Sutro was present. 
Case 5.—A gentleman aged 64. January 6, 1879. Uric acid and 
phosphatic mixed, which had caused great suffering. Much relieved; 
he passes all his urine by catheter. Dr. A. K. Longhurst was present. 
A little removed at a second sitting, a day or two after. 
Case 6.—A gentleman aged 69. January 22, 1879. Uric acid, 
weighing 172 grains ; in 11 minutes. Sent to me by Mr. Lathbury, of 
Finsbury. Successful; this patient had also diabetes. 
Case 7.—A gentleman aged 68. January 31, 1879. Uric acid, 
weighing 114 grains; in 9 minutes : a rapid recovery. Sent to me by 
Mr. J. H. Walters, of Farringdon, 
Case 8.—A gentleman aged 79. February 12, 1879. Phosphatic, 
weighing 194 grains, in 12 minutes. I had cut him a year before, 
removing four uric acid calculi. He made a quick recovery, but passes, 
as before, all his urine by catheter from enlarged prostate. Mr. 
Clover gave ether on both occasions. 
Case 9,—A gentleman aged 65. February 13, 1879. Phosphatic, 
116 grains; in 6 minutes. He passes most of his urine by catheter. 
Sent by Mr, Holberton, of Hampton. 
Case 10.—A gentleman aged 69. March 15, 1879, Uric acid, 
200 grains ; in 10 minutes. A few fragments left were removed at two 
explorations soon after; a good recovery. Seen with Dr. Bantock, who 
was present at the operation. 
Case 11,-—A gentleman aged 65. March 15, 1879, Uric acid. 
Dr. Bantock, Dr. Muir, and others present. A good recovery. 
Case 12.—A youth aged 16. March 28, 1879. Oxalates and 
urates mixed, rather small. Mr. Cadge, and Mr. E. Harrison present. 
Case 13.—A gentleman aged 82. March 23, 1879. Phosphatic, 
about 60 grains. Dr. Smith, of Great Hadham, present; CASES OF LITHQTRITY AT A SINGLE SITTING. 
Case 14.—A. gentleman aged 47. March 28, 1879. Pure triple 
phosphate, weighing 94 grains; in 7 minutes. Sent to me by Dr. 
Mitchell, of New Cross, who was present at the operation, as were 
also Mr. Cadge and Mr. Reginald Harrison. 
Case 15.—A gentleman aged 63. June 2, 1879. Phosphatic, 
weighing 68 grains; in 6 minutes. Mr. Bailey gave ether; Dr. 
Keyes, of New York,, was present. He has to pass a catheter three 
times a day, not emptying his bladder naturally. 
Case, 16.—A gentleman aged 66. June 2, 1879. Uric acid, 
weighing 175 grains ; in 10 minutes. Recovery complete. Seen with 
Dr. G. 0. Rees, who was present at the operation. 
Case 17.—A gentleman aged 70. June 12, 1879. Uric acid, 
weighing 198 grains ; in 10 minutes. Recovery complete. Sent to 
me by Dr. Ryott, of Newbury, who was present at the operation. 
Case 18.—A gentleman aged 70. June 25,1879. Mixed oxalates 
and urates, weighing 214 grains ; in 12 minutes. Recovery complete. 
Seen with Dr. George Johnson, who was pi'esent at the operation. 
Case 19.—A gentleman aged 60. June 20, 1879. Oxalate of lime, 
weighing 165 grains; in 9 minutes. Recovery complete. Seen with 
Mr. Morgan, of Sussex Place, and his son, who gave ether. 
Case 20.—A medical man, aged 41. July 16, 1879. Phosphatic, 
weighing 208 grains; in 15 minutes. I removed ten grains subse- 
quently. He had orchitis and fever, and made a slow recovery. 
Case 21.—A gentleman aged 78. July 19, 1879. Uric acid, 
weighing 329 grains; in 25 minutes. At his age Mr. Clover preferred 
not to give ether longer, and I postponed the proceeding three days, 
removing then 192 grains more, in 13 minutes, making a total of 521 
grains (or nearly 1 ounce and 1 drachm) of very hard uric acid. 
Recovery complete. Sent to me by Mr. Quain, of Cavendish Square, 
and is well now (1880). 
Case 22.—A gentleman aged 58. July 31, 1879. Uric acid, 
weighing 145 grains; in 11 minutes. Recovery complete. Seen with 
Dr. George Johnson, who was present at the operation. 
< Case 23.—A French gentleman aged 67. July 31, 1879. Uric 
acid and some phosphate, weighing 40 grains; in about 7 minutes. 
Dr. George Johnson and others present. A rather tedious recovery, 
never emptying his bladder except by catheter. 
Case 24.—A gentleman aged 56. August 7, 1879. Uric acid, 
weighing 106 grains; in 10 minutes. Mr. M. B. Hill and Mr. John 
Morgan present. Some irritation of the bladder continued, and was 
troublesome for a few weeks, and then subsided. 
Case 25.—A gentleman aged 56. August 13, 1879. Uric acid. CASES OF LITHOTRITY AT A SINGLE SITTING. 
193 
Has some narrowing of the urethra at three and a half inches from the 
orifice, so that a smaller evacuating catheter than usual had to he 
attached to the aspirator. Weighed 123 grains ; in 12 minutes. Sent 
to me by Dr. Kidd ; Mr. John Morgan and Dr. Lebec, of Paris, 
present. A good recovery. 
Case 26.—A gentleman aged 54. August 19, 1879. Uric acid, 
weighing 45 grains; in 6 minutes. Mr. John Morgan present. A 
good recovery. 
Case 27.—A gentleman aged 70. August 16, 1879. Phosphatic, 
weighing 42 grains ; in 5 minutes. A good recovery. 
Case 28.—A gentleman aged 65, December 5, 1879. Uric acid 
and oxalate, weighing 40 grains; in 5 minutes. His attendant, Dr. 
Marsden, of Grosvenor Street, was present. A good deal of irritation 
followed ; and although no phosphatic deposits or cystitis appeai'ed, he 
passes water frequently, although without pain or blood. Otherwise 
he is quite well. 
Case 29.—A gentleman aged 55. December 3, 1879. Uric acid. 
I removed 158 grains at a sitting of 10 minutes, leaving a little more 
in the bladder, which I removed (29 grains) a day or two after. Mr. 
William Rose, of King’s College Hospital, was present. An excellent 
recovery. 
Case 30.—A gentleman aged 62. January 1, 1880, Uric acid, 
weighing 98 grains; in 8 minutes. Sent to me by Dr. Moore, of 
Lancaster. A good recovery. 
Case 31.—A gentleman aged 57. January 22, 1880. Uric acid, 
weighing 65 grains; in 5 minutes. Sent to me by Mr. J. E. 
Williams, of Whitstable. A somewhat tedious recovery, but he gra- 
dually attained an improved condition. 
Case 32.—A gentleman aged 70. February 28, 1880. Uric acid, 
weighing 308 grains, in 18 minutes; finding 15 grains more three 
days after. Mr. Henry Smith, of King’s College Hospital, saw this 
case with me. A rapid and complete recovery. 
Case 33.—A gentleman aged 66. March 2, 1880. Uric acid, 
weighing 78 grains; in 6 minutes. Dr. George Johnson was present 
at the operation. A rapid and complete recovery. 
Case 34.—A gentleman aged 65. March 20, 1880. Uric acid, 
weighing 51 grains; in 4 minutes. Sent to me by Dr. Handheld 
Jones. He had orchitis and made a rather slow, but complete re- 
covery. 
Case 35.—A gentleman aged 73. April 26, Uric acid, weigh- 
ing 96 grains; in 9 minutes. Mr. Erichsen and Mr, Furner, of 
Brighton, were present. A good recovery. CHAPTER XII. 
THE EMPLOYMENT OF LITHOTRITY IN CASES WHERE, BESIDES 
CALCULUS, SERIOUS ORGANIC DISEASE OR OTHER COMPLICA- 
TION EXISTS. 
Lithotrity in—1. Organic Stricture of the Urethra—2, Hypertrophy of 
Prostate —3. Atony and Paralysis of the Bladder—4. Sacculation of the 
Bladder—5. Tumours of the Bladder—6. Renal Disease—7. Multiple 
Calculi. 
Thus far it has been assumed, in describing the proceedings of 
Lithotrity in detail, that the cases to which it is applied are 
those of patients in the enjoyment of ordinary health, or, at all 
events, that no serious disease besides that of stone is present. 
It is now necessary to inquire what modifications of the 
operation may be necessary for those instances where organic 
disease of some kind is superadded to the calculous malady, and 
complicates the case. 
These may be enumerated for our purpose as follows:— 
Organic stricture of the urethra. The prostate gland much 
enlarged by hypertrophy. Confirmed atony, and paralysis of 
the bladder. Sacculated bladder. Tumours of the bladder. 
Renal disease. 
1. Organic stricture of the urethra.—This condition has 
always been regarded as an insuperable obstacle to Lithotrity. 
I have now operated on several cases with success and without 
any serious difficulty. 
The manner which I have adopted for overcoming the 
difficulty is by employing the plan of 4 continuous dilatation ’ 
during three, four, or five days before the ensuing sitting. A 
gum catheter, of small size, is introduced and tied in the bladder, LITHOTRITY WITH STRICTURE AND PROSTATIC HYPERTROPHY. 
a proceeding which merely confines the patient to the house, 
not necessarily to bed. In two days this may be replaced by a 
larger size, say No. 6 or 7, and in two or three more, by No. 10 
or 11. It is then desirable to give ether and to use a rather 
small flat-bladed lithotrite, introducing it three or four times, 
and carefully removing the debris made. The catheter is 
then again tied in, and another sitting may follow in two or 
three days. The debris should be made fine, and an evacuating 
catheter of No. 11 in size employed to remove it. When 
writing the previous edition of this work, I was concluding the 
treatment of a fourth patient, then lying in one of my wTards at 
University College Hospital, on this system; and he was soon 
afterwards discharged cured. He had been cut for stone eight 
years before, and this time had a phosphatic formation of rather 
large size in his bladder. There was a stricture at five inches 
from the meatus, admitting, at most, No. 6 on admission. 
It is not to be concluded that all cases of stricture will be 
amenable to Lithotrity; but there is no doubt that for most it 
may be made successful, and I think always whenever the stone 
is small. For large hard stones Lithotomy will still probably 
be preferable. 
2. Hypertrophy of the prostate.—The coincidence of a 
moderate development of this condition with calculus in the 
bladder I have found to be so frequent in elderly patients, and 
so inconsiderable in its bearing on the operation, that I do not 
regard it as worth taking into consideration in relation to 
treatment. But when the gland is very large, and when it is 
eccentric in form, as through the presence of polypoid out- 
growths or of rounded masses into the cavity of the bladder, a 
serious complication is presented to the surgeon. I am bound 
to say, however, after operating on a considerable number of 
such cases, that less difficulty is presented than might be anti- 
cipated. Careful manipulation to avoid bleeding, one of the 
principal sources of evil, is essential, and therefore gentle and 
restrained movements of the lithotrite must be adopted. At 
the same time, much of the work must be done with blades 
reversed, and even dipped deeply behind the prostatic growth ; 
and this is by no means difficult, the depression there admitting 
access of the instrument as readily, or more so, than in the L1TH0TRITY WITH HYPERTROPHY OF THE PROSTATE; 
healthy bladder. But the fragments are not expelled by the 
natural efforts, and must be removed by the aspirator, which 
is now especially useful. The use of the ordinary catheter is 
often necessary for these patients as a habit, and by its means 
some of the finer debris passes ; and a little washing out daily 
with the four-ounce gum bottle—not with a powerful syringe, 
—assists the process, if all has not been removed at the opera- 
tion. It is by no means unimportant to maintain a gently re- 
laxed condition of the bowels, which favours alike the expul- 
sion of urine and of debris in these subjects, while constipation 
always adds to their discomfort. If straining or tenesmus 
occur, morphia suppositories or, better still, subcutaneous injec- 
tion, can be employed. The frequent use of a very hot bidet is 
superior to hip-baths, as being less weakening, less troublesome 
to the feeble and aged patient, and sometimes really more 
efficient. 
Occasionally, during an attack of great frequency in micturi- 
tion, a vulcanised catheter may be retained for a few days with 
singular advantage; or the ordinary gum catheter, according to 
circumstances. Sometimes, however, it cannot be borne. 
In one case of an elderly man who had found it necessary 
to empty the bladder every two hours day and night, having 
no power to pass any urine by his own efforts ; and who was 
the subject of a large phosphatic calculus, the inlying catheter 
could not be tolerated Its presence produced extreme distress, 
while, after crushing and removing very freely by the aspirator, 
there was increased frequency in the calls for the instrument. 
Under these conditions I made a small perineal opening, and 
by it introduced into the bladder a vulcanised catheter, which 
gave immediate relief, and was tolerated for several days with 
admirable results. I should have no hesitation in practising 
or recommending this procedure in similar circumstances. The 
making of a small opening in the perineum on a grooved staff is 
a very simple matter, and the wound heals readily when no 
longer required. 
Of the general treatment of such patients I say nothing 
here, beyond adverting to the need which always exists for the 
surgeon to be guided mainly in each case by the knowledge of 
previous habits and constitutional tendencies, which at sixty, WITH ATONY, PARALYSIS, A IS I) SACCULATION. 
197 
seventy, or eighty years of age are not to be ignored, or much 
interfered with ; and that also, especially for these, a study of 
diet and habitudes is as necessary as the study of medicine, 
strictly so called. 
3. Confirmed atony and paralysis of the bladder.—With 
either of these two different conditions, it is by no means 
uncommon to find stone in the bladder. Patients who are 
younger than those who are the subjects of retained urine from 
hypertrophied prostate, already referred to, find it necessary, 
from the causes above named, to pass all their urine by catheter; 
and when they form stone, it is mostly phosphatic in character. 
Here the complication is less formidable than that which has 
just been described. The organs are habituated to the contact 
of instruments; no deformity exists; there is only a flaccid 
bladder and a want of tone in its coats. All that is necessary, 
beyond the crushing of the stone, is its removal by the litho- 
trite and the aspirator. 
4. Sacculation of the bladder.-—This is one of the most 
serious and unpromising conditions which can complicate any 
proceedings to remove a stone. It is unquestionably unfavour- 
able in Lithotomy, and in Lithotrity it is the source of failure 
and of danger. Unhappily, the diagnosis of sacculation is not 
by any means always possible. I have diagnosed a sac during 
life, and verified the statement by autopsy ; but in the majority 
of cases in which sacs exist, I know no means of accurately 
.determining the fact during life. For example, after some years 
of obstruction to the outflow of urine, partially relieved by the 
catheter, or not, an elderly patient may exhibit the following 
phenomena :—He habitually uses the catheter, say, two or three 
times daily, and after the contents of the bladder have been 
apparently withdrawn, some dribbling of turbid urine through 
the instrument continues. This occurring only to a slight 
extent, denotes merely inequalities in the cavity, produced 
most commonly by irregular masses of prostatic outgrowth. 
Put if it continues to a considerable extent, and, a fortiori, if, 
having made the patient lie on each side alternately for two or 
three minutes, he rises to the standing position, and then some 
ounces more are withdrawn, there can be no doubt as to the 
existence of some sac or sacculi in the bladder. This experi- 198 
merit I have tried repeatedly, and upon it have founded a 
diagnosis of sacculation which has been ultimately confirmed 
by examination after death. In one of the cases in which 
these circumstances occurred, I found two small calculi within 
the sac, where they never could have been detected during life. 
In cases of death in aged patients, occurring after Litho- 
tomy and Lithotrity, and especially when it follows slowly and 
insidiously the commencement of habitual use of the catheter, 
for elderly men who had been the subjects of long neglected 
chronic retention of urine from enlarged prostate, it is by no 
means uncommon to find sacs in the bladder. Often these are 
small and numerous, less frequently they are large, but in any 
case they seem to conduce in some manner to the unfavourable 
issue. They become the depositories of decomposed urine, 
which rarely altogether issues from them; thus chronic but 
severe inflammation is set up, and not only cystitis, but even 
peritonitis, may be produced, for many lie in close contact with 
that membrane. As a result of performing Lithotrity, frag- 
ments may be caught in these recesses, where the foreign matters 
doubtless increase irritation, while their removal becomes im- 
possible. When, in the course of the operation, the surgeon 
has reason to believe that sacculation exists, an additional argu- 
ment is furnished for removing all the debris, if possible, at a 
single sitting. 
Should, however, the diagnosis be clear before commencing 
any proceeding, it is possible, other conditions being equal, 
that Lithotomy might be somewhat less hazardous for such a 
case than Lithotrity. 
5. Tumours of the bladder.—These—simple prostatic 
growths being of course not included in this category—are so 
rare, that the question of applying Lithotrity for a patient with 
a tumour in the bladder can very seldom arise. I have operated 
in two instances only, and in these the growth was cancerous. 
The only indication presented was to operate with extreme 
gentleness and care, so as to avoid occasioning haemorrhage. 
In these cases, the space for operating was limited; but this, if 
the stone is not large, is scarcely a serious objection. Each 
patient lived a short time after the removal of the calculus, 
and his sufferings were mitigated in consequence. 
LITHOTRITY WITH TUMOURS OF THE BLADDER; WITH RENAL DISEASE, AND MULTIPLE CALCULI. 
199 
6. Renal disease.—I have had to perform Lithotrity several 
times for patients suffering with manifest and advanced disease 
of the kidneys. Such individuals exhibit tendency to severe 
constitutional disturbance, such as fever, irregularities in the 
excretion of urine, &c., more readily than those who are not so 
affected. It is often with no little anxiety that the symptoms 
must be watched in these cases. The main object of the 
surgeon in performing the necessary manipulations, is to pro- 
duce as little irritation as possible. Probably this will be in 
the long run accomplished as well, or better, by a single com- 
plete sitting than by repeated small ones. The condition and 
strength of the patient must be considered. The retention of 
fragments in the bladder in the circumstances described will 
probably be more likely to propagate irritation to the kidney 
than their removal at one operation, provided the surgeon is 
capable of accomplishing this skilfully and without inflicting 
injury. All possible care should be taken of the patient’s ex- 
ternal conditions : he should be confined to his bed, or at all 
events to his room, and on the appearance of any fever, or of 
pain in his loins, hot cataplasms of linseed, sprinkled with 
mustard, should be applied to the back. All rapid changes of 
temperature should be provided against, the sufficient action 
of the bowels ensured, and the powers of life supported by 
unirritating nutritious diet. 
7. Multiple calculi.—It is by no means uncommon among 
elderly patients to find several small calculi in the same 
bladder. Weight for weight, the advantage is on the side of 
the numerous calculi, as compared with the single one. No 
large fragments are made in granulating small stones: no 
sharp, rough, and irritating masses follow the crushing process. 
When two or three calculi of considerable size are found in the 
bladder, in the place of one, the amount of manipulation which 
will be involved by the necessary crushing, although consider- 
able, is notably less than if the total amount of calculous matter 
existed in a single compact mass. In dealing with a case in 
which the presence of two or three stones, say, each the size of 
a filbert, has been demonstrated, one only need be attacked 
at first. The unbroken stone, with its surface more or less 
smooth, is a much less irritating object than the angular pieces LITH0TR1TY AND MULTIPLE CALCULI. 
which are produced by a single crush of the instrument, and 
may be left for a subsequent sitting, if desired. 
It is by no means necessary to interfere with a second or 
a third entire stone, after crushing and removing the first; 
although there is no reason why the whole should not be 
removed at one sitting, if all the circumstances of the case are 
favourable to the adoption of this method. CHAPTER XIII. 
THE RESULTS OF LITHOTRITY. 
Difficulty of estimating the Results of Lithotrity.—Small Phosphatic Concre- 
tions not to be regarded as ‘ Stone.’—Weight of Debris should always be 
recorded.—P>rodie’s Experience.—Reports by Civiale.—The Author’s Ex- 
perience, embracing 422 Cases.—Its Results analysed:—1, The Recover}’ 
Rate ; Causes of Death ; Tabular View of all the Fatal Cases in the Series 
2. General Condition of Patients afterwards.—3. The Return of the Malady. 
—Nature and Composition of the Calculi. 
During the forty or fifty years which have elapsed since Litho- 
trity first claimed to be recognised as a surgical operation, more 
or less applicable to a large number of cases of extreme import- 
ance, occasional attempts have been made to determine with 
precision the results derived from its employment. At first 
sight this object might be thought easily attainable, since it 
would seem necessary only to compare a sufficiently large 
number of cases, so treated, with a similar number of cases 
by the single pre-existing operation, that of Lithotomy. The 
capabilities of that method were -well known, or might be ob- 
tained without difficulty. The cutting operation had been 
applied under all circumstances, and to all cases, the young and 
old ; to stones of all sizes, small and large ; and the effect of it, 
in any case, could never be doubtful. 
With Lithotrity, however, it was soon found to be a much 
less easy matter to arrive at an accurate appreciation of the 
result. After a few years of trial, it was quite obvious that the 
crushing method was even more hazardous than cutting for 
large stones ; and for a few stones of particularly hard structure 
it was impracticable. For a great majority of the cases of in- 
fants and children, it was certainly less successful than Litho- 
tomy. It was applicable, then, only to a certain proportion 202 
RESULTS OF LITHOTRITY : BRODIE’S -CASES. 
of adult cases ; and did not include among them the most for- 
midable. On this ground alone, the comparison between its 
capabilities and those of the old method could not be easy. 
One thing was clear, namely, that as it was only applicable to 
what might be called, to some extent, selected cases, its results 
for these ought to be very successful, or Lithotomy ought not 
to be set aside for it. At the same time, it was not to be for- 
gotten, that although Lithotrity necessarily demands, as a con- 
dition of successful performance, a stone of not too large a size, 
it does not necessarily demand youth or strength of constitution, 
that it makes no insuperable difficulty of any age, nor a serious 
objection to whatever feebleness of body great age involves, 
provided only the first condition exists, viz. that the stone be 
small. 
An absolute comparison of results, therefore, is difficult. 
The value of Lithotrity cannot be estimated, unless the ages of 
the patients and the size of the stones dealt with are accurately 
known. For it is obvious that if the Lithotrity of one surgeon 
embraces only stones of three drachms in weight, while that of 
another surgeon deals with all that occur up to five or six 
drachms or more, the operation of the latter will in the aggre- 
gate be a more hazardous proceeding, and will be attended with 
more numerous and graver casualties, than the operation of the 
former. After much consideration of the question, I confess it 
appeared to me that, owing to these and other circumstances, 
an accurate and carefid appreciation of the results of Lithotrity 
has not hitherto been made. One, perhaps, in the early his- 
tory of the operation possessed the characters named, so far as 
it went, viz. a paper contributed by the late Sir B. Brodie to 
the Transactions of the Medical and Chirurgical Society, fifteen 
years ago: at which time it excited much interest. 
The distinguished author made no endeavour to establish 
a case either for or against Lithotrity. He recorded all the 
casualties, and made no attempt to lessen their importance, or 
in any manner to explain away their relation to the operation. 
And in regarding this record of Sir. B. Brodie’s experience as, 
perhaps, one of the best existing contributions to a real knowT- 
ledge of the value of Lithotrity, I do not overlook the fact that 
during the last fewT the late M. Civiale has published RESULTS: CTMALE'S CASES 
203 
annual reports of his practice, giving the number of patients, 
and in part the results of his operations. These reports, how- 
ever, never at any time contained the particulars which are 
essential in order to enable others to form a judgment, and 
which I have felt it a duty to furnish in the table of cases now 
given at the end of this work. It was impossible to know that 
clever operator without feeling that his natural bias for an 
operation he had mainly designed, was the first to perform, and 
with which he wTas so intimately identified during life, and even 
after death, led him, as is universally confessed, to estimate 
his results more favourably than an unbiassed looker-on could 
venture to do. In short, he barely admitted that Lithotrity 
could occasion death. It is useless to deny this fact, nor that 
it influences all his writings on this subject. He invariably 
attributed death, when it occurred in the course or after a case 
of Lithotrity, to some other cause; never to the operation. 
Such was, without doubt, his conscientious belief; and practi- 
cally for him, although he did not formally affirm it, Lithotrity 
wras never fatal.1 But the mode of reasoning he employed 
would render almost every operation in surgery innocent of 
fatal results. To Civiale I desire, on every ground, public and 
private, to render due homage. It is no small boon that his 
skill and indomitable perseverance have conferred on suffering 
humanity. But the mode of estimating the results of an 
operation which he adopted in relation to Lithotrity, is not one 
wThich is, or can be, accepted here. As long as it is an accepted 
formulary that death may be produced by a surgical operation, 
and that the liability to cause death is a quality wLich can be 
approximately estimated by observation, and the knowledge of 
which enables us to speak of an operation as more or less grave, 
according to the amount of such liability proved to exist, wre 
cannot make an exception of Lithotrity. Lithotrity does not 
less surely destroy life in certain cases, although no palpable 
lesion may be produced, than Lithotomy does, when the neces- 
sary wound proves fatal. The catastrophe is only much more 
obvious in the one case than in the other. 
With this conviction, I have therefore made it my object to 
1 La Lithotritic et la Taille. Par Civiale. Paris, 1870. Chap. X.: ‘ La 
Lithotritie, peut-elle occasionncr la mort ? ’ RESULTS : ANALYSIS OF CASES 
test, as carefully and impartially as it is in my power, the 
operation of crushing the stone as applied to all cases up to a 
certain weight, with regard to its after results, both immediate 
and remote. The main objects of inquiry being the number 
per cent, of recoveries after the operation, the proportion of 
cases in which the stone recurs, and the condition of the 
recovered patient in after life; the last being, from the nature 
of things, the least easy of inquiry. 
With this end in view I presented to the Royal Medical and 
Chirurgical Society, as already referred to (page 118), an analysis 
of 500 consecutive cases of operation on adult males performed 
by myself for calculus in the bladder, accompanied by the cal- 
culi removed: the Lithotomy cases being 78 in number ; and 
those of Lithotrity being 442. 
Of every case I possess full written notes, made at the time, 
as well as the stone itself (with very few exceptions indeed), 
carefully preserved and labelled for reference. I adhere to the 
system of verifying each one by naming some gentleman who 
has seen it with me,—a system unnecessary, I am quite ready 
to believe, for my contemporaries, but which will form a 
guarantee of accuracy to unknown or future observers and com- 
mentators. The cases themselves will be found in the Appen- 
dix at the end of the volume, each briefly reported; further 
details being afforded of all those which terminated fatally. 
In offering an analysis of these 422 consecutive cases of 
Lithotrity, I must first recall the fact that all occurred in adults, 
and for the most part of an advanced age. And here let me 
remind the reader, that in comparing statistics relative to 
the operations of Lithotomy and Lithotrity, all numerical tables 
are worthless which do not separate the cases of children from 
those of adults, so different are the results of operations, 
especially by the knife, which occur above and below puberty 
respectively. Next, let it be observed that several of these 
patients have been operated on twice ; some as many as three 
times ; and there are two very remarkable instances of four 
operations on the same individual. (Table, Nos. 62 and 74.) 
In all these cases of operation repeated on the same person, 
there has been a considerable lapse of time between each per- 
formance ; and full evidence of the existence of a fresh forma- OPERATED OX BY THE AUTHOR. 
205 
tion has been present, or the case would not have been so 
registered. 
The removal of some phosphatic concretions, from the 
bladders of elderly men who do not empty the organ naturally, 
has never been admitted by me into the category of operations 
for stone. They form a class by themselves to be referred to 
hereafter, in which the lithotrite is of the highest value in 
preventing the formation of large phosphatic calculi. But in 
constitutions which are strongly disposed to excrete a large 
amount of uric acid by the kidney, it not infrequently happens, 
when the first calculus has been removed, that after an interval 
of two or three years of freedom from all vesical symptoms, 
they again appear, and a second formation is detected, and 
Lithotrity is again resorted to. A third formation is not very 
common, nevertheless in exceptional instances the process may 
be even again repeated. Thus, in the one case referred to, the 
patient formed three large uric acid calculi consecutively, with 
several years of good health between each, and finally a large 
phosphatic one, and each of these was successfully removed by 
Lithotrity. This is a history nearly unique in my experience, 
and those four large calculi may be seen in a group, all belong- 
ing to Case No. 62 in this series. They occurred in a gentleman 
who passed all his time in London, where he was well known, 
and who died at an advanced age some time after the last 
operation. Now, in the paper by Sir B. Brodie, already referred 
to, 115 cases were recorded. But Sir B. Brodie frankly states 
that eight of them occurred in the person of one individual in 
the course of as many years (!), and that other cases of a simi- 
lar kind were included (vol. xxxviii. p. 185). So that the 115 
cases probably represented considerably less than a hundred in- 
dividuals. Such numerous repetitions of the proceeding however 
cannot now be regarded as distinct 4 operations for the stone.’ 
Each doubtless, in the case referred to, was a small phosphatic 
formation. In this manner I might have greatly augmented 
the number of my cases had I reckoned as such the removal 
by the lithotrite of a small phosphatic concretion, such as fre- 
quently occurs in the bladder of an elderly man with old-stand- 
ing hypertrophy of the prostate, necessitating, as it often does, 
withdrawal of all the urine by catheter. In this condition many 206 
RESULTS OF LITHOTRITY; ANALYSIS 
persons live, in tolerable comfort, for twenty years or more. 
But it is by no means rare, in some of these cases, to find the 
symptoms aggravated by the presence of a small phosphatic 
concretion, weighing perhaps from ten to twenty grains, too 
large to wash out, but which a single introduction of the 
lithotrite suffices to remove. This proceeding may be repeated 
sometimes once or twice in a year ; and thus, for a single indi- 
vidual, the surgeon may have to repeat the process six, eight, 
or even ten times. These concretions I have never allowed to 
rank as ( stones,’ and have not admitted them into my series, 
otherwise I might have reckoned at least a hundred more ‘ cases.’ 
I hope, in future, to give the precise weight, in grains, of all 
the debris obtained in each case, a plan which the increased 
use of the aspirator renders more easy of accomplishment. 
Illustrations of such conditions may be seen at Nos. Ill, 207, 
211, 276, 359, 381, 409, 410, and others in the list at the end 
of the volume. 
Lastly, it must be remembered that the expectation of life, 
and the general quality, as regards health, of these patients is 
a little below the average; since it includes so many of those 
old and confirmed cases which seek the aid of a well-known 
operator, as a forlorn hope, and are attracted for this purpose 
from every part of the world. Most of these patients are from 
different parts of Great Britain; but the table includes also 
patients from France, Germany, Portugal, Turkey, Russia, 
Sweden, Norway, Canada, Belgium, the United States, Cali- 
fornia, the East Indies, and New Zealand. 
In commencing this analysis it is necessary to bear in mind 
certain important facts relative to age. They may be briefly 
stated as follows:—The mean age of the 422 cases is rather 
more than 61 years. 
The youngest patient was 21 years old; the eldest was 84 
years. There wTere about 100 cases of 70 years of age and up- 
wards ; and more than 250 cases of 60 years and upwards. Next, 
with regard to that important point, the size and weight of the 
stone, I may say that I have, as a rule, to which but few excep- 
tions have occurred, applied Lithotrity to every case of ston 
under my care which has been obviously beneath an ounce in 
weight. At one ounce and upwards I have preferred Lithotomy. OF CASES OPERATED ON BY THE AUTHOR. 
207 
I may add, for the sake of giving a criterion as to size, that a 
uric acid stone which weighs an ounce equals in size a large 
date. I know no better comparison. 
In examining the results of the operation in these cases, I 
shall inquire, first—What is the rate per cent, of recovery after 
the.operation ? Secondly, What is the general condition of the 
patient after it ? And, thirdly, In how many instances is there 
a return of the malady ? 
In considering the first subject, viz. the number of reco- 
veries per cent. wThich took place, I must request attention to 
the following statements, which are extremely important in 
relation to the question:— 
Istly. That I have only twice in my life found it necessary 
or desirable to complete by the knife a case of stone in which 
I have commenced the operation by crushing. This was not 
unfrequently done by Civiale when the patient’s life has been 
in danger; and in such circumstances, if death has occurred, it 
has not been placed to the account of Lithotrity. 
2ndly. That I have not left incomplete or unfinished a single 
case of stone on wThich the operation of crushing has once been 
commenced: a plan which has been pursued elsewhere, when 
great difficulty or danger has arisen. The result of sending a 
patient into the country 1 in these circumstances can very rarely 
be otherwise than hazardous, or fatal. But when death has so 
taken place, it appears likewise not to have been placed to the 
account of Lithotrity. It appears to us in this country unusual 
to send away uncompleted cases; and it is very rare indeed 
here to refuse any operative aid to any calculous patients who 
apply for relief. 
3rdly. I have not refused, or at most in three or four instances, 
to operate in any case of stone by one means or the other ; and 
I have sometimes consented, rather than refuse the patient all 
chance of life, to perform Lithotrity, when he has absolutely 
refused my advice, that Lithotomy would be for him the better 
operation. I am certain that two or three of the fatal cases in 
my table occurred in individuals for whom, had I not been 
fettered by circumstances, Lithotomy would have been the pre- 
ferable proceeding. Certainly, as a rule, the surgeon must 
1 See Civiale, Reports on lithotrity. Paris. CAUSES OF DEATH IN THE AUTHOR’S CASES, 
decline to perform any operation but that which appears t< 
him the better of two courses open ; but in rare exceptions h< 
cannot refuse to be influenced by circumstances, and adopt tin 
less promising, when by its means some hope of saving life 
exists. 
I may now say that the deaths which occurred from ah 
causes, during or after the conclusion of treatment, among the 
422 cases of patients averaging 61 years of age, were 32 in 
number, although one or two of them ought, I think, not to be 
so reckoned; but I wish to err on the wrong side, and am 
content to accept 32. This constitutes a rate of recovery ol 
921 per cent., or a mortality of per cent. My first 84 cases 
included 4 deaths, or a rate of 95 per cent, of recovery. The 
subsequent cases were a little less promising, on the grounds 
named above, and I consider the result therefore to be even 
better than the preceding. For only two or three bad cases tell 
heavily against a small percentage rate of mortality in the total. 
I have taken great pains to ascertain, and to record as accu- 
rately as possible, the cause of death in each case. The follow- 
ing table presents the result, as well as the age, of each one of 
the 32 fatal cases; together with remarks relating thereto. 
It will be seen that acute nephritis, pyelitis, and cystitis 
are frequent causes of death: the most common being the 
first-named. Now, a certain amount of cystitis is common 
enough, in some degree, but usually slight and evanescent in 
character: it is usually met with at some time or another in 
most cases of Lithotrity, where several sittings are necessary. 
In some individuals, however, invasion of the kidney follows it, 
and is announced by a severe rigor, succeeded by other rigors 
at intervals of a few hours. Several severe rigors occurring 
consecutively, as, say, one or two daily during three or four 
days, should arouse anxiety on this head. It is rare indeed, 
with these signs, that some affection of the kidney is absent. 
Fever continues, and slowly increasing exhaustion, and if 
recovery does not take place, the patient sinks in from seven to 
twenty-one days; suppression of urine occasionally, but not 
generally, taking place. The autopsy reveals marked traces of 
inflammatory action in one or both kidneys and ureters, and, 
mostly, deposits of pus are formed in the renal structure, and CAUSES OF DEATH AMONG AUTHOR’S CASES. 
209 
Table of Deaths following Lithoteity. 
No. in 
Series 
Age 
Remarks 
Cause 
3 
68 
Unfit for operation 
Calculous disease of kidneys 
and dilated ureters. 
11 
69 
... 
Diseased kidneys and dilated 
ureters. 
13 
81 
Unfit for operation; if any, he 
should have been cut 
Haemorrhage, 
16 
69 
... 
Fever, mania, delirium tre- 
mens (?). 
23 
77 
Unfit for operation ; treated at a 
distance in the country 
Acute cystitis and fever. 
72 
64 
Disease of heart .... 
Exhaustion. 
85 
69 
Unfit for operation, but demand- 
ing relief 
Ditto. 
95 
73 
Ought to have been cut, but he 
refused 
Acute cystitis and fever. 
109 
80 
Fever and exhaustion. 
118 
59 
... 
Pyaemia and local abscesses. 
142 
68 
Ought to have been cut, but he 
refused 
Acute cystitis and fever. 
162 
70 
... 
Nephritis and suppression of 
urine. 
164 
72 
Stone large ; might have been cut 
Chronic Bright’s disease. 
167 
65 
Ditto ..... 
Acute nephritis. 
187 
62 
... 
Acute cystitis and fever. 
199 
55 
... 
Chronic Bright’s disease and 
pyelitis. 
202 
62 
... 
Pyaemia, joint affections. 
234 
74 
The pyaemia occurred after he left 
town, six weeks after operation 
Phlebitis of leg after operation, 
and subsequent pyaemia 
245 
32 
Unfit for operation, which was 
done to relieve suffering 
Chronic Bright’s disease. 
256 
64 
Pyelitis and exhaustion 
269 
52 
... 
Pyelitis and fever. 
272 
66 
Probably might have been cut . 
. 
Diseased kidneys and dilated 
ureters. 
277 
77 
Pyaemia. 
294 
75 
Very feeble and unfit for any ope- 
ration 
Fever and exhaustion. 
306 
57 
Large stone, very feeble 
Exhaustion. 
311 
65 
... 
Diseased kidneys and dilated 
ureters. 
327 
66 
Ditto. 
371 
81 
Fever and exhaustion. 
374 
61 
Diseased kidneys and dilated 
ureters 
388 
70 
Pyaemia. 
424 
58 
... 
Nephritis and exhaustion. 
434 
75 
Fever and exhaustion. 
N.B. Particulars of each case will be found in the Appendix. RENAL DISEASE AND CYSTITIS CAUSING DEATH. 
in the course of the ureter. I am satisfied that in some or all 
of these cases, chronic pyelitis, if not chronic nephritis, also, 
has pre-existed, occasioned by the calculous affection before 
any operative interference took place. It must be admitted 
that, at present, we have not an unfailing means of ascer- 
taining the existence of these conditions. There may be no 
albumen in the urine, and not necessarily are there any deposits 
in the urine, significant of the renal affection. The urine of a 
calculous patient frequently contains mucus, pus, and blood ; 
but whether the origin of these is in the bladder (naturally its 
most common source from the irritation of the calculus), or in 
the organs above, it is impossible always to determine, and 
usually there are no casts or other pathognomonic signs of 
disorganising renal structure. In fact, neither physical signs, 
nor subjective symptoms, are by any means frequently present, 
yet advanced pyelitis, and even sometimes chronic nephritis, 
may exist. This subject, and its bearing on the question of 
the choice of operation for stone in the bladder, I have dis- 
cussed at considerable length in another work.1 
Another cause of death is acute cystitis, apart from any 
serious renal affection. In such cases the bladder may or may 
not be sacculated to some extent—most frequently the latter 
state exists. When these pouches, not by any means ne- 
cessarily large, have been formed in the bladder, any instru- 
mental interference, which is continued or repeated (such as 
daily catheterism for the purpose of relieving an atonied 
bladder), is liable not unfrequently to induce slowly cystitis or 
pyelitis, which ultimately proves fatal. Two or three examples 
of death by this way occur in the table just given. 
Lastly, it is worthy of remark that no less than five cases of 
pyaemia occurred: while in the twenty-nine deaths among my 
Lithotomy cases (see page 73) only one occurred. The con- 
nection between pyaemia and the operation of crushing is, I 
believe, to be accounted for thus. Cystitis is mostly produced 
by the presence of sharp fragments in the bladder, which, if 
permitted to remain, may give rise to inflamed vesical veins ; 
1 Clinical Lectures on Diseases of the Urinary Organs, 5th edit. London: 
Churchill, 1879. Lecture XVI. CONDITIONS IN WHICH DEATH IS ALMOST INEVITABLE 
the products of inflammation are readily carried into the cir- 
culation, and thus may give rise to purulent deposits. 
In the paper of Brodie, before alluded to, the causes of 
death were placed under the two following heads; and I quote 
his words as most suitable to the purpose here:— 
4 First. Cases in which there was a fatal result, arising 
solely from the operation itself. 
4 Secondly. Cases in which a similar result was to be 
attributed to the co-existence of some other disease, brought 
into an active state by the shock of the operation, but which 
disease would in itself have been sooner or later the cause of 
death, even if the operation had not been performed.’1 
Now, although it is not possible to draw a hard and fast 
line by the indications here given, still they furnish a useful 
and fair classification, by which it will not be difficult to 
arrange the cases of death before us. I take it for granted, 
that the existence of advanced organic disease of the bladder 
and of the kidney must be held to place any case exhibiting it 
in the second category, or that in which death must have 
occurred sooner or later, even if the operation had not been 
performed. Having made numerous anatomical examinations 
after deaths occurring through disease of the urinary organs, 
after surgical operations upon them of various kinds, I may say 
that the organic changes alluded to are distinctly definable, 
and they are as follows:— 
1. Marked sacculation of the bladder. 
2. Chronic pyelitis with distended ureter. 
3. Marked organic changes of a chronic character in the 
kidney structure. 
Could the existence of these conditions be accurately dia- 
gnosed beforehand, it might become a question whether the 
crushing operation, or any operation at all, should be per- 
formed. For there is little doubt that the existence of such 
organic changes is almost as surely a source of fatal issue in 
Lithotomy as in Lithotrity. Now, in the thirty-two cases before 
us, one or other of these conditions certainly existed in nine 
or ten cases; and had it been possible to be aware of them, the 
operation would not have been performed, and the patient might 
1 Medico- (Jhirwgical Transactions, vol. xxxviii. p. 186. 
p 2 CONDITION OF PATIENTS AFTER LITHOTRITY. 
have lived a little longer, with much suffering, it is true; and 
he ultimately must have died at no distant period. 
Eliminating these, we have but twenty-three cases in 422, 
in which the death might be attributed to the surgical opera- 
tion, or little more than 5 per cent. 
The general and local condition of patients after Lithotrity 
is a subject which has not been studied, perhaps, so much as it 
deserves. Very little space can be accorded to it here, but 
there are nevertheless matters of much interest attaching to 
the after-history of an individual who has formed a stone, and 
has submitted to an operation issuing in its successful removal. 
A very large number of patients recorded in my list are living 
still, free from any sign of the old complaint, and enjoying fair 
health, age considered. On frequently seeing instances of the 
excellent health and condition of a large proportion of these 
elderly men on whom I have some years ago performed Litho- 
trity, I am forcibly reminded of the well-known axiom which 
Deschamps chose as the motto of his classical work on Stone 
(‘ causa sublata effectus tollitur ’); happily true of so many. 
With a few it is otherwise, and more so in middle life, I think, 
even than in advanced age. In exceptional instances chronic 
inflammation still affects the bladder, or it may be the organs 
above, and impaired health and local troubles of some kind still 
persist. The operation can but remove the stone, and those 
troubles which were due solely to its existence. Symptoms 
due to other causes, associated or not, as the case may be, with 
calculous formation, will not disappear with the removal of the 
foreign body. It would be interesting to know to what extent 
a kidney, in which a calculus has once been formed, is damaged 
in the process. Necessarily, not much perhaps, or at all; but 
sometimes, no doubt, it is irretrievably deteriorated, and is a 
cause of future ill-health. Then the irritation produced by the 
operation itself is doubtless answerable in a few cases for the 
production of after troubles : but I am bound to say such irrita- 
tion ought to be inconsiderable. It was formerly not so, with 
the clumsy apparatus, the enormous lithotrites, and rough 
handling, once employed in Lithotrity, and now for the most 
part swept away from practice. Neither was it so when large 
and angular fragments were dragged through the neck of the RECURRENCE OF CALCULUS : TWO MODES OF. 
bladder, and along the urethra—a practice which has often 
proved damaging to patients, and consequently to the credit of 
the operation, of which in reality it forms no part. In order to 
ensure, first, recovery, and subsequently a complete and lasting 
cure, it is impossible to avoid too sedulously such mechanical 
interference. I believe, if the principle of crushing and remov- 
ing all the calculus at one operation, when practicable without 
excess of manipulation, and always performed with delicacy and 
care, be adopted, the best guarantee is obtained against the 
existence of chronic cystitis afterwards. 
Thirdly. Recurrence of calculus. 
Among the 500 cases, there are fifty-six in which the 
calculus has reappeared, and in which the operation has been 
again performed. Let it be repeated here, that the mere 
removal of a few phosphatic debris, subsequently occurring, has 
not been reckoned as an operation, but only the reformation 
of a fresh calculus after a year or more of absence on the part 
of the patient. 
Now, there are two ways by which calculous matter reap- 
pears after an operation of Lithotrity. First, there may be a 
fresh descent from the kidney into the bladder; either of a 
uric-acid or an oxalate-of-lime calculus, and but very rarely of a 
phosphatic formation : any one of these having found its way 
into the bladder, if not expelled naturally, or removed by 
artificial means, will form in time a larger stone. This occur- 
rence may follow equally either the cutting or the crushing 
operation, and does take place in a certain proportion of all 
cases. The descent of a freshly formed uric acid calculus was 
noted in exactly twenty of the 500 cases; the intervals between 
the first and second stone varying from one year to eight. 
Secondly. Another, and a wholly different mode of calculous 
formation has to be described. And this is more common than 
the other. To a certain extent, but not altogether, it is to be 
accepted as an opprobrium to Lithotrity. Happily, the fre- 
quency of its recurrence is to be diminished by perfecting the 
crushing operation in all its details. At the same time, it is 
by no means unknown after Lithotomy, although it is rare 
after that operation. It occurred in from thirty to forty cases 
of the 500. In those conditions of the bladder wholly uncon- PHOSPHATIC DEPOSITS AFTER LITHOTRITY. 
nected with the presence of stone, in which the organ is not 
emptied by the natural efforts, so common among elderly men, 
chronic cystitis may arise and become the point of departure 
for the production of phosphatic deposits. If prolonged chronic 
inflammation of the bladder is produced or perpetuated by 
mechanical disturbance, due in part to the pre-existence of the 
stone itself in the organ, in part to the employment of instru- 
ments, and in part to the presence of sharp irritating fragments 
produced in the operation, a large quantity of triple phosphate is 
often rapidly formed within the bladder, and becomes a more 
or less persisting deposit. If neglected, fresh calculus is very 
likely to result. No doubt, in most cases, by much care, by 
emptying the bladder daily, injecting it, &c., this reproduction 
may be prevented. In some constitutions, the tendency to 
produce phosphatic deposit thus is much more marked than in 
others, and the formation in question by no means corresponds 
precisely with the degree of inflammation which has been 
present. A small degree will give rise to it in some indi- 
viduals ; a very large degree will fail to do so in others. Still 
it is quite clear that the more perfect is the operation of Litho- 
trity—that is, the smaller the amount of irritation produced by 
the mechanical means employed—the smaller is the risk of its 
occurrence. Hence it is unquestionably a sequence of Litho- 
trity which is diminishing, and will diminish, in the same ratio 
that the operation itself becomes more perfect. It is an addi- 
tional reason, if one were wanting, for avoiding, by every means 
possible, all sources of injury to the bladder and urethra, on the 
principles already enunciated. 
In some cases the tendency to form these phosphatic 
deposits is subdued by treatment, or wears itself out in time: 
I have had several patients in whom it has disappeared. In 
all cases the morbid product can be always easily removed, 
and the patient relieved, by the lithotrite and the aspirator. 
One cause of persisting phosphatic formation, although a rare 
one, is beyond doubt encysted calculus. This I have been able 
to verify. A sac of the bladder, perhaps usually a small one, 
contains a calculus, the narrow neck of the sac not permitting 
the possibility of escape to the foreign body. A small surface 
of the calculus is thus exposed in the bladder; on this surface WITH STONE SMALL, LITHOTRITY ALMOST ALWAYS SUCCESSFUL. 
phosphatic salts are encrusted, and as the deposit goes on, a 
more or less spheroidal body is produced, the attachment of 
which to the encysted calculus is by a narrow and brittle neck. 
Ultimately this snaps, and a phosphatic calculus is set free in 
the bladder. This is removed, the symptoms disappear or are 
much relieved, and the process again commences as before, and 
is reproduced again and again. I may repeat that I have 
several times observed this condition—in the dead body not 
infrequently, in the living three or four times. One of these 
latter cases was identified by examination with my friend, Mr. 
Cadge, of Norwich, when in consultation on a long and trouble- 
some case of this kind. I have exhibited and recorded several 
post-mortem examples of this condition at the Pathological 
Society, and elsewhere. 
I now come to the important practical conclusion which, I 
beg to submit, is logically derivable from the data before us. 
It is not offered here as my opinion, or as the opinion of any 
other person experienced on this subject. It is a conclusion 
which the facts recorded inevitably indicate. I have long ago 
had to contend that Lithotrity, properly performed, is an 
eminently successful operation; the proof that it is so is now 
patent to all. For a certain and by no means limited number 
of cases, its success may be regarded as a certainty; absolutely 
without fear of any contingency, except such as attends the 
minor operations of surgery ; for example, the opening of a 
small abscess or the passing of a catheter. For I have lost but 
one patient in the whole course of my experience after crush- 
ing a stone which ivas no larger than a small nut: a case 
which has occurred since the series of 500 reported in the 
Appendix, and therefore not appearing there. And this is a 
size at which, with very, very few exceptions indeed, every 
stone ought to be discovered. But this very fact leads me to 
remark, that the success of Lithotrity cannot therefore be con- 
sidered, apart from a knowledge of the extent, in regard of the 
magnitude of the stone and the constitution of the patient, 
to which the capabilities of the operation have been pushed. 
When it is employed for stones as large as a date or a small 
chestnut—and it is impossible to deny the excellent chance of 
success which this method offers to the subjects of such stones 216 
NATURE OF STONE IN AUTHOR’S CASES. 
—a certain, but still only small, proportion of deaths must be 
expected. And the rate of mortality will correspond with 
augmentation in the size of the stone, and with the amount of 
existing disease, and age, on the part of the patient. Given a 
small stone, in a fairly healthy person, and success is certain ; 
the possibility of contingency in such a case depending only on 
the presence of those remote and excessively rare conditions 
which will make, for an individual here and there, the mere 
passing of a catheter a cause of death. 
As to the extent to which I have pushed the capabilities of 
the operation here, the preservation of the debris, all of which 
have been exhibited at the Medical and Chirurgical Society, 
enabled the observer to judge. Many of them were as large as 
a chestnut, and some were much larger. Further, it has been 
already stated in the seventh chapter, ‘ On the Results of 
Lithotomy,’ that while the proportion of patients submitted to 
Lithotomy and to Lithotrity respectively has been among some 
operators about equal—although the proportion crushed now, I 
believe, by most surgeons, is mostly larger than that submitted 
to the knife—I have ventured to regard Lithotrity as the rule, 
applying it to five out of every six adult cases, and to employ 
Lithotomy only as the exception. 
It may be as well to put on record here the composition of 
the calculi. Of the 500— 
313 were uric acid and the urates, in the ordinary sense of the 
term. In all calculi there is usually found a slight admix- 
ture of other varieties. 
99 were phosphatic of the ordinary kinds. 
50 were mixed ; urates and phosphates. 
9 were mixed; urates and oxalates. 
16 were oxalate of lime. 
6 were mixed; oxalates and phosphates. 
1 was cystic oxide. 
1 was pure phosphate of lime, 
1 was phosphate and carbonate of lime, probably formed on 
large nuclei from the prostate. 
4 were phosphatic, deposited on foreign bodies introduced into 
the bladder; these being, in two cases, a portion of ex- 
foliated bone ; in one a piece of sealing-wax, and in one a 
piece of bougie. CHAPTER XIV. 
ON THE CHOICE OF PROCEEDINGS BEST ADAPTED TO 
DIFFERENT CASES. 
Importance of accurate Diagnosis.—Without it Choice of Operation impossible. 
—Hounding.—Classification of Stones.—Questions to be determined re- 
specting the Stone.—1. The Age of the Patient—Results of Investigation ; 
Ratios of Death at Different Ages in 1,827 Cases of the Lateral Operation, 
Metropolitan and Provincial; how affected by Age ; Prevalence at Different 
Ages.—2. Absence or Presence of Local Disease, their bearing on the ques- 
tion of Operation.—8. Susceptibility to Constitutional Disturbance.—Final 
Deductions as to Choice of Operation for Different Patients.—When not 
to Operate.—Immense Importance of detecting the Stone at an early period. 
In approaching that final appreciation of the various methods 
which have been described, we cannot but be struck with the 
single broad feature which marks our subject at the present 
day, and distinguishes it from the subject as it has been dealt 
with in times which are past. 
An appreciation of methods was impossible when only one 
method existed; or at most, but one other for very exceptional 
cases. Given the simple fact of stone in the bladder, it wras 
but a very few years ago removed, as a matter of* course, by 
incision after the lateral method; only here and there the 
high operation was resorted to. Nevertheless, the body to be 
removed might be so small as to be almost inappreciable ; it 
was sometimes carried out by the first gush of urine when the 
bladder w*as opened, and was never discovered. It might be 
smaller in size than an apple-pip, or as large as a turkey’s egg, 
still one and the same set of incisions was practised ; these 
being lengthened, perhaps, in some cases, if the existence of a 
very large stone was suspected. But as new methods of operat- 
ing were designed, and especially when the possibility of remov- 
ing a calculus by crushing had been demonstrated, a new ground of inquiry became necessary to success, one which had been 
almost overlooked because barely required before. It followed 
instantly from the new phase into which practice had entered, 
that a diagnosis of the size, form, and chemical characters of 
the stone was absolutely necessary. With various modes of 
Lithotomy to select from, adapted to various conditions of the 
patient and of the stone itself; with Lithotrity and its varied 
resources besides, it becomes at once a matter of the highest 
importance, if any advantage is to accrue from the discovery of 
the latter, that the case and the method should be judiciously 
adapted to each other. Otherwise it might happen—and I do 
not hesitate to say that it did happen, in the earlier experiences 
of Lithotrity, especially when it was first attempted by others 
than the originators of the art—that the new method, although 
a great advance in surgery, at this time actually increased the 
fatality from stone operations, and was a positive calamity for 
many stone patients at that era. I have abundant evidence of 
the increased mortality which was occasioned by it during the 
period in which its application was mainly experimental. This 
apparent paradox is easily explained ; the cause was, partly, 
that experience was at first necessarily wanting, by which to 
form rules for the operator’s guidance; and partly, that the 
importance of diagnosing the characters of the stone had not 
been perceived. Hence patients who were well adapted for 
Lithotomy, and who would have been saved by it had Lithotrity 
not come into vogue, were submitted to the crushing operation, 
which was unfitted to their cases and terminated them fatally. 
Hence, alSo, much undeserved obloquy fell on Lithotrity. 
Such obvious illustrations of want of adaptation in the method 
to the case were then numerous, a sad but necessary result 
of the failure to form a correct diagnosis as to the nature 
of the body to be removed from the bladder, and of the varied 
capabilities and adaptation of each of the principal means for 
effecting its removal. And I will venture to say with deliberate 
conviction, that the importance of such a diagnosis is not suffi- 
ciently perceived at the present day, and consequently only a 
portion of the advantages placed within our reach by modern 
methods have yet been attained. The increased resources of 
surgery render this a most important branch of inquiry; one, 
THE VALUE AND IMPORTANCE OF ACCURATE indeed, to which it is absolutely necessary for the practical 
surgeon to devote himself. Otherwise these resources will 
become the occasion of misfortune rather than of benefit, and 
will diminish rather than augment the success of his practice. 
It must therefore appear that an appreciation of the abso- 
lute and comparative values of the varied operations which are 
offered for our selection is not possible, unless it first be granted 
that we are able to diagnose the physical and chemical characters 
of the stone, before any attempt is made to remove it from the 
bladder. Unless, then, this can be done—unless, indeed, it is 
done with tolerable accuracy—it will be better to return to the 
use of a single method, say the lateral operation, than to risk 
the application by guess of a method inapplicable to the case. 
Thus, to take an extreme, but quite possible, case for illustra- 
tion, let us suppose two adults, one of whom has a small, friable 
stone, the other a large compact one; that, being deceived as 
to the relative proportions of the stone from want of care in 
diagnosis, I decide to cut the patient with small stone and to 
crush the large stone; I run a certain risk of losing both, and 
do so; whereas, had the terms of my decision been reversed, 
the chances are that both were saved. But had the lateral 
operation been employed in both, the chances are equally great 
that I should at all events have saved one. 
I repeat, then, that it is probably safer, uniformly to 
practise Lithotomy in every instance, if the surgeon does not 
arrive at an accurate diagnosis of the nature of the stone, and 
select an operation in accordance with it. 
There are two principal facts which it is necessary to ascer- 
tain respecting any stone which it is proposed to remove from 
the bladder: its size and its texture. In a degree subordinate 
to the latter character, it is desirable to know its chemical 
characters. It is in a less degree important, also, to ascertain 
the patient’s susceptibility in relation to instrumental inter- 
ference, a matter which has already been alluded to. 
In sounding a patient for the purposes of diagnosis, we 
should place him usually in the ordinary position for Lithotrity, 
as already described (p. 140); if we do not succeed in that posi- 
tion, or if his prostate is enlarged, he should be placed with 
the pelvis higher still. Furthermore, it is absolutely neces- 
DIAGNOSIS IN ALL CASES BEFORE OPERATING. ACCURATE DIAGNOSIS BY MEANS OF 
sary that the sound should have a form altogether different 
from that of a common catheter. Its curved part, or beak, 
should be little more than an inch long, and have more of a 
tendency to form an angle with the shaft than exists in the 
catheter. It can then be easily inclined to right or left, or 
rotated completely if need be. Various forms are employed for 
the purpose ; that shown at Fig. 86, and represented in the 
Fir. 86. 
Sound, with small curve, for exploring the bladder. An opening is seen in the convexity of 
the curve for increasing or diminishing the fluid in the cavity. The beak is solid. 
reversed position within the bladder, is an excellent model, and, 
being less angular than some, passes with ease: it is hollow 
also, enabling the operator to inject water into the bladder, 
or to withdraw some, without change of instruments for the 
purpose. Thirdly, we may use a sound which enables us to 
measure the stone with precision. It may have a blade which 
opens so as to seize it, and an index in the handle, like that in 
a lithotrite, which indicates the diameter when seized. But a 
light lithotrite, with the cylindrical handle (see fig. 60, p. 137), is 
the best instrument to measure with; the sound with a sliding 
blade is superseded by it. But it is a material advantage to 
employ the cylindrical handle also for the ordinary sound, since 
the instrument may be turned on its axis, right or left, or be 
reversed, with greater ease and delicacy than the sound with a 
flat handle as usually made; only it is necessary that a mark 
should be placed on the handle to indicate the direction of the 
beak (fig. 87). 
The act of sounding should be performed precisely in the THE SOUND OR LITHOTR1TE. 
221 
manner in which the search for the stone or for fragments by 
the lithotrite is conducted, and which has been already fully 
described. A large stone, it may be recollected, 
is generally encountered immediately on en- 
tering the bladder, near to its neck. A small 
one is often found in the same situation—not 
always, being sometimes at the back of the 
trigone ; and all often lie either right or left of 
the median line. If not at once encountered, 
it is necessary to explore consecutively and 
carefully the upper and lower parts, and the 
sides of the bladder; also occasionally with 
much, but always with a small quantity of fluid 
in it; and finally in the upright, as well as in 
the horizontal position, although this latter 
position is very rarely necessary. When, not- 
withstanding all, the stone still remains un- 
detected, as when it lies behind an enlarged 
prostate, for example, and in some other cir- 
cumstances, something may be gained by pla- 
cing the forefinger in the rectum, where the 
stone may be felt distinctly, or lifted up so as 
to place it between the finger and the sound, 
or between the jaws of the lithotrite. 
The stone being found, the characters are 
next to be determined. These may be classi- 
fied as follows for facility of reference :— 
I. Size.—With regard to size, stones may 
be classified as Small, 
Medium, and 
Large. 
II. Texture. — With regard to texture, 
stones may be classified as Soft, and 
Hard. 
And hard stones may be either -T triable, or 
I Compact. 
Every possible variety in size necessarily exists 
between the two extremes of small and large, 
and some latitude in the use of these terms, 
Fig. 87. 
Hollow Sound, 
with cylindrical han- 
dle, for exploring the 
bladder. as well as in that of medium, must be afforded. Hence, 
they convey only an approximative estimate in any case : a 
stone, however, measuring an inch in diameter, which may 
be held to include the mean of two diameters, the longest 
and the shortest, may be regarded as a type of the medium 
size. 
MODES OF FRACTURE IN DIFFERENT STONES. 
With regard to texture, the variations are more marked: 
each chemical constitution indicating distinctly certain physical 
characters. 
Soft Stones are phosphatic, with chiefly earthy bases. The 
urine is alkaline, and is charged with earthy phosphates. Pus 
and mucus are also commonly present. 
Hard Stones are oxalate of lime, uric acid, urate of soda, 
and mixed, i.e. alternating layers of uric acid, or urate with 
phosphatic deposit. The urine is mostly acid, contains crystals 
of uric acid, the amorphous deposit, of urate of soda, or the 
octohedra of oxalate of lime ; and if any of these are found as a 
persistent deposit in any given case, it helps to establish the 
nature of the calculus. 
But while all of these are c hard,’ some are friable, while 
others are not so, but exceedingly compact in their structure. 
This is a distinction of great practical import in Lithotrity. 
Hard, but friable, stones break without the exercise of great 
power ; and they crumble into small granular masses instead of 
fracturing into sharp angular portions, as stones of compact 
structure are prone to do. 
Each kind of calculus has its own mode of breaking. Thus 
oxalate of lime, which is very compact, requires great power to 
fracture it, and it mostly forms irregular jagged masses. 
A uric calculus, when nearly pure, has an exceedingly 
compact texture ; it requires considerable power, and fractures 
into wedge-like splinters, which are very hard and sharp. 
Urate of soda is looser in texture, friable, and granulates 
easily under smaller degrees of power than are required for 
either of the preceding calculi. The mixed calculus also breaks 
easily, because its several layers have unequal powers of resis- 
tance ; the phosphatic constituent granulates, and the thin 
alternating layers of uric acid, or the urates, fracture into flat 
and shell-like pieces. These general indications are practically QUESTIONS TO BE SOLVED BY DIAGNOSIS. 
sufficient without descending to minor distinctions or rare 
varieties of calculus. 
Cystine—but this is of very rare occurrence—is hard, and 
rather friable; it breaks up into small granular masses and 
passes easily. I crushed a large one twelve years ago in the 
person of a gentleman, aged eighty years ; and he is still living 
and well. (See case Appendix, No. 127). 
Still more rare is pure phosphate of lime. It is very hard, 
and breaks into angular or rhomboidal masses. 
We can and ought, then, in every case, before selecting the 
operation for its removal, to determine— 
1. Whether a calculus is large, medium, or small, which can 
be done by measuring it by means of the lithotrite. Attention 
to the previous duration of symptoms will, of itself, afford some 
clue to the size, and especially if we are acquainted, from obser- 
vation of the urine, with the chemical character, of the stone. 
A pure uric acid calculus is slowly formed ; so is oxalate of lime. 
Urate of soda concretes in a shorter space of time, the mixed 
form more quickly still; and the phosphatic are produced with 
greater rapidity than any. 
2. Whether the calculus be hard or soft is determined by 
the click, or ring, obtained on striking it with the instrument 
in the bladder: clear and sonorous in the case of hard stones, 
and dull in that of soft ones. 
3. Whether it is friable or compact in texture may be 
generally determined by ascertaining what is the persistent 
deposit in the urine during some days or weeks, if not pre- 
viously known; from which one may almost certainly judge of 
the chemical nature, and hence of the physical structure, of 
the existing calculus, remembering, however, that phosphates 
are frequently present from irritation produced by acid calculi. 
But in very many cases small calculi have been passed before, 
and their composition is known; and that which is in the 
bladder now will mostly be identical in kind. 
4. It is necessary to ascertain whether there is one calculus 
only, or more than one, in the bladder—sometimes a matter of 
importance. It is exceedingly difficult, if not impossible, to 
determine this accurately with the simple sound, the signs 
afforded to it by multiple calculi being very deceptive. With the Lithotrite it is easily determined. One calculus being 
seized, it is held between the blades, and the se'arch is con- 
tinued for a few moments with the stone in that position. If 
another is present, it is almost instantly struck either by the 
instrument or by the stone already secured within its grasp. 
In this manner I have often verified the presence of a calculus 
on each side of the instrument as it lies in the bladder, 
showing the existence of at least three stones. It is necessary 
that the calculus between the jaws of the lithotrite be firmly 
grasped and does not rattle between them, or this will produce 
a sound exactly like that of striking another calculus. I have 
known the presence of multiple stone asserted by error arising 
from this circumstance. 
Having thus determined these particulars respecting the 
stone or stones, we are in possession of the first series of data 
which enable us to decide on the operation to be recommended. 
The remaining series of data necessary, consists in the con- 
dition of the patient, local and general, and may be obtained 
under the following heads:— 
1. Age. 
2. Absence or presence of local disease. 
3 His susceptibility to constitutional disturbance as a result 
of local irritation. 
1. The age of the patient;— 
This is an important element in dealing with this subject. 
So much so that the early age of the patient, a few cases only 
excepted, may be held generally to decide the nature of the 
operation at once. By an early age I mean infancy and boy- 
hood ; or, to speak more exactly, from birth up to twelve or 
fourteen years. 
At this period of life there is little temptation to employ 
Lithotrity, Lithotomy being very successful, and occasioning a 
mortality of only one in about sixteen cases under twelve years 
of age. Lithotrity has never approached these results for 
young subjects. But the propriety of employing it becomes a 
matter for consideration between fourteen and twenty, if the 
stone is not large, and is easily dealt with. It becomes almost 
the rule subsequently, as far as to forty years of age, under 
the same condition. But, in general terms, the period which 
CONDITION OF PATIENT TO BE CONSIDERED BEFORE OPERATING. embraces all ages above twenty years, is essentially the period 
for crushing the stone; that during which we may derive 
the greatest aid from it; provided always, that some other con- 
siderations, which shall be discussed hereafter, are fully taken 
into account in dealing with individual cases. 
These considerations arise from the analysis of the 1827 
carefully reported Hospital cases, which are studied minutely, 
and at length, in Chapter VII., on the {Eesults of Lithotomy.’ 
But in order to show the prevalence of calculus at different 
periods of life, among the classes who form Hospital patients, 
the annexed table of that series is appended here, extending 
from the first to the eighty-first year of life. 
RESULTS OF HOSPITAL LITHOTOMY AT ALL ACxES. 
Age of Patient. Number of 
Years. Patients. 
1 ... 7 
2 ... 74 
3 ... 116 
4 ... 153 
5 . . 123 
6 ... 00 
7 ... 86 
8 ... 49 
9 ... 57 
10 ... 50 
11 ... 35 
12 ... 58 
13 ... 32 
14 ... 35 
15 ... 26 
16 ... 27 
17 ... 18 
18 ... 26 
19 ... 19 
20 ... 13 
21 ... 12 
22 ... 10 
23 ... 9 
24 ... 12 
25 ... 11 
26 ... 10 
27 ... 5 
28 ... 6 
29 ... 11 
30 ... 11 
31 ... 3 
Carried forward 1204 
Age of Patient. Number of 
Tears. Patients. 
Brought forward 1204 
32 ... 14 
33 ... 7 
34 ... 9 
35 ... 9 
36 ... 5 
37 ... 3 
38 ... 14 
39 ... 4 
40 ... 21 
41 ... 4 
42 ... 7 
43 ... 11 
44 ... 4 
45 ... 17 
46 ... 11 
47 ... 15 
48 ... 6 
49 ... 10 
50 ... 23 
51 ... 15 
52 ... 11 
53 ... 17 
54 ... 25 
55 ... 23 
56 ... 26 
57 ... 25 
58 ... 16 
59 ... 22 
60 ... 33 
61 ... 17 
Carried forward 1628 CHOICE OF OPERATION AS INFLUENCED BY AGE. 
Age of Patient. Number of 
Years. Patients. 
Brought forward 1628 
62 ... 22 
63 ... 22 
64 ... 16 
65 ... 26 
66 ... 20 
67 ... 14 
68 ... 17 
69 ... 8 
70 ... 16 
71 ... 8 
Carried forward 1797 
Age of Patient. Number of 
Years. Patients. 
Brought forward 1797 
72 ... 5 
73 ... 4 
74 ... 2 
75 ... 9 
76 ... 4 
77 ... 0 
78 ... 1 
79 ... 0 
80 ... 4 
81 ... 1 
Total 1827 
The following facts appear from its analysis:— 
First. That one third of the entire number of cases occur 
during the first six and a half or seven years of life. 
Second. That one-half of the entire number occur before 
the thirteenth year is completed. 
Granting that Lithotomy should be employed in childhood 
and boyhood, as a rule to which there are few exceptions, it 
follows that this method must be applicable to fully one-half the 
entire number of hospital calculous cases. 
What is, then, the period of life when the individual is 
most liable to be affected with calculus ? It has been common 
to answer, in childhood. A very superficial glance at these 
figures might confirm some reader in this opinion. I believe, 
however, that it is the period between fifty and seventy years, 
and of this the latter half of the term especially. Certainly, 
the proportion of elderly calculous patients to the existing 
population at their own age is much larger than the proportion 
of children afflicted is to the number of existing children. This 
is the only accurate method of viewing the question. Calculus is 
most common between fifty and seventy; appears in the next 
degree of frequency between two and six years; and least fre- 
quently of all, perhaps, between twenty-six and thirty-six years 
—when, indeed, it is rare. 
2. It is necessary to ascertain the absence or presence of 
local disease. Malignant disease of the bladder, for example, 
would generally be held to contra-indicate any operative inter- 
ference : not necessarily so, however. Two of my cases at INFLUENCE OF DISEASE IN DETERMINING THE OPERATION. 
227 
University College are examples in which intense suffering was 
greatly relieved by Lithotrity, and it also lengthened life. Such 
instances are exceptional. 
But by local disease here is mainly intended organic 
changes in the kidney ; severe or persisting cystitis ; enlarge- 
ment of the prostate ; and stricture of the urethra. 
With regard to the first named, it is not very common to 
find calculus associated with those systemic changes which 
manifest themselves in the production of either fatty deposit, 
or those degenerations of structure commonly known as Bright’s 
disease, and the existence of which is evidenced by persistent 
albuminuria, renal casts in the urine, and, in advanced stages, 
by dropsical effusions in the cellular tissue, and in derange- 
ments of the cerebral functions. If such evidence is present, 
the stage of the disorder must guide us as to the propriety of 
entertaining the question of affording operative relief of any 
kind. For one case, No. 53 in the series in the Appendix, life 
was made much more comfortable, and beyond doubt prolonged 
several months, by removal of a large phosphatic stone. The 
patient was in an advanced stage of Bright’s disease; he died 
within a year from the conclusion of the operation. Encour- 
aged by this result, I operated in another, but probably more 
advanced case (No. 177) in University College Hospital, but 
death rapidly followed. The post-mortem showed both kidneys 
to be largely changed in structure. When the disease is in 
an advanced stage, no condition is more unpromising for the 
success of any operative procedure. 
But there is another class of renal affections not to be 
confounded with these blood disorders, in which the organic 
change in the kidney results from pre-existing irritation of the 
bladder, or urethra. We commonly meet with patients, the 
subjects of chronic nephritis and pyelitis, who owe the existence 
of these complaints to an obstinate stricture, to chronic disease 
of the prostate, or to a calculus which has long remained in 
the bladder. We find in the most advanced cases of this kind, 
after death, the kidney diminished in size, the cortical sub- 
stance especially so; interstitial deposits, and often small col- 
lections of pus in the renal substance, while the pel vis may 
be dilated, and, in some cases, is enormously so. Such are the 228 
INFLUENCE OF DISEASE IN DETERMINING THE OPERATION. 
results of obstructive disease of the urethra and neck of the 
bladder, .accompanied, as it always must be, more or less, by 
chronic inflammation extending up the urinary track. And it 
is with this type of disease that we have ordinarily to deal in 
discussing the question of operative procedure. Now the signs 
of this pathological state are not so clear as those which belong 
to the blood disorders above referred to. Furthermore, they 
cannot be distinctly isolated from the symptoms which belong 
to the urethral or vesical disease from which they derived their 
existence. They are not, by any means, to be discovered by 
urine analysis; and their existence can only be imperfectly 
inferred from symptoms which after all are by no means to 
be regarded as pathognomonic in their character. The patient 
complains of pains in the back and loins, and often in the 
groins and testicles; is probably tender on one or both sides on 
deep palpation through the abdominal muscles in the region of 
the kidney ; is rather emaciated, and has gradually lost flesh ; 
is weak and depressed, subject to chills and feverishness, 
amounting to rigors sometimes, after slight irritations, after 
the use of a catheter and the like. The urine is variable in its 
quantity and characters, and always contains pus, sometimes in 
great abundance. Still, we can by no means be certain from 
any signs or symptoms, that the changes described exist in any 
given case, and it is certain that they prejudice exceedingly 
the result of an operation. Examples are afforded by Nos. 3, 
11, 199, 272, 311, 327, 374, and 425 in the series referred to.1 
3. This group of symptoms leads us insensibly to the next 
class of phenomena, viz. those which indicate considerable 
susceptibility to general disturbance from sources of local irrita- 
tion, no organic disease whatever existing. There are many 
cases indicated in this division, in which extreme tendency to 
rigor exists, not on account of any existing renal implication, 
for, as before said, none may be present, but from some other 
and less obvious cause. 
There are some constitutions in which the nervous system 
appears to be so susceptible, as we express it, that almost any 
mechanical interference with the urethra, or bladder, is followed 
1 See a full discussion of this subject in my Clinical Lectures, 5th ed. 1879. 
Lecture XVI. PREPARATORY TREATMENT.—THE CASES OF CHILDREN. 
by startling symptoms obviously depending on some kind of 
shock propagated to the nervous centres, and consisting in 
syncope, rigor, vomiting, depression, with intense pains in the 
back, loins, and elsewhere. These, although alarming, are, 
generally, not dangerous, unlike those symptoms which, closely 
resembling them, depend on organic renal disease. Now, in 
none of these cases is it usually desirable to attempt the removal 
of a stone by any method which requires repeated manipulation 
in the bladder or urethra. It is better, perhaps, to deal with 
it by one operation, and this is usually within our power, now, 
by Lithotrity. 
Nevertheless, much more may be done with the last-named 
class than with the first. The cases belonging to it are improv- 
able by general management, whereas those of the first steadily 
grow worse with time. And here we see, incidentally, the 
value of the preliminary treatment already referred to, and 
which may thus be briefly summed up :— 
Some preparatory treatment may be useful in view’ of either 
Lithotomy or Lithotrity; and it is desirable in certain excep- 
tional cases to pass a few times sounds of gradually increasing 
calibre, to accustom the urethra to the contact of instruments, 
and to increase its calibre, before the commencement of Litho- 
trity. But where the urethra is capacious, and its sensibility 
not great, such preliminary treatment is wholly unnecessary. 
With these brief preliminary remarks, the way is now’ cleared 
for some final deductions relative to the operations to be em- 
ployed in the various cases met with in practice. 
1. For all cases of calculus during the periods of infancy, 
childhood, and boyhood, which may be regarded as from one to 
twelve or fourteen years, the following course appears to be the 
most judicious:— 
To practise Lateral Lithotomy as the rule; the mortality 
from which varies during this period from one in eleven to one 
in twenty-eight cases; the mean of the whole being about one 
in fifteen cases. 
The exceptional cases are those in w’hich the stone is only a 
little too large to pass by the urethra, and therefore small. For 
these, there is no occasion to perform Lithotomy. Opposed as 
I am to Lithotrity in children, as a rule, for reasons already LITHOTOMY OK LITHOTRITY FOR HEALTHY ADULTS. 
named, I nevertheless believe, when the stone is so small as to 
be easily pulverised at a single crushing by a slender lithotrite, 
it is the simplest and best method of proceeding, and that when 
the stone can be well and easily crushed in two sittings, it may 
be admissible. 
With regard to Median Lithotomy in children, there appears 
to be no objection to it, provided a director or gorget conducts 
the finger into the bladder. At the same time, I do not know 
that it offers any advantage over the lateral operation. 
2. In adult cases we have to decide between Lithotomy and 
Lithotrity; and if the former is indicated, to point out the 
particular form to be employed. 
First, Lithotomy or Lithotrity ? 
The special indications for these operations must be con- 
sidered as they relate to two separate classes of patients. 
a. In tolerably strong and healthy adult patients. 
b. In feeble and diseased adult patients. 
This division is of more practical value than a division 
founded on age, because the influence of age is less strongly 
marked after manhood has been attained than before. If age 
be regarded alone, the period between twenty-five and forty 
years gives the best results, viz. one death in eleven and a half 
cases, from Lateral Lithotomy. But the data are comparatively 
few, since it is the period of all others when stone is most rare. 
The question of age and its effects in adults is therefore included 
in the major one of constitutional conditions. 
1. In the class of healthy adults. 
If the calculus is of full medium size, and of course when 
smaller, whether soft, friable, or compact, it should be crushed. 
But the term ( medium ’ admits of some extension in rela- 
tion to size, for uric acid calculi, with the more powerful instru- 
ments, and the aspirator now used ; although for oxalate of 
lime calculi, the size denoted should not be much exceeded, 
the spheroidal form of these stones making a medium-sized 
calculus (one inch in diameter) mostly large enough for Litho- 
trity. 
If there is any special or exceptional ground for rejecting 
Lithotrity in such cases, the ordinary median operation may be 
employed. Indeed, these are the sole conditions, I believe, in LITHOTOMY OR L1THOTRITY FOR DISEASED ADULTS. 
which it is now advisable, since Lithotrity has rendered it for 
the most part an unnecessary proceeding. But when, as owing 
to the presence of a very narrow or unmanageable stricture, the 
crushing process is inapplicable, and the stone is small or of 
4 small medium ’ size, this is perhaps the best mode of removing 
it, as we shall see further on. But, on the other hand, if the 
stone is large, and especially if it be also one of compact 
structure, the Lateral operation would generally be the best to 
select. For a large and friable stone Lithotrity may be success- 
ful, but such an one offering between twenty-five and forty 
years of age would probably be as well dealt with also by 
Lateral Lithotomy. 
2. The question is to be considered for feeble and diseased 
patients. 
a. Where there is no marked disease of the urinary organs, 
but feeble and failing strength ;— 
If the calculus is of medium size and friable, there is no 
question that Lithotrity should be the operation selected. If 
it should be even hard and compact in structure, I doubt 
whether in these cases any form of Lithotomy would afford 
better results. 
h. Where wTell-marked disease of some portion of the urinary 
organs exists. 
In stricture of the urethra, especially if it has existed long, 
and is well marked, Lithotomy is preferable to Lithotrity if the 
calculus is large. But I have been able to accomplish so much 
recently by Lithotrity, for cases of stricture, by tying in a 
catheter (see page 194), that for small, and even medium-sized 
stones, the crushing process will often be found applicable. If, 
however, the stricture proves very unmanageable, the Median 
operation may be selected, while its line of incision, being 
central, may be easily made to divide also the rigid tissues of 
the stricture. 
In hypertrophied prostate, with a quiet condition of the 
bladder, Lithotrity is successful with small and medium-sized 
stones. But with an irritable condition of bladder, and with 
compact and large stones, Lateral Lithotomy seems preferable, 
and, in such, seems to be more successful than Median operations. 
In cases where the bladder cannot expel its contents on LITHOTOMY OR LITHOTRITY FOR DISEASED ADULTS. 
account of loss of power in its coats, i.e. atony, and not on 
account of enlarged prostate, no objection lies, on that ground 
merely, against Lithotrity ; indeed, such a condition is more 
favourable to success than that of undue irritability of the organ. 
This is now known to most practical lithotritists, although it is 
a condition which, not long ago, was held to contra-indicate 
Lithotrity. 
In marked disease of the bladder, cystitis with constitu- 
tional disturbance, tumours, simple or malignant, or if the 
existence of sacculi may be suspected, Lithotrity is very haz- 
ardous, so also is Lithotomy. But it cannot now be said that 
Lithotrity is inadmissible. 
Finally, for cases of either class where the stone is of ex- 
tremely large size, such as are now rarely met with, say from 
four ounces upwards, I doubt whether experience can indicate, 
on the whole, a safer method than the Lateral operation, aided 
or not by a double incision of the prostate. It is in these cir- 
cumstances that the apparatus of Civiale, for crushing a large 
stone before extracting, through the perineal wound, becomes 
applicable. For this purpose he preferred a central opening 
into the bladder, the Medio-bilateral operation; and I think, in 
order to work the instrument efficiently, that such incisions 
may perhaps give a better chance to it than the Lateral. 
The high operation offers, perhaps, as good a chance, if the 
bladder be distensible, and the patient is not corpulent. Bata, 
however, are wanting to determine the value of this as well as 
that of the recto-vesical operation in relation to extremely large 
stones. Probably the latter might be regarded as the safer pro- 
cedure were it not for its liability to be followed by permanent 
fistula. 
There is a question inevitably presenting itself sometimes, 
which is rarely dealt with by surgical writers, viz. Should we 
ever refuse to perform an operation for the relief of the 
calculous patient, and if so, under what circumstances ? In 
practice, this question must be answered ; and the manner of 
answering it influences very much the rate of mortality result- 
ing from operative proceedings. I think in England and in 
Scotland very few cases are rejected as unfit for operation, 
certainly in hospital practice; in private there are, from various QUESTION OF REFUSING TO OPERATE BY EITHER MODE. 
causes, more examples ot unremoved stone, bo much may be 
done to mitigate suffering for those whose means enable them 
to command every resource available for the purpose, that the 
alternative of an operation, rendered hazardous by the magni- 
tude of the calculus, or other unfavourable circumstance, is not 
necessarily adopted. It is widely otherwise with the poor, and 
it is sometimes a difficult point to determine whether continuous 
suffering or a severe operation involves the graver consequences 
to life. Mostly, the patient himself desires to turn the scale in 
favour of the latter alternative rather than be abandoned to the 
hopeless prospect of unrelieved suffering. In France a larger 
proportion of cases is, I think, rejected. Lithotomy is not so 
successful there, on comparing the results, in large numbers, of 
practice in the two countries; and the operation appears to me 
to be more dreaded by both surgeon and patient. It is more 
rarely performed, and thus it is, perhaps, that there seems to 
exist a want of that confident familiarity with Lithotomy which 
distinguishes the practised English operator, and which doubt- 
less conduces to success. On the other hand, those who practise 
Lithotrity in France appear unwilling to hazard its application 
to very unpromising cases, and no doubt they act justly and 
prudently in so doing. Take, for example, the practice of M. 
Civiale, during the year 1862, which is a fair specimen of his 
experience, both before and after that period. He reported that 
he had treated during that year sixty-nine calculous patients: 
sixty-six men, two women, and a child ; forty-five in private 
practice; twenty-four at Hopital Neckar. Fifty-eight of these 
were operated on: forty-five were submitted to Lithotrity ; of 
these eight were partially cured; and it was successful in all 
the remainder but one. 
Ten were treated by Lithotomy; three were cured, two 
relieved, and five died. Three were treated by a combination 
of Lithotomy and Lithotrity; two were cured, the other has 
incontinence of urine. 
In eleven cases operative means have been adjourned or 
considered impossible. 
Now, although the Lithotrity, as here recorded, is extremely 
successful, every English surgeon will feel surprised to find an 
operation declined in one of every six adult cases, and that one- QUESTION OF REFUSING TO OPERATE BY ANY MODE. 
half of the Lithotomy cases were fatal. It must be obvious to 
all who are familiar with the practice of this country, that no- 
thing like this proportion of cases is adjudged unfit for opera- 
tion. 
Are they, or are we, right in thus acting ? Without enter- 
ing upon a discussion of the numerous topics which the answer 
to this question might give rise to, I shall simply appeal to the 
results of English Lithotomy in the very worst cases, viz. those 
of large stone and broken-down constitution. If such an appeal 
shows that two out of three, or three and a half, recover, and it 
does so, I think we are justified in offering that chance to a 
patient whose only other prospect is a lingering death, greatly 
aggravated in its misery if his circumstances are narrow. 
There is one condition, perhaps, which must be held as 
sufficient ground in a bad case, such as described above, for 
refusing to operate, and that is the presence of advanced renal 
disease ; and when this can be affirmed to exist, I think it may 
be said that such a patient will certainly die, and that the 
surgeon is not justified in accelerating his fate. There are, 
however, a good many examples among us, in private practice 
particularly, although certainly less now (1880) than twenty 
years ago, of patients who resolve not to risk any interference. 
I have had under my own care four patients, all at an advanced 
age, so greatly relieved by the daily use of the decoction of 
Triticum repens, that they have (in two of the cases I think 
unwisely) declined to submit to any operation. Certainly 1 
have seen no circumstances in which that useful agent is more 
valuable than in those of calculus, sometimes when it is in the 
kidney, but especially when it is in the bladder, and I have 
received similar testimony from several of my professional 
brethren. 
The foregoing observations, then, will be sufficient to 
enunciate the general principles which extended observation 
and experience indicate, in my opinion, to be our guides in 
selecting the proper procedure for given cases. Nevertheless, 
it is not presumed that every example can be brought to rule 
and measure, so to speak, and be mathematically fitted to the 
process requisite for it. Let it be well understood that they 
are held forth as principles to indicate the way, not as rigid IMPORTANCE OF DETECTING THE STONE IN AN EARLY STAGE. 
laws knowing no exception. Since the last edition, I have in 
practice, as I have now by precept, extended somewhat the 
application of Lithotrity; adopting with success the method of 
removing as much as possible at a single sitting, or by means 
of at most two sittings, with aspirator and large evacuating 
catheters. 
I must now call attention to the advantage of discovering 
calculus in the early stage, of which several of the cases in the 
Appendix are examples. Many years ago I brought this subject 
forward at the Medical Society of London, reading five cases, 
with the view of illustrating what appears to me the great 
importance of this practice. For I do not hesitate to affirm 
that Lithotrity for a small, compact, or friable stone occurring 
in a tolerably healthy subject, devoid of unusual local suscepti- 
bility, at any age above puberty, is, if properly performed, an 
operation almost absolutely devoid of danger. Such a state- 
ment cannot be made of any other mode of operating for stone. 
In proof of this I am in a position to assert that, having now- 
performed the operation some hundreds of times (1880), I have 
lost but one patient in whom the calculus was no larger than a 
small nut, and he was the subject of renal disease. 
It follows then, — since every calculus is during a portion of 
its history small, and passes, generally, not very rapidly, 
through the early stages of formation; and since deteriorated 
health much more frequently succeeds to than accompanies its 
formation,—it follows, I repeat, that calculus of the bladder is 
removable, if its presence be early diagnosed, in almost every 
case, with little or no danger. 
No proposition can be more logically incontrovertible than 
this: yet the practice of the past, so far as it depends on dia- 
gnosis, though steadily improving, has done so by very slow and 
gradual d grees. Its truth, however, pregnant as it is with the 
happiest results for humanity, only requires to be known and 
acted on, in order to achieve at once a great advance, and one 
which I am sure is within our reach. In this department, as 
in every other of the wide domains of medicine and surgery, 
diagnosis is the one thing needful. That diagnosis is slowly 
reducing the size of the stone year by year, and has been doing 
so during some past time, is demonstrable from our museums. IMPORTANCE OF DETECTING THE STONE AT AN EARLY STAGE. 
Take that of Norwich, for example, which is, thanks to the 
surgical genius of East Anglia, the most perfect and complete 
record, literally 4 graven in stone,’ that the world possesses of 
calculous experience. When the art of surgical diagnosis was 
young, the stone was often overlooked, until its large size and 
long existence precluded the possibility of the oversight con- 
tinuing. Hence, among the stones removed there in the end 
of the last century, are seen masses which now most rarely 
come to light. I calculated the sizes presented during each 
consecutive ten years down to the present time, and noted the 
significant fact that they are gradually decreasing in size. In 
other wrords, it has been successively true at different periods, 
that the stone now is detected in an earlier stage of its exis- 
tence than formerly. 
Thus the first, or earliest, 100 stones in the Norwich dn 
Museum have an average weight to each of , 8*64 
The second 100 ....... 7*07 
The succeeding 400 . . . . . .5*95 
But how much too late is still the stone detected. Ought 
any man, who complains of his symptoms, within reach of 
competent skill, to carry a stone in his bladder for more than 
twelve months, nay, more than eight, or six ? And if detected 
thus early, if discovered when it assumes the size of a bean, or 
at most that of an almond, how often would it be necessary to 
lithotomise an adult? There can be no doubt that skill in 
diagnosis is greatly on the increase, and, from this fact, I may 
venture to foretell, without any pretension to the gift of 
prophecy, that year by year the stone will be detected sooner 
and sooner still, and that, therefore, pari passu, Lithotomy 
will become less necessary, and Lithotrity more often applicable. 
Add to this the fact that the unchangeable conditions of 
anatomy leave little more to be effected, probably, in the mode 
of removing stone by the knife, while the improved applica- 
tion of mechanics to Lithotrity is, year by year, perfecting the 
process. 
I say little here of chemical solvents in the treatment of 
already-formed calculus. In exceptional cases, they possibly 
may have been of some service. But their special application is to the earlier stage of the calculous diathesis, antecedent to 
true stone formation; for the solution of those particles which, 
aggregated, form the stone. For the action of solvents we 
require minute mechanical division of the material to be acted 
upon. And here we have it. It is but one step further still in 
the application of diagnostic science, which recognises in the 
persistent undue deposit of crystalline material in the urine, 
and certain associated symptoms, that calculus-formation is 
imminent or impending; and internal solvents arrest the form- 
ation of precipitated deposit, while, which is much more im- 
portant, the erring tendency of the economy is gradually cor- 
rected by medical treatment, diet, and hygiene.* But of this, 
enough; for the terms of my subject are purely surgical, and 
there is no further need that I overstep that imaginary line 
which is supposed to trace the confines of medicine and surgery. 
A subject which, nevertheless, illustrates well the important 
truth that no man can be a good practical surgeon who is not 
also an intelligent physician. 
CONCLUSION. 
237 
1 See this subject discussed in the Clinical Lectures, 5th ed. London, 1879. 
Lecture XVII. APPENDIX. 
TABLE OF 500 OPERATIONS FOR STONE IN THE 
CASES OF MALE ADULTS ONLY. 
The following Table contains a brief account of every Male Adult 
case, without exception, of Stone in the Bladder, which has been 
operated on by myself up to January 1877. 
The name of each patient, his age, the nature of the operation, the 
year in which it was performed, the species and number of the calculi 
present, and the after-history so far as I have been able to ascertain 
it, are recorded; each particular in a separate column. 
In addition to these facts, the distinction between patients treated 
by me in University College Hospital, and those who were in private, 
is indicated; the letter ‘H ’ in the second column indicating a hospital 
patient : these ceased in 1874 when I resigned my appointment there. 
When the column is blank, the patients consulted me in private : in 
connection with these the name of the medical man who sent the 
patient, or who saw him with me, is appended. There are a very 
few cases of patients who had no other medical attendant than 
myself. 
The first column contains a series of numerals only, from one 
upwards; each of these numbers indicates a single patient, and not 
merely an operation. The highest figure of the series, therefore, repre- 
sents the precise number of individuals operated on, and not the number 
of the operations performed, which is considerably greater : inasmuch 
as some patients have been operated on twice or three times; and 
there are, in the entire series, three persons on each of whom four 
operations have been performed. (See pages 71 and 118). 241 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
1 
1857 
32 
H. C. 
Phosphatic. 
Successful: a second operation 
in 1859; and was well in 
1861; died at Barcelona in 
1862, and at autopsy a stone 
was found in the kidney only. 
Seen with Mr. Tweed, of 
Brook Street. I record two 
operations. 
2 
H. 
1859 
36 
H. A. 
Oxalate. 
Successful: I saw him six 
years after: and no return. 
3 
H. 
99 
68 
0. G. 
Uric; three. 
Too large for crushing, which 
ought not to have been at- 
tempted. I was then not 
sufficiently aware of the im- 
portance of making an ac- 
curate diagnosis before opera- 
ting. Death. 
4 
1860 
74 
H. W. 
Phosphatic. 
Lateral: Sir W illiam Fergusson 
held the staff: patient died, 
apparently of exhaustion, on 
tenth day. Death. 
5 
J’ 
76 
J. VV. 
Uric; two. 
Successful: a patient of Mr. 
Gatis, Wolverhampton: lived 
until 86, enjoying excellent 
health, and no return. 
6 
H. 
99 
57 
P. I?. 
Phosphatic. 
Successful: a second stone in 
1863; and made a good re- 
covery. I record two opera- 
tions. 
7 
H. 
1861 
22 
D. S. 
Phosphatic, 
on sealing- 
wax. 
Successful: he said he had passed 
a piece of sealing-wax into the 
urethra as a bougie, and let it 
slip in six months ago. I 
cut him by the median; on 
the ninth day had severe 
haemorrhage ; made a good re- 
covery. 1 saw him well two 
years after. 
8 
99 
69 
Jas. E. 
Phosphatic. 
Successful: lateral; Mr. Erichsen 
holding staff. Two years after 
I relieved him by removing 
phosphatic matter with ' the 
lithotrite, which I do not 
record as an operation. 
9 
99 
43 
J. Q. 
Uric 
Successful: median; Mr. 
Erichsen held the staff. He 
made an excellent recovery. 
10 
99 
64 
G. L. 
R 
Uric 
Successful: I saw this case at 
Brighton, with Mr. Tatham. 
Is living now (1876). OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Litliotrity 
Lithotomy 
Calc. 
Results 
11 
18G1 
69 
W. T. 
Uric. 
A large uric acid stone success- 
fully removed in seven sit- 
tings. After this he was able 
to take exercise, but gradu- 
ally sank with renal disease 
six weeks after. Sent by Mr. 
Gatis, of Wolverhampton. I 
accept it as a death, although 
the fatal result can scarcely be 
attributed to the operation. 
Death. 
12 
H. 
1802 
23 
J. L. 
Oxalate. 
Successful: no return during 
eight years after operation 
(1870), the last time I saw 
him. 
13 
14 
81 
K. D. 
Uric; seve- 
ral. 
Much haemorrhage after a short 
and easy sitting, but the 
calculi were too large for 
lithotrity. I had not then 
learned the importance of 
diagnosing precisely the con- 
tents of the bladder. Death. 
75 
C. W. H. 
• 
Uric; seve- 
ral. 
Successful; I crushed others in 
1863, and again in 1869. He 
lived, with no return, in good 
health six years longer, and 
died of old age at 83. I re- 
cord two operations. 
15 
71 
A. P. 
Uric; two. 
Successful: the median, Mr. 
Erichsen holding the staff. I 
saw the patient in good health, 
and very active for his years 
(88), in March 1880. 
16 
69 
L. T. 
Uric. 
After an easy crushing, he ap- 
peared to be doing well. 
Fever came on in a few days, 
delirium tremens, and he died 
maniacal on the twelfth day. 
Death. 
17 
/ 
68 
H. H. 
Uric. 
Median: he sank about three 
weeks after the operation, 
which promised, until a few 
(lays before death, to be suc- 
cessful ; the cause apparently 
exhaustion ; probably he had 
some renal disease. "Death. 
18 
1863 
61 
D. 
Phosphatic. 
Successful: lived several years 
after with his son, Dr. 
Dieudonne, of Essex Street, 
Strand. No. 
Hosp. or 
Private 
Date 
Age 
Lithotrlty 
Lithotomy 
Calc. 
Results 
19 
1863 
56 
H. R. H. 
Uric, 
Successful: was well eight years, 
after which I crushed a second 
uric acid stone in 1872, and he 
again made an excellent re- 
covery. I record two opera- 
tions. 
20 
72 
L. 
Phosphatic. 
Successful: he lived two and a 
half years afterwards in com- 
fort, and without return of 
stone symptoms. 
21 
73 
J. B. S. 
Uric; nu- 
merous. 
Median : Mr. Erichsen holding 
the staff. He died on the 
fifth day apparently exhausted. 
The stones were very numer- 
ous and some spontaneously 
broken, perhaps fifty alto- 
gether. Death. 
22 
73 
W. J. 
Phosphatic. 
Successful: lived several years 
after with his son, Dr. E. 
Jackson, of Sheffield. 
23 
77 
F, 
Uric. 
I operated at a distance, at 
Hendon, which was an error. 
The patient had retention of 
urine, and his medical atten- 
dant used the catheter fre- 
quently and with great diffi- 
culty ; and death soon occur- 
red.* Since this, I rarely con- 
sent to operate unless the 
patient comes to reside near 
me for a time. Death. 
24 
65 
T, C. 
Uric; two. 
Successful: I operated at Bou- 
logne, going six times for the 
purpose: he was in charge of 
Dr. Perrochaud there, whose 
skill and attention made him 
a valuable ally. The patient 
lived several years afterwards 
without return, and died of a 
cerebral affection. 
25 
H. 
59 
T. P. 
Uric. 
Successful. 
26 
r 
H. 
42 
D. D. 
Uric. 
Successful: median; calculus 
upwards of an ounce in 
weight. 
27 
H. 
61 
W. H. 
Uric; two. 
Successful: median; weighed 
together one ounce and a half. 
28 
H. 
44 
VV. L. 
E 
Uric. 
2 
Successful: median ; calculus up- 
j wards of an ounce in weight. 
OPERATIONS FOR STONE IN MALE ADULTS. 244 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity I Lithotomy 
Calc. 
Results 
29 
1863 
45 
M. 
Phosphatic. 
Successful: a very large stone ; 
the patient had lost nearly all 
power of the lower limbs from 
spinal disease. He lived some 
time after, free from trouble. 
I saw him with Mr. T. W. 
Cowell, of Piccadilly. 
30 
5? 
74 
R. T. 
Uric, 
Successful: quite well for a year 
or two after, and died from 
some accident. I saw him 
with Dr, Cupiss, of Great 
Grimsby. 
31 
1864 
69 
J. W. 
Uric; two. 
Successful: had a second stone 
a year and a half after which 
I crushed, and he lived some 
time after that without any 
return. Seen with Mr. Gay- 
leard, of Devonshire Street. I 
record two operations. 
32 
JJ 
45 
J. S. W. 
Uric. 
Successful: was well three 
years; then had symptoms of 
stone during a year, and I 
operated again in 1868. No 
return after. He wrote me in 
1871 he was quite well. Dr. 
Koepl was present on the first 
occasion, and Dr. Keith, of 
Aberdeen, at the second. I re- 
cord two operations. 
33 
J* 
69 
J. M. 
Uric. 
Considerably relieved, and left 
for the country. A fortnight 
after he complained of return 
of pain. Six weeks after he 
had severe rigors, no instru- 
ments having been used ; he 
gradually sank in about a 
month. At the autopsy seve- 
ral calculi were found in the 
right kidney; in the left a 
large abscess. The patient 
was sent to me by Dr. Drury, 
of Harley Street. 
34 
>> 
46 
P. T. 
Oxalate. 
Successful: Dr. Pancoast, of 
Philadelphia, was present at 
two of the sittings. Heard 
he was well eight or nine years 
after. 
35 
74 
W. H. 
Uric. 
Median, for which the stone was, 
I think, too large. Mr. Berke- 
ley Hill held the staff. The 
stone was flat, resembling an 
oyster-shell, and was removed 
with difficulty. He died of 
peritonitis. Death. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
36 
37 
38 
Hosp. or 
Private 
Data 
Ago 
Lithotrity 
Lithotomy 
Calc. 
Results 
1864 
69 
R. B. 
Large, uric 
and phos- 
phates. 
Successful: was seen by Mr. B. 
Hill several times in my ab- 
sence. Lived six or seven 
years after, free from any 
trouble, and died of old age, 
after a very active life. 
r> 
48 
N. H. C. 
Uric. 
Successful: he was a military 
surgeon in India, and had 
himself cut 200 patients. He 
made a good recovery, and 
lived several years more in 
India: he returned, however, 
with diseased liver, and died, 
but had no return of the cal- 
culous disorder. 
yy 
70 
D. H. 
U rate and 
phosphate. 
Successful: had blood-poisoning 
with deposits in the lung, but 
recovered after a long strug- 
gle ; attended by Mr. B. Hill 
with myself. He became 
quite strong and well for seve- 
ral years, and then formed a 
second stone, which was 
crushed successfully eight 
years after. Two years later 
he died at nearly eighty years 
of age. I record two opera- 
tions. 
39 
yy 
68 
E. J. P. 
Urates and 
phosphates. 
Successful: saw him with Mr. 
Harris, of Gower Street. Two 
years after he called on me 
quite well. 
40 
H. 
» 
63 
P. P. 
Uric. 
Successful: lateral; removing 
a stone fully 2 oz, in weight. 
41 
48 
C. P. 
Uric. 
Successful: no return ; health 
excellent, and living now 
(1880). This case was con- 
fided to me by Mr. Hilton, of 
Guy’s, who was leaving Lon- 
don for his holiday; he was 
present at the first sitting. 
42 
yy 
62 
T. T. 
Uric. 
Successful: saw him with Mr. 
Hammerton, of Piccadilly, 
who was present at even* sit- 
ting. I saw him well in 1869 ; 
there had been no return. 
43 
yy 
62 
Col. B. 
Large uric. 
Successful: no return ; recovery 
excellent. I saw him well in 
1867. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
44 
1864 
59 
R. P. 
Uric. 
It was small, and I enjoined no 
restrictions as to movement 
after operation. He had severe 
fever and cystitis, but ulti- 
mately made a good recovery. 
45 
H. 
>> 
59 
J. H. 
Uric. 
Successful: a good recovery ; 
remaining well three years; 
then symptoms reappeared, 
and he came to the Hospital 
at the end of 1868. I per- 
formed lithotrity again, and 
he left quite well. I record 
two operations. 
46 
>) 
75 
J. A. 
Phosphatic. 
Successful: saw him with Mr. 
Tatham, of Brighton. The 
patient never emptied his 
bladder but by catheter. In 
1866 he had another stone, 
which I crushed with much 
relief. He lived a year or so 
longer, with much trouble and 
frequent catheterism. I record 
two operations. 
47 
68 
T. M. 
Uric. 
Successful: saw him with Mr. 
P. Jackson, of Wimpole Street; 
was perfectly free from troubles 
for some years. In 1870 he 
came with another uric acid 
stone which was also crushed 
with excellent residt. He is 
living and well now, 1876. I 
record two operations. 
48 
57 
J. K, 
Oxalate. 
Successful: saw him with Mr. 
Ray, of Dulwich. Some years 
after the patient was troubled 
with retention, and had a 
phosphatic calculus, which I 
crashed five years after the 
first. He was living and in 
fair health, 1876. 1 record two 
operations. 
49 
1865 
84 
S. K. S. 
Uric. 
Successful: the oldest case I 
have operated on ; an uncle of 
the late Mr. Solly, the sur- 
geon, who saw him with me. 
The patient had no return, and 
lived two and a half years 
after. OPERATIONS FOR STONE IN MALE ADULTS. 
247 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
50 
1865 
60 
E. T. 
Phosphatic. 
Successful: passes urine by 
catheter; a year after he had 
again symptoms, and I re- 
moved a second stone in 1866. 
No re> urn after ; he continued 
an active life until his death in 
1875. I record two operations. 
51 
75 
Capt. M. 
Phosphatic. 
Successful: a year and half 
later I removed another rather 
large stone ; after this I occa- 
sionally removed a phosphatic 
concretion, but he had excel- 
lent health, and died at eighty 
of apoplexy. I saw him 
throughout with Mr. C. A. 
Aikin. I record two opera- 
tions. 
52 
61 
T. 0. 
Large, uric. 
Successful: it was a large stone 
for lithotrity, and required ten 
sittings; saw him with Dr. 
A. Simpson, of Glasgow. 
53 
5) 
59 
H. C. 
Phosphatic. 
Successful: the subject of ad- 
vanced albuminuria; and I 
operated to relieve his suffer- 
ings. He died a little less 
than a year after; seen with 
Dr. Sharpe, of Norwood. 
54 
65 
J. G. 
IIric. 
Successful: from Naval Hos- 
pital, Plymouth. I heard from 
him six months after that he 
was well, but not subse- 
quently. 
55 
56 
% 
53 
A. M. 
Uric. 
Successful: sent by Mr. Yeal, 
Grimsby. Had excellent 
health, and no return for six 
years; then slight symptoms 
during two years ; came with 
a fresh uric acid calculus in 
1873, and was again success- 
fully treated by lithotrity. 
Living and well now, 1879. I 
record two operations. 
H. 
62 
G. B. 
Phosphatic. 
The bladder much thickened 
and diseased ; but relieved 
after two crushings. Returned 
to Framlingham, Suffolk, 
whence his attendant, Mr. 
Jeaffreson, wrote me that he 
shortly afterwards died of 
peritonitis. Autopsy: Blad- 
der involved in a mass of 
cancer on one side and saccu - 
lated; no calculus. The 
death here was clearly due to 
cancer. 248 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
57 
1865 
71 
R. F. 
Uric ; three. 
Not very successful at first; but 
much relieved; six months 
after I removed a small phos- 
phatic calculus. Subsequently7 
he was free from trouble, and I 
heard from him as being well 
in 1869. Seen with Dr. A. 
Simpson, of Glasgow. 
58 
H. 
99 
28 
E. B. 
Phosphatic. 
Successful. 
59 
H. 
99 
71 
J. P. 
Uric and 
phosphate. 
Menio - bilateral; successful. 
Stone large, and crushed it. 
before removing. Fragments 
weighed 3£ oz. 
60 
99 
62 
R. B. 
Uric. 
Successful; and had no return. 
Lived in good health and 
activity several years, and 
died in 1875, A patient of 
Dr. Boyd, Durham. 
61 
99 
74 
W. M. 
Uric. 
Successful: had a large prostate, 
which occasioned some little 
difficulty. He lived two and a 
half years after; saw him with 
Mr. C. King, of Highbury. 
62 
99 
70 
G. M. 
Large uric. 
Successful; this patient pro- 
duced more calculi than any 
man I ever knew, except one 
(No. 74). I removed a large 
calculus of uric acid in 1865, 
with freedom from symptoms 
up to 1867. In 1868 a mode- 
rate-sized uric acid calculus. 
In 1870, a large collection of 
calculi, some as big as a pea, 
about one hundred. In 1871, 
a mixed calculus, phosphatic 
and uric, large. He lived to 
1873, passing all his urine by- 
catheter, and suffering much 
from vesical troubles, but 
without further calculus form- 
ation, dying at the age of 78. 
I record four operations. 
63 
9f 
62 
J. R. 
Uric. 
Relieved : no return of calculus : 
but chronic cystitis some time. 
Seven years after he was 
greatly relieved by learning to 
pass a catheter, being then 
unable to empty the bladder ; 
since which I have heard no- 
thing more. Seen with Mr. 
M. B. Hill. 
64 
99 
61 
Baron 
de T. 
Uric. 
Successful: was seen with Dr. 
Greenhow. OPERATIONS FOR STONE IN MALE ADULTS. 
249 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
65 
1865 
73 
J. K. 
Oxalate, 
Medio-bilateral: Mr. Erichsen 
held the staff. Stone weighed 
2| ounces, a specimen of rough 
‘ mulberry,’ and difficult to 
extract. He died, slowly ex- 
hausted, on the 23rd day after 
operation. Death. 
66 
H. 
39 
F. B. 
Phosphatic, 
bony nu- 
cleus. 
Successful: I found and ex- 
tracted a piece of bone, the 
nucleus of the stone, on first 
crushing it. Then I learned 
that several years before he 
had chronic disease of hip- 
joint. Bone had been ex- 
foliated externally, and no 
doubt a portion had also made 
its way into the bladder. Sent 
by Dr. N. West, Alford, Lin- 
colnshire. 
67 
69 
P. B- 
Uric and 
phosphatic; 
two. 
Successful: seen with Dr. Bu- 
chanan, of Glasgow. He had 
been cut three years before and 
two uric acid stones removed. 
He lived several years after. 
68 
47 
J. D. 
Phosphatic. 
Successful: no return two years 
after when I saw him. Sent 
by Mr. Ehind, of Shipley, 
Yorkshire. 
69 
i9 
65 
C. F. 
Uric. 
Successful: saw him well one 
year after. Three years after 
saw him again, with chronic 
cystitis ; there was no calculus 
but he did not empty the blad- 
der, from enlarged prostate, 
and learned to pass the cathe- 
ter. Sent by Mr. Warwick, 
Southwell, Notts. 
70 
71 
64 
R. S. 
Uric. 
Successful: had no symptoms a 
year after when I saw him. 
Was attended by Mr. M. B. 
Hill with me, and seen by Dr. 
Seegen, of Carlsbad. 
65 
VV. H. G. 
L. 
Uric, 
Successful: saw him next year 
quite well. Seen by Mr. Clover 
only, who gave chloroform. 250 
OPERATIONS FOR STONE IN MALE ADULTS 
No. 
Hosp. or 
Private 
* 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
72 
18G5 
G4 
C. F. 
Phosphatic. 
At first consultation with Mr. 
E. Wright, of Clapham, I 
stated that the case was un- 
promising. either for litho- 
tomy or lithotrity ; but his 
symptoms being severe, would 
not refuse a chance by the 
latter operation. The prostate 
was very large and the bladder 
small: he had also organic 
disease of the heart. After 
five sittings fever set in; he 
gradually became weaker, and 
died suddenly while taking 
food, about a month after the 
last sitting. I am satisfied to 
accept this as a death following 
lithotrity, although the actual 
cause of death at last was 
diseased heart. Death. 
73 
6G 
H. L. 
Uric; large. 
After removal of the stone in 
eight sittings, there was some 
chronic cystitis. I saw him a 
year afterwards ; he passed a 
catheter daily, and washed out 
the bladder to remove phos- 
phatic matter which occasion- 
ally formed. Sent by Dr. M. 
Foster, Huntingdon. 
74 
GO 
G. A. N. 
Phosphatic. 
Successful: made a good re- 
covery after eight sittings, and 
continued well for two or three 
years. Five years after he was 
unable to pass any urine except 
by catheter, and had a large 
phosphatic calculus. More 
than a year later he came with 
a third, requiring four sittings. 
After two years more he came 
with a fourth as large as the 
preceding, and requiring four 
sittings. He died about three 
months after with advanced 
renal and bladder disease. 
This case, with G2 and 220, are 
the only cases in which I have 
removed on four distinct oc- 
casions a large calculus, and 
recorded four operations on one 
individual. 
75 
5> 
56 
J. T. 
Uric; two. 
Successful: sent by Dr. W. 
Morris, of Petworth : was well 
for several (8 or 9) years. Ten 
years after (1875) came with 
symptoms of a year's duration, 
with Mr. W. Hope, of Pet- 
worth, having another uric 
acid stone which I crushed 
with same result as before. I 
record two operations. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
76 
1866 
05 
W. H. 
Phosphatic 
and urates; 
several. 
Successful: passes most urine 
by catheter, having enlarged 
prostate. Dr. M. Foster, of 
Huntingdon, saw this case 
with me. Seven years after, 
in 1873, he had no return of 
calculus, and was in good 
health. In 1878 he had a large 
uric acid stone, and I cut him 
successfully. 
77 
99 
53 
G. M. 
Phosphatic 
and uric. 
Stone removed after much 
trouble. He had chronic cys- 
titis and passed phosphates for 
some months after, sometimes 
with much suffering. Another 
. portion was subsequently re- 
moved. After this, he wrote 
me that he was better than he 
had been for years. Sent by 
the late Dr. Brinton, and Dr. 
Phillips, of Coventry. 
78 
99 
67 
G. S. 
Uric. 
Successful: sent by Dr. C. S. 
Webber, of Connaught Square. 
Had no return and is enjoying 
excellent health (1877), eleven 
years after operation. 
79 
67 
A. W. 
Uric; large. 
Successful: nine sittings. Seen 
only by my assistant, Mr. J. 
Foster: lived several years 
after. 
80 
99 
68 
J. E. 
Uric; large. 
Medio-bilateral: successful: M r. 
Erichsen held the staff. A 
rounded mass, a prostatic tu- 
mour, about an inch in dia- 
meter, came away, and almost 
no bleeding occurred. Patient 
enjoyed good health for several 
years, and died in 1877. 
81 
99 
66 
W. P, 
Uric. 
Successful: the stone small, and 
removed in two sittings. But 
fever following the second was 
severe and prolonged. He 
ultimately became strong, had 
no return of the calculus, and 
was living in 1878. Seen 
throughout by Dr. S. Monck- 
ton, of Maidstone. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
82 
1866 
72 
J. B. 
Phosphatic. 
Successful: passes all urine by 
catheter, prostate very large ; 
perfectly relieved for" several 
months. More than a year 
after he formed another stone, 
which I also successfully re- 
moved. I saw him a year and 
a half after, but there was no 
return. Seen with Mr. C. 
Butler, of Ingatestone. I re- 
cord two operations. 
83 
99 
80 
• 
J. M. 
Uric with 
oxalate. 
Medio-bilateral; not so much his 
age, which was eighty, as his 
bad condition produced by 
several soundings by different 
surgeons made it an almost 
hopeless case from the first. 
Sir J as. Paget agreed with me 
in this, and that the operation 
was his only chance. Sir 
James held the staff, and all 
went well at first, but the 
patient sank exhausted on the 
24th day after operation. 
Death, 
84 
99 
63 
R. H. 
Uric. 
Successful: saw him two years 
after without any return of 
stone symptoms. Seen by Dr. 
Chas. Mayo and by Dr. Tavlor, 
of Guildford. 
85 
99 
69 
T. M. 
Phosphatic ; 
several. 
He had advanced disease of the 
bladder, and an enormous 
prostate ; but was suffering so 
much from his calculi that I 
made an attempt to remove 
them, notwithstanding his 
unpromising condition. He 
gradually sank from debility. 
Seen with Mr. W. S. Foster, of 
Newport. Death. 
86 
99 
74 
W. R. 
Uric acid; 
large. 
Successful : had no return, and 
hunted regularly as master of 
hounds at Faversham after. 1 
saw him quite well five years 
later. Next year he was 
killed, being eighty years old, 
by a fall from his horse when 
hunting. 
87 
99 
66 
H. M. 
Uric; many. 
Successful: no return. I saw 
him well in 1876 when opera- 
ting upon a brother : case No. 
423. OPERATIONS FOR STONE IN MALE ADULTS. 
253 
No. 
Hosp. or 
Private 
Bate 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
88 
1866 
70 
W. A. U. 
Uric. 
Successful: seen with Dr Ead- 
cliffe, of Cavendish Square. 
Lived several years after in 
comfort, and without return of 
symptoms. 
89 
>5 
48 
K. S. C. 
Phosphatic. 
Successful: seen with Dr. Hud- 
son, of Cork Street. 
90 
67 
T. C. 
Uric. 
Successful: no return ; and is 
living now and in good health, 
in 1880. Seen by Dr. G. 0. 
Kees. 
91 
H. 
69 
J. T. 
Uric and 
oxalate. 
Medio-bilateral: Mr. Erichsen 
held the staff. Stone weighed 
2J oz. He sank in fourteen 
days after operation. Death. 
92 
H. 
V 
59 
J. S. 
Uric. 
Medio-bilateral: had peritonitis 
six hours after operation, and 
died in three days. At the 
autopsy, a small opening was 
found at the upper part of the 
bladder, which was soft and 
friable, no doubt made by the 
long staff with a large curve, 
commonly used when the pros- 
tate is large. Death. 
93 
H. 
49 
T. H. 
Uric; two 
large. 
Successful; returned home after 
eight sittings, without any 
symptoms. 
94 
H, 
39 
D. E. 
Uric; large. 
Successful; left after seven sit- 
tings, quite free from symp- 
toms. 
95 
73 
A. F. L. 
Uric; large. 
The stone proved larger than I 
had anticipated. He was 
averse to lithotomy, which 
might have been better for 
him ; and I consented to crush, 
and entirely removed it in 
several sittings, but he died 
exhausted with fever and cys- 
titis. Death. 254 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
96 
1866 
67 
Rev. W. 
H. C. 
Phosphatic. 
n 
A most unpromising case. Signs 
of renal disease existed, oedema 
of the legs, and advanced dis- 
ease of the bladder ; also com- 
plete phymosis. The urethra 
was blocked with phosphatic 
ddbris, and the urine flowed 
involuntarily. I operated first 
on the urethra and cleared it, 
then crushed the stone in five 
sittings, with perfect success. 
The other symptoms were 
greatly relieved. In 1873 he 
called on me in fair health. 
Seen with Mr. P. C. Chadwick, 
of Wrington. 
97 
>5 
70 
Rev. 
H. T. T. 
Uric; seve- 
ral. 
Successful: had no return for 
two years, and continued 
his duty at Bury St. Edmunds 
as before. In 1869 he came 
with another calculus, which 
had recently come down from 
the kidney. It was crushed 
once ; he had no vesical irrita- 
tion, and was doing as well as 
possible, when he died suddenly 
from valvular disease of the 
heart, as his sister had done 
before him. 
98 
55 
T, C. 
Uric. 
Medio-bilateral: made an excel- 
lent recovery, and went back 
to Leighton Buzzard before 
the end of a month. The stone 
weighed oz. 
99 
H, 
55 
M. 0. 
Phosphatic. 
Successful: I saw him a year 
after; no return of the calculus. 
He used his catheter daily, as 
before the operation, having 
long had atony of the bladder, 
and inability to empty its con- 
tents. 
100 
78 
J.C. 
Uric. 
Medio-bilateral: J. Foster held 
the staff. Seen with Dr. Robt. 
J. Black, of De Beauvoir Town, 
No bleeding at the time, but 
much came on after, and the 
wound was plugged. Two 
days after he again had severe 
hemorrhage, and died on the 
eleventh day after the opera- 
tion. Death. 255 
OPERATIONS FOR STONE IN MALE ADULTS. 
No Hosp'or 
| Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
101 
H. 
1866 
40 
W. M. 
Phosphatic; 
two or three. 
He was known to have organic 
renal disease, and I consented 
to remove these small calculi 
to relieve his symptoms. This 
was done in two sittings, and 
he left the Hospital, dying of 
renal disease a month or two 
after. 
102 
H. 
yy 
52 
R. T. W. 
Phosphatic; 
very large. 
Successful; had been cut by 
Syme some time ago, and still 
had fistulous opening. He was 
anxious not to be cut again, 
and begged to be crashed. I 
found a bladder full of calculus, 
not very hard, and consented 
to try lithotrity. In fifteen 
sittings, during two months, I 
removed all; he left cured, 
and lived several years in fair 
health. 
103 
yy 
76 
J. A. 
Uric; two. 
Successful: he lived several years 
without return: seen with 
Mr. Blaker, of Brighton. 
104 
yy 
67 
T. H. P. 
Phosphatic. 
Had a narrow stricture, for which 
I did internal urethrotomy. 
His symptoms not being much 
improved, I examined his 
bladder, found a calculus, and 
did median lithotomy. He 
died on the 21st day after the 
operation. Death. 
105 
H. 
yy 
60 
R. E. 
Phosphatic 
and uric. 
Successful. 
106 
yy 
64 
T. H. 
Uric. 
Successful: no return of calculus 
up to 1877, when I last saw 
him ; was also under the care 
of Dr, Lionel Beale. 
107 
JJ 
75 
J. R. P. 
Uric; large. 
Successful: had no return when 
I saw him next year. Seen 
with Dr. E. Davies, of Gower 
Street. 
108 
1867 
50 
R. L. 
Oxalate and 
phosphatic. 
Large and apparently phosphatic. 
The result of four sittings was 
the removal of a thick layer 
leaving a hard large oxalate 
of lime, which could not be 
crushed. I did lateral litho- 
tomy, Sir W. Fergusson hold- 
ing the staff, and removed a 
stone weighing If oz. Death 
on the third day with peri- 
tonitis. Dr. Owen Rees saw 
him with me. 256 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lifhotrity 
Lithotomy 
Calc. 
Results 
109 
1867 
80 
W. N. 
Uric. 
Severe cystitis after second sit- 
ting ; stone was removed in 
four, but he sank soon after. 
Death. 
110 
H. 
99 
70 
T.G. 
Mixed; 
uric and 
phosphatic. 
Successful: much trouble with 
enlarged prostate and cystitis, 
ultimately left the Hospital 
without symptoms. 
111 
99 
69 
W. J. 
Phosphatic; 
large. 
Enlarged prostate, and habitually 
used catheter. Saw him with 
Dr. Owen Kees, and removed 
calculus in six sittings. One 
year and three-quarters after 
this I crushed another in four 
sittings. Two years more 
elapsed and then I removed a 
concretion or two, af;er which 
he lived without any return 
of stone for a year and a half, 
and died at seventy-five. I 
record two operations. 
112 
99 
61 
L. L. 
Uric; three 
or four small. 
Successful: sent by Dr. Seegen, 
of Carlsbad. 
113 
99 
63 
A. M. 
Uric; three 
or four small. 
Successful: had been seen and 
examined by Mr. Ayerst some 
time previously. 
114 
99 
35 
J. D. 
Uric; three. 
Successful: medio-bilateral, done, 
at his request, although on ac- 
count of extreme exhaustion 
after a voyage of great suffering 
from the Cape, both Sir Jas. 
Paget, who held the staff, and 
I thought him almost abso- 
lutely without a chance of 
recovery. He got well, how- 
ever, slowly, and lived several 
years. 
115 
99 
59 
J. H. 
Uric; very 
large. 
Successful: ten sittings were re- 
quired ; seen with Mr. R. Lamb, 
of Barnsbury. 
116 
99 
71 
Dr. C. 
Phosphatic. 
Successful: had considerable 
prostatic enlargement, and 
passed no urine except by 
catheter. Three years aftf r, I 
removed a second stcne. One 
year later he found his catheter 
so difficult to manage, that 1 
gave him temporary relief by 
opening the bladder above the 
pubes. He died a few weeks 
after. I record two operations. OPERATIONS FOR STONE IN MALE ADULTS. 
257 
No. 
Hoi'.p. or 
Private 
Date 
Age 
Litbotrity 
■ 1 
Lithotomy 
Calc. 
Results 
117 
H. 
18G7 
63 
E. C. 
Uric; large. 
Successful: medio-bilateral. 
118 
69 
S. G. 
Uric. 
A week from first sitting symp- 
toms of blood-poisoning ap- 
peared, with large abscess :n 
the neck. No cystitis, and 
urine clear to the last: seen 
with Mr. Marshall, of Bedford 
Square. Death. 
119 
99 
77 
C. T. 
Uric ; seve- 
ral, small. 
Successful: seen with Mr. E. 
Newton, of Upper Wimpole 
Street. Remained well three 
or four years. More than five 
years after, being eighty-two, 
he formed more calculi, which 
I crushed. He lived two years 
longer, with no return. I 
record two operations. 
120 
99 
64 
W. B. 
Uric. 
Successful: seen by Dr. Gibson, 
of Dundee, under whose care 
he was. 
121 
99 
40 
J. W. B. 
Phosphatic. 
Successful: sent by Dr. Boyd, 
of Durham. He continued 
well above two years, and then 
had fresh symptoms. Three 
years after I found a stone of 
moderate size, and crushed it; 
he has continued well ever 
since, and is enjoying good 
health (1880). I record two 
operations. 
122 
79 
T. 0. 
Uric; three. 
Medio-bilateral: Sir Jas. Paget 
held the staff. We agreed it 
was necessary to relieve his 
sufferings, but were not san- 
guine, from his age and condi- 
tion, as to the result. He sank 
from exhaustion in a few 
days. Death. 
123 
” 
66 
W. B 
Uric. 
Successful: seen with Dr. Allen, 
of Albion Place, Hyde Park. 
124 
” 
35 
s. s. 
Phosphatic. 
Successful: seen with Mr. Price, 
of Stamford Hill. 
125 
1 
| 61 
E. M. 
S 
Uric; large. 
Successful: seen with Dr. 
Heslop, of Birmingham. I 
saw him a year after, perfectly 
well. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Ago 
Lithotrity 
Lithotomy 
Calc. 
Results 
126 
1867 
71 
C. J. s. 
Uric; nu- 
merous. 
Successful: seen with Dr. 
Painter, of Brompton. Some 
were crushed, others washed 
out, not less than fifty or sixty 
in number altogether; he 
lived a year or two after, 
and passed others of a similar 
kind. 
127 
81 
H. L. 
Cystic 
oxide ; 
large. 
Successful; it required nine sit- 
tings. was easily crushed in 
granular debris which came 
away easily ; he made an ex- 
cellent recover)’ and is still 
living (1880). Seen by seve- 
ral of my friends, from the 
rarity of the case. 
128 
” 
67 
S. E. D. 
Uric. 
Successful: the patient had no 
return and is living now 
(1880). 
129 
66 
Lord K. 
Uric ; two. 
Successful: sent by Dr. Thomas 
Keith, of Edinburgh. 
130 
>> 
71 
E. P. 
Uric. 
Successful: a year and a half 
after had a mixed uric and 
phosphatic stone crushed in 
four sittings. After this lie 
lived two years and a half 
without return, and died at 
seventy-five, of some other 
malady. I record two opera- 
tions. 
131 
59 
A. M. 
U ric ; three 
or four. 
Successful; seen with his son, 
the late Dr. Murray ; also by 
Dr. Kelburne King, of Hull. 
Living and in good health, 
without return of symptoms 
(1879). 
132 
— 
71 
B. A. 
Uric. 
Successful: his health was good, 
and no symptoms of fever, 
cystitis, or other disease ex- 
isted. He fell down dead as 
he was walking to the water- 
closet one morning, the cause 
being mitral disease. His 
father and brother had died in 
the same sudden manner. OPERATIONS FOR STONE IN MALE ADULTS. 
259 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
133 
1867 
5? 
A. C. 
Uric and 
phosphate. 
He passed all his urine by cathe- 
ter, which it was necessary 
to use very often, and he suf- 
fered severely. The removal 
of the stone relieved this con- 
dition partially. He con- 
tinued to pass his catheter a 
year or so after, and died of 
disease of the bladder. 
134 
60 
P. N. 
Uric; mime 
rous. 
Successful: requiring ten sit- 
tings for removal. Seen with 
Dr. Nash, of Netting Hill. A 
year after he had a phosphatic 
stone, removed in three sit- 
tings. After this, no return. 
I saw him well in 1870. He 
passed all his urine by catheter. 
I record two operations. 
135 
' 
41 
C. M. 
Uric. 
Successful: Mr. C. Heath pre- 
sent at the first sitting. I 
saw the patient in June, 1874 ; 
no return of symptoms. 
136 
1868 
47 
F. L. 
Uric ; large 
Successful: a patient of Mr. 
Pritchard, of Retford. Nine 
sittings required. He was 
long free from symptoms. 
About three years after he 
came with another large uric 
acid calculus, which required 
seven sittings. Two years 
later (1873) he was quite well. 
In June, 1878, I removed a 
third large uric acid stone, 
and he made an excellent re- 
covery. He writes me quite 
well, July, 1870. I record 
three operations. 
137 
67 
G. P. 
Uric; large. 
Summoned by Messrs. Ceely, of 
Aylesbury, to Wendover, to 
perform the operation (medio- 
bilateral) : it was simple, easy; 
no sign of danger appeared 
during the first three days. 
After this he had a sudden 
seizure of paralysis, and died 
in a few hours. Is this a 
death ‘ due to the operation ’ ? 
138 
H. 
” 
55 
J. S. 
i Uric and 
phoSphatic. 
Successful: a labourer, from 
Essex. Sent by Mr. Baker 
Brown. 
139 
H. 
50 
S. K. 
s 2 
Uric. 
Successful: sent by Dr. Price 
Jones, of Surbiton. 260 
OPERATIONS FOR STONE IN MALE ADLLTS. 
No 
Hosp. oi 
| Private 
J Date 
Age 
j Lithotriti 
! 
' . Lithotom 
y Calc. 
Results 
14 ( 
) H. 
| 1868 
51 
G. S. 
Uric; large. 
Successful: required nine sit- 
tings. Sent by Dr. Lightfoot, 
of Kirkby Moorside, York- 
shire. 
141 
I H 
55 
E. B. 
Uric acid; 
two. 
Successful : a large amount of 
calculus requiring eight sit- 
tings. 
142 
68 
E. R. C. 
Large uric 
and phos- 
phatic. 
The calculus was chiefly uric 
acid, very compact, and only 
coated with phosphates. He 
ought to have been treated by 
1 lithotomy, but strongly ob- 
jected to it. He died after the 
fourth sitting, of severe 
cystitis produced by sharp 
fragments. Death. 
143 
68 
Lord de B 
Uric ; seve- 
ral. 
Successful; had stricture, and a 
small lithotrite was con- 
structed expressly; had had 
diabetes several years. He 
made a good recovery, without 
return, living a year or two 
after, and dying of diabetes. 
Seen with Dr. R merer. 
144 
76 
Sir R. K. 
Uric; two. 
Successful: eight sittings ; seen 
with Sir Thos. Watson. He 
had no return, living several 
years afterwards. 
145 
66 
Lord S. L. 
Uric. 
Successful: passed almost all 
urine by catheter. Three and 
a half years afterwards he 
had severe symptoms, and I 
crushed some small calculi in 
five sittings. In nearly two 
years more 1 crushed another, 
mixed urates and phosphates. 
H e lived a year or two longer, 
suffering severely from in- 
ability to pass any water ex- 
cept by catheter, from phos- 
phatic deposits, and from 
cystitis. Seen with Mr. 
Turner, of Brighton, and 
others. I record three opera- 
tions. 
116 
1 
66 
J. R, 
Uric. 
Successful; very stout, with 
large prostate; stone weighed 
1£ ounce. He lost much blood 
on the first and on the fourth 
day, but ultimately made a 
good recovery. 
117 
i 
H. 
” 
86 
J.K. 
| 
Uric. 
Successful: sent from Saxmund- 
ham, Suffoik. OPERATIONS FOR STONE IN MALE ADULTS. 
261 
No. 
!losp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
148 
H. 
1868 
65 
J. T. 
Uric, 
Large uric acid weighing 2\ 
ounces; removed by Dupuy- 
tren’e bilateral. He died of 
peritonitis on the fifth dav. 
Much dilatation of ureters 
and pelves of kidneys found at 
autopsy. 
149 
68 
W. L. 
Uric and 
phosphatic. 
Lateral: the stone was not very 
large; but the prostate was 
enormous in size. After 
thirty-six hours a rigor fol- 
lowed by suppression of urine, 
and soon after by death. At 
the autopsy, the prostate was 
found as large as a full-sized 
orange; there was no peritonitis. 
150 
H. 
70 
M. D. 
Uric. 
Successful: lateral. Went 
home well in three weeks. 
151 
H. 
58 
S. C. 
Uric. 
Five sittings. After the opera- 
tion was finished, he went out, 
caught cold, and had sore 
throat, followed by oedema 
glottidis, for which laryn- 
gotomy was performed. He 
apparently recovered in a 
week’s time, and the tube was 
removed. Ten days after this 
the oedema reappeared. The 
wound was reopened and the 
tube introduced; but he gra- 
dually sank in four days. 
The autopsy showed the blad- 
der to be perfectly healthy. 
This death cannot therefore, be 
reckoned to lithotrity. 
152 
72 
0. J. 
Uric. 
Successful: was very feeble, the 
bladder was atonied; he 
learned to pass a catheter and 
did so three times a day. He 
returned to Carnarvon, and 
died there a few months after. 
153 
65 
p. p. 
Uric; two 
large. 
Successful: a large quantity re- 
moved in thirteen sittings. 
Seen with Dr. Ringer. A year 
after I crushed a phosphatic 
calculus. He remained well 
some years, but lost power to 
empty his bladder and used 
the catheter. Three years and 
a half later I removed a large 
phosphatic calculus, and he 
lived two years longer without 
return, dying of a cerebral 
affection. Saw him with Mr. 
Sequeira, of Aldgate. I record 
three operations. 262 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Eesults 
154 
1868 
62 
w. c. 
Uric; seve- 
ral small. 
Successful: remained free from 
symptoms one year and a half; 
then had symptoms for ten 
months, and came in November, 
1870. I crushed another, uric 
acid; he made a capital re- 
covery, and lived three years 
after in good health. In 1873 
I crushed another, uric acid ; 
and he left me ■well, as before. 
Seen with Dr. Packman, of 
Ware. I record three opera- 
tions. 
155 
9) 
58 
L. M. R. 
Uric. 
Successful: seen with Mr. R. 
Phillips, of Leinster Square. 
No return for six or seven years. 
In July, 1876, he came, having 
several, uric acid, in his blad- 
der : removed in four sittings ; 
Dr. Bissett Smith and Mr. John 
Morgan present. In June, 
1878, I operated a third time, 
removing several calculi, in 
two sittings, and he made a 
good recovery. I record three 
operations. 
156 
99 
60 
— D. 
Oxalate. 
Successful: seen with Dr. G. O. 
Rees and Mr. Aikin. Living 
in good health, without return 
(1879). 
157 
” 
59 
Mr. Jus- 
tice M. 
Uric and 
phosphatic. 
Successful: seen also with Mr. 
Aikin. No return. Living and 
in good health (1880). 
158 
99 
53 
Rev. 
F. B. 
Uric. 
Successful; lateral. Dr. Keith, 
of Aberdeen, held the staff, 
being in London. A rapid 
recovery. I saw him well in 
1874. 
150 
H. 
29 
J. N. 
Uric. 
Lateral-: stone weighed 2f oz. 
He did well for the first three 
weeks, but got bed-sores a week 
after the operation. I left town 
for my holiday at the end of 
three weeks, expecting him to 
recover, but learned that lie 
gradually sank about a fort- 
night after from exhaustion. 
Death. 
160 
99 
70 
T. H. 
Uric; three. 
Successful; left soon after for 
New Zealand, quite well; seen 
with Dr. Gavin Milroy. OPERATIONS FOR STONE IN MALE ADULTS. 
263 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Eesnlts 
161 
1868 
65 
Dr. P. 
Uric. 
Successful: four years after he 
had no return, but could not 
empty his bladder from large 
prostate, and he learned to pass 
a catheter. Two years after 
(1854), he came with a large 
phosphatic calculus, which I 
crushed successfully. He lived 
more than a year, dying with 
disease of bladder and prostate 
at seventy-three years of age. 
I record two operations. 
162 
H. 
70 
G. B. 
Uric. 
Two days after first crushing he 
had a rigor, and complete sup- 
pression of urine for thirty 
hours. Urine then reappeared, 
but rigors came on again, and 
two days after he died; the 
urine having been clear to the 
last. At the autopsy the bladder 
was found free from inflamma- 
tion; half the calculus was 
there, the rest having passed. 
One kidney was healthy, the 
other showed marks of recent 
inflammation. No disease else- 
where. It is remarkable that 
this state of kidney should 
occur after operation on the 
bladder, without inflammation 
of it, the urine being clear 
throughout. Death. 
♦ 
163 
68 
E. H. 
Uric; large. 
Lateral: seen with Mr. Parsons, 
at Godalming, Surrey. He 
died three days after of peri- 
tonitis. Death. 
164 
72 
D. P. 
Uric; large. 
Lithotomy might have been 
better, the calculus being large 
for crushing. After seven 
sittings, the patient had sup- 
pression lasting thirty-six 
hours, then the urine became 
clear, and subsequently he 
greatly improved, so that I 
crushed again, nearly finishing 
the stone. He gradually sank, 
and died a few days after. At 
the autopsy the right kidney 
showed fatty degeneration, the 
left marks of recent inflamma- 
tion, and an abscess. Two or 
three small fragments were in 
the bladder. Had been under 
the care of Dr. Bayntun, of 
Bath. Death. 264 
OPERATIONS FOR STONE IN MALE ADULTS 
No. 
Hosp. or 
Private 
Date 
1868 
Age 
lathotrity 
Lithotomy 
Calc. 
Results 
165 
58 
G. L. T. 
Uric. 
Successful: seen with Dr. Pi ice, 
of Dublin. I saw this gentle- 
man in excellent health in 
May, 1879. 
166 
62 
S. T. S. 
Uric. 
Successful: seen with Mr. Newn- 
ham, of Wolverhampton. I 
met the patient a year after 
quite well. 
167 
H. 
65 
w. w. 
Uric; large. 
After ten sittings, when the 
greater part was removed, he 
had much fever and cystitis. 
During the next fortnight he 
gradually sank. The autopsy 
showed marks of chronic in- 
flammation of bladder. One 
kidney was tolerably healthy, 
the other contained deposits of 
pus. Death. 
168 
H. 
” 
63 
J. L. 
Uric. 
Much cystitis, but he left the 
Hospital greatly relieved. 
169 
49 
• 
Capt. A. 
Urates and 
phosphates; 
large. 
Successful after nine sittings: 
seen with Dr. Macaldin, of 
Islington. 1 saw him in 1876 ; 
no return of the calculus, but 
learned to use his catheter, for 
loss of power to pass urine by 
his own efforts. 
170 
64 
J. S. 
J.S. 
Uric. 
In October, 1868, I crushed at 
six sittings several small cal- 
culi, after which he had fever 
and orchitis. Then he went 
out of town, and in March had 
abscesses in the perineum and 
parts adjacent. In April, 1869, 
I found a small stone, and per- 
formed lateral lithotomy, Sir 
W. Fergusson holding the staff. 
I opened a very large abscess 
at the first incision, and re- 
moved two small stones. He 
made a slow but good recovery, 
and, being a surgeon, attended 
to his own practice all the 
next autumn and ■winter. 
171 
» 
51 
W. H. W. 
Uric; large. 
Successful after ten sittings: 
seen with Dr. Langmore. I 
saw him well a year afterwards. 
172 
73 
— H. 
Uric; seve- 
ral. 
Successful; seen with Mr. Gar- 
lick, of Bloomsbury. OPERATIONS FOE STONE IN MALE ADULTS. 
265 
Ko. 
Hosp. or 
Private 
Date 
Age 
Litliotrity 
Lithotomy 
Calc. 
Results 
173 
18G8 
55 
A. J. M. 
Uric; large. 
Lateral: went on well until the 
ninth day, when severe hfemor- 
rliage took place, and continued 
. in spite of all efforts to stop it; 
he died from its effects on the 
twelfth day after. Death. 
174 
” 
66 
Capt. D 
Uric. 
Lateral, successful: with Mr. E. 
Newton, of Upper Wimpole 
Street. I saw him in the fol- 
lowing year quite well. 
175 
>1 
68 
Gen. G. 
Uric and 
oxalates. 
Successful: the patient was very 
feeble, requiring constant 
catheterism ; but made a good 
recovery, and returned to the 
country, having learned to pass 
the catheter for himself. Sub- 
sequently he had fever and 
■- ied. Seen with Mr. Barratt, 
of Welshpool. 
176 
” 
69 
J. B. W. 
Uric. 
Successful: a patient of Mr. 
Dansey, of Devonport. In the 
following year I saw him per- 
fectly free from symptoms. 
177 
II. 
yy 
29 
J. K. 
Phosphatic. 
Had advanced disease of kidneys, 
and bad health. I dared not 
cut him, and resolved to offer 
a chance of temporary relief, 
by lithotrity. His case re- 
sembled No. 35. I made two 
small crushings, and he pass;d 
some debris, but I did not 
repeat the attempt. He had 
much albumen in the urine, 
and gradually sank in three 
weeks. The autopsy showed 
marked signs of chronic disease 
of one kidney, with abscess, 
chronic cystitis, and two por- 
tions of phosphatic calculus in 
the bladder. The death was 
due to long-standing renal 
affection. 
178 
1869 
6] 
T. S. B. 
Uric. 
Successful; went back to his 
home at Hammersmith, within 
a month after operation, quite 
well. 
179 
yy 
48 
A. P. 
Uric ; two 
or three. 
Successful: a Turkish admiral, 
who since held an important 
command in the Black Sea 
Fleet in 1877. Seen with Mr. 
J. G. Forbes, of Hyde Park. No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
180 
H. 
1869 
3G 
VV, K. 
Ui ic. 
The lateral; sank gradually, 
fourteen days after. The au- 
topsy revealed advanced dis- 
ease of kidneys. Death. 
181 
67 
T. A. 
Uric. 
Successful; seen once with Dr 
McLeod, of Glasgow. Four 
years after he was obliged to 
use a catheter, from advanced 
prostatic disease, of which he 
died, but had no return of the 
stone. 
182 
32 
F. H. 
Uric and 
oxalates. 
Successful: Mr. Newnham, of 
Wolverhampton, saw this pa- 
tient with me. 
183 
79 
H. VV. 
Phosphates; 
several. 
Successful: nine sittings ; seen 
with Mr. E. Tayloe, of Clap- 
ham. He lived nearly four 
years after, without return of 
stone, although he required the 
catheter for hypertrophy of the 
prostate. 
184 
67 
T. C. 
Uric ; three. 
Successful: seen with Mr. Bos- 
tock, of Horsham. I heard 
from him a year after that he 
had no return. 
185 
74 
P. L. 
Uric. 
Successful; conjointly under the 
care of Mr. Clover and myself, 
and lived several years after 
without return. 
186 
H. 
75 
T. A. 
Uric. 
Lateral ; successful: much gout 
during recovery, which re- 
tarded it, but returned to 
business within three months 
after. 
187 
5? 
62 
Mr. Jus- 
tice D. 
Uric. 
Seen with Dr. R. McDonnell, of 
Dublin. I crushed the stone 
at one sitting, March 31st. 
No fever during first three 
days, and in all respects well. 
Then rigors; urine retained, 
bloody, required catheter, and 
he gradually sank and died 
April 17. Death. 
OPERATIONS FOR STONE IN MALE ADULTS. OPERATIONS FOR STONE IN MALE ADULTS. 
267 
No. 
Hosp. or 
Private 
Date 
Age 
Litiiotrlty 
Lithotomy 
Calc. 
Results 
188 
1869 
73 
R. P. 
Uric and 
oxalates ; 
two large. 
Successful: fourteen sittings ; 
seen with Dr. 0. C. Maurice, 
of Reading. A year after had 
a renal attack, and passed a 
small calculus into his bladder; 
it was removed in two sittings. 
After this enjoyed good health, 
and freedom from his com- 
plaint, living four years 
longer. I record two opera- 
tions. 
189 
99 
72 
C. K. 
Uric. 
Five sittings: seen with Mr. 
Macilwain. Afterwards some 
cerebral symptoms occurred, 
and Dr. Owen Rees saw him. 
In June effusion on the brain 
suddenly appeared, and he died 
in a few hours. The cause of 
death was due to cerebral 
changes of long standing, and 
in so far as the operation weak- 
ened the patient, its effect may 
have been prejudicial, but it 
cannot be regarded as the cause 
of death. 
190 
99 
56 
C. L. 
Uric. 
Successful: seen with Dr. Connor, 
of Battersea. I saw him a 
year afterwards quite well. 
191 
99 
66 
— Y. 
Uric; many. 
Successful: many calculi, of 
different sizes, were removed 
in seven sittings. Seen with 
Mr. Cribb, of Highbury. 
192 
99 
65 
— w. 
Oxalate with 
phosphates ; 
large. 
Lateral. He was very weak, and 
passed all his water by catheter 
(twelve times in the twenty- 
four hours) from enlarged 
prostate : died exhausted seven 
days after operation. Death. 
193 
99 
74 
w. c. 
Uric and 
phosphatic; 
one encyst- 
ed. 
Lateral; from which he re- 
covered. I removed a large 
stone, leaving another impos- 
sible to remove, enveloped in a 
sac, near the neck of the blad- 
der. He died about a month 
after; the autopsy showed that 
this stone could not have been 
removed during life. He cer- 
tainly did not die from the 
operation: the wound nearly 
healed, but much irritation re- 
mained, produced by the re- 
maining stone, which caused 
the fatal result. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
194 
18,69 
G1 
H. S. 
Uric. 
Lateral; after which he made a 
sound but slow recovery. The 
patient is living now, 1879. 
195 
76 
W. P. 
Uric. 
Successful: seen with Sir ffm, 
Fergusson. 
196 
66 
W. F. 
Phosphalic. 
Lateral; successful: sent by Dr. 
Francis, of Northampton. A 
man weighing nearly 300 
pounds. Sir Win. Fergusson 
held the staff. The stone 
weighed above three ounces : 
he made a slow but sound 
recovery, and lived some years 
after. 
197 
H. 
>> 
60 
J. w. 
Uric and 
phosp hatic. 
Successful: went home well, but 
failing to empty bladder by his 
own efforts, formed in a year 
and a quarter a phosphatic 
stone, for which he came again 
to the Hospital for crashing. 
He was taught to use the 
catheter, and wash out blad- 
der, and did so for two years, 
after which his instruments 
were worn out and were not 
replaced. Three years after 
he came with another stone, 
which was again crushed at 
the Hospital, and he was sup- 
plied with instruments as be- 
fore. He wrote in 1875 that 
he continued well; and he 
came in 1879 for advice, but 
without fresh calculus. I re- 
port three operations. 
198 
H. 
26 
TL H. W. 
1 
Oxalates 
and uric. 
A man in the third stage of 
phthisis, was transferred from 
a medical ward to mine with 
severe symptoms of stone. I 
found a small calculus, which 
I crushed in two sittings. He 
was sent back, free from 
urinary troubles, to the phy- 
sician’s ward, where he ulti- 
mately died of phthisis. 269 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
199 
1869 
55 
Lord S. 
Uric; large. 
Seen with Sir Thomas Watson 
and others. The patient had 
slight feverish attacks, and 
several sittings, calculous 
matter, chiefly removed by 
Clover’s bottle. The bladder 
was atonied, and he required 
the catheter several times a day. 
He left town for the country, 
taking daily drives, but he 
gradually lost strength, was 
confined to the house, and sank 
in a few weeks. There was no 
autopsy, but the case was evi- 
denTy one of suppurative renal 
disease and pyelitis. Death. 
200 
>5 
47 
Dr. G. 
Uric. 
Successful: a Russian medical 
man who travelled in great 
suffering from Siberia for tire 
operation, and left well in four 
weeks: was seen by several 
medical men here. 
201 
GO 
E. N. 
Uric ; large. 
Successful: seven sittings : sent 
by Dr. Stilling, of Hesse- 
Cassel. Rather slow recovery, 
but quite well ultimately. I 
saw him in good health in 
1872. Not emptying his blad- 
der then, I taught him to pass 
the catheter. 
202 
„ | 
62 
L.F. 
Uric. 
After the second crushing, had 
pyaemia with affection of the 
joints, and died in ten days. 
Seen with Dr. Baumler, of 
Finsbury Place. Death. 
I 203 
1 
52 
E. D. 
Urie. 
Successful: seen with Mr. Ryot, 
of Newbury. 
OPERATIONS FOR STONE IN MALE ADULTS. 270 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Litliotrity 
Lithotomy 
Calc. 
Results 
204 
1869 
61 
J. B. 
Uric. 
♦ 
Successful: sent by Dr. Savile, 
of East Eetford ; no symptoms 
for a year or two, after which 
they reappeared ; but he did not 
come again until March, 1874, 
■when I found a large uric acid 
calculus, requiring fen sittings. 
On one occasion the lithotrite 
became impacted with calcu- 
lous debris, requiring slight 
operation, and this was fol- 
lowed by good recovery. A 
year andfour months after (in 
1875) he came with a smallish 
uric acid calculus, requiring 
two sittings. Again, August, 
1877: numerous calculi re- 
moved in four sittings. This 
case is not surpassed for rapid- 
ity of uric acid production by 
any I have seen : No. 62 ap- 
proaches it. He is quite well, 
1879. I record four opera- 
tions. 
205 
71 
J. D. 
Uric. 
Successful: seen with Mr. Ryot, 
of Newbury. 
206 
H. 
65 
W. B. 
Uric. 
Successful: nine sittings. Sent 
by Mr. Druitt, of Wimborne. 
207 
H. 
J* 
57 
W. L. 
Uric ; large. 
Ultimately successful : nine sit- 
tings. Discharged in Decem- 
ber, with some irritation of the 
bladder. Returned in March, 
1870, with a small phosphatic 
formation, which was rapidly 
removed. He recovered by 
daily use of injections. Sent 
by Mr. Jalland, of Horncastle. 
208 
H. 
69 
J. M. 
Uric: large. 
Successful; seven sittings. Sent 
by Dr. Canham, of Ramsgate. 
Two years after, having been 
quite well during nine months 
succeeding first operation, he 
came with another, which I 
removed in five sittings. I 
record two operations. 
209 
H. 
65 
VV. IV 
Uric ; large. 
Eight sittings ; much fever and 
debility ; relieved only. 
210 
48 
W. K. 
Uiic 
Successful : a surgeon at Wol- 
verton. His practice called 
him away after four sittings 
within a fortnight. The stone 
was perfectly removed, and bis 
symptoms were rapidly im- 
proving when he left, and I 
heard no more of him. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Litliotrity 
Lithotomy 
Calc. 
Results 
211 
18G9 
73 
Sir R. S 
Phosphatic. 
Successful : had enlarged pro- 
state, and T taught him to 
use catheter, which he did 
four times daily. During next 
three years I often removed a 
small piece of phosphatic mat- 
ter which he failed to wash 
out. In 1874 he had a second 
stone, requiring four sittings; I 
saw him with Mr. W. Lawrence, 
of Chiswick. In the autumn 
he died, during my absence, 
under the care of Mr. Foster, 
at nearly eighty years of age. 
I record two operations. 
212 
75 
Admiral 
R. 
Uric. 
Successful: seen with Dr. Pavy. 
Pursued an active life, and 
enjoyed excellent health for 
several years after. 
213 
69 
Dr. S. 
Uric. 
Successful: a medical man ; six 
sittings; but he left me too 
soon, to attend to practice. A 
year and a half after he came, 
having neglected tc empty the 
bladder, as I had directed, with 
a phosphatic calculus, which 
I crushed. I record two 
operations. 
214 
99 
40 
Dr. M. 
Uric. 
Successful: from Sandown, Isle 
of Wight; an excellent re- 
covery. Saw him four years 
after quite well. 
215 
99 
04 
J. S. J. 
Urates and 
phosphates. 
He submitted to one sitting only, 
by which much was removed; 
he appeared greatly relieved, 
but absolutely declined further 
examination, and I believe 
there was no reappearance of 
symptoms. 
216 
99 
35 
. 
R. J. 
• 
Almost pore 
phosphate 
of lime. 
Successful: had been confined 
during four years to recumbent 
position for curvature of spine, 
under care of Mr. Brodhurst, 
and had made a good recovery. 
This calculus is one of ex- 
tremely rare form ; I saw him 
two and a half years after, 
passing occasionally a little 
phosphatic matter, but with- 
out any symptoms of stone. 
217 
I 
” 
69 
J. B. K. 
Uric. 
Successful: seen with Dr. Price 
Jones, of Surbiton. 272 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
218 
1870 
38 
L. A. T. 
Phosphatic; 
with fatty 
matter. 
Successful : a small mixed cal- 
culus of peculiar kind, the 
basis being triple phosphate 
with organic matter, mostly 
fat: two sittings. There was 
a tendency for this material to 
reappear ; but was quite con- 
trolled by daily washing the 
bladder. Has been perfectly 
free from symptoms for seve- 
ral years; and is enjoying 
perfect health (1880). 
219 
” 
55 
Prof. (4. 
W. E. 
Uric. 
Successful : no return, and in 
perfect health now (1880). 
220 
55 
73 
N. P. 
U ric. 
Successful: seen with Dr. Smith, 
of Little Hadham, Herts. H e 
was quite well, and hunted re- 
gularly for some years after. 
At Christmas, 1874, he came 
up with another, which I 
crushed in six sittings ; excel- 
lent recovery. In January, 
1877, I crushed a third, and he 
recovered rapidly. In January, 
1879, I crushed a fourth, of 
considerable size ; recovery as 
before; never empties his 
bladder now, and passes cathe- 
ter four times a day. Is re- 
markably active, although 
eighty-two years ; but is sub- 
ject to phosphatic deposits, 
which are mostly removed by 
washing the bladder. I re- 
cord four operations. 
221 
H. 
59 
64 
S. G. 
Uric; two. 
Successful: much calculus ; re- 
quiring eight sittings; treat- 
ment delayed by gout. No 
return of symptoms, and now 
quite well (1879). 
222 
H. 
» 
22 
A. R. 
Uric and 
oxalate. 
Successful. 
223 
” 
4!) 
F. S. 
Uric. 
Successful: seen with Mr. J. 
Story, of London. OPERATIONS FOR STONE IN MALE ADULTS. 
273 
No. 
Hosp. 01- 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
224 
1870 
04 
T. B. 
Uric. 
Successful: Mr. Clover gave 
chloroform ; Mr. Foster held 
the staff. In this case the 
end of the male blade had 
snapped off in attempting to 
crush, and I did lithotomy in 
consequence, removing a large 
stone and the portion of blade. 
The only instance in my expe- 
rience in which fracture of a 
lithotriie has occurred. He 
recovered well, returned to 
East Kirkby, Lincolnshire, 
about live weeks after. See 
p. 133-4. 
225 
H 
” 
. 
57 
VV H. 
Uric. 
Successful: had no symptoms for 
two years after: half a year 
later he came with a small 
calculus, which I crushed in 
two sittings, leaving well. I 
record two operations. 
226 
63 
F. J. S. 
Uric. 
Successful: seen with Dr. Dobell; 
had enlarged prostate, and I 
taught him to use the catheter. 
He lived about a year and a 
half after, dying of renal 
disease. 
227 
>> 
70 
A. S. Le 
M. 
Uric and 
phosphatic; 
numerous. 
Successful: for five years had 
passed all urine by catheter; 
much calculus removed in six 
sittings. Seen with Mr. Hill, 
of Stanhope Terrace, Bays - 
water. I saw him five years 
after with Dr. Saunders ; for 
advanced disease of bladder, 
but no return of calculus, and 
he died soon after at seventy- 
six years. 
228 
61 
J. H. 
U ric. 
Successful: sent by Dr. Kilbers, 
of Brighton. 
229 
73 
B. G. 
Uric. 
Successful: sent by Mr. Coles, of 
Yeovil. Remained well nearly 
three years. Soon after I 
crushed a small calculus for 
him at Southsea w-ith Dr. 
Jackson of that place. I saw 
him well here three years after 
that. I record two operations. 
1 230 
71 
I). 
Uric. 
Successful : seen with Dr. Brace, 
of London. 
1 231 
H. 
" 
65 
J. W. 
T 
Uric; large. 
Successful: lateral; with a little 
trouble from anebylosed hip. 
1 A rapid recovery. No. 
Hosp. or 
Private 
Date 
Age 
Litliotrity 
Lithotomy 
Calc. 
Resu'ts 
232 
1870 
GO 
W. F. 
Uric. 
Lateral: stone not large, but he 
had very severe cystitis after 
sounding; and I thought it 
better to cut him at once. He 
died of peritonitis three days 
after operation. John Foster 
held t*'e staff; Mr. Clover 
gave chloroform. Roth father 
and uncle ‘ died of stone.’ 
Death. 
233 
£9 
R. T. 
R. T. 
Phosphatic. 
Successful : lateral; Mr. Clover 
gave chloroform; J. Foster 
held staff. An excellent reco- 
very. Not more than half a 
year after he came with a 
phosphatic calculus, which re- 
quired several sittings to re- 
move. After this was free 
from all symptoms, and remains 
so still (1876). 
234 
55 
74 
W. V. 
Uric ; large. 
Eight sittings: seen with Mr. 
Dickenson, of Chelsea. The 
stone was entirely removed, 
the case appeared to be success- 
ful, and he left town for the 
sea-side. But he had phlebitis 
of one leg: symptoms of 
pyaemia appeared very insidi- 
ously, and proved fatal. Death. 
235 
5’ 
81 
G. C. 
Phosphatic. 
Stricture of urethra: seen with 
Mr. Hilliard, of Shefford, 
Beds: a good illustration of 
the successful application of 
lithotrity to calculus with 
stricture of old standing. See 
p. 194. 
236 
” 
28 
J. C. F. 
M. 
Phosphatic. 
Successful: seen with Dr. 
Sibson. No return of calculus 
when I saw him last in 1874. 
237 
H. 
55 
60 
J. R. 
Uric, plios - 
phatic. 
Successful. 
23 3 
” 
CO 
J. S. 
Uric. 
Successful: seen with Dr. 
Roberts, of Portmadoc, Wales. 
239 
55 
46 
W. A. 
Uric. 
Successful: from Guernsey. I 
saw him well in 1875. 
240 
*5 
51 
C.G. 
Phosphatic. 
Successful, after nine sittings: 
sent by Dr. Blaikie, of 
Oswestrv. 
OPERATIONS FOR STONE IN MALE ADULTS. OPERATIONS FOR STONE IN MALE ADULTS. 
275 
No 
Hosp. or 
Private 
! 
Date j 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results. 
241 
H. 
1870 
72 
R. C. 
Uric ; large 
and small. 
Successful, after seventeen sit- 
tings, of which two were by 
Mr. B. Hill, and two by Mr. 
C. Heath, in my absence ; sue 
cess perfect: the quantity re- 
moved was very large. 
242 
H. 
54 
E. L. 
Uric; large. 
Successful after twelve sittings ; 
sent by Dr. Roberts, of Port- 
madoc. 
243 
H. 
» 
48 
J. P. 
Phospliatic. 
Successful: he was cut for stone 
eight years ago ; lithotrity re- 
cently attempted without suc- 
cess. Health bad ; and has 
stricture which barely admits 
No. 7 ; tied in catheter a few 
days, then operated, removing 
as much debris as possible. 
This process was repeated 
several times, and much calcu- 
lus removed. He does not 
empty the bladder, and passes 
catheter three times daily; 
much relieved. 
244 
II. 
„ 
23 
J. P. 
Phosphatic. 
Successful: great debility-, with 
albuminuria. But his suffer- 
ings made it necessary to 
operate, with great care, during 
ten weeks. Left greatly im- 
proved, and called six weeks 
after to report better health 
than for two years past. 
245 
” 
32 
S. S. 
Phosphatic. 
Had advanced renal disease, 
imder care of Mr. Craven, of 
Hull. I kept him three weeks 
under observation, before 
operating, and did so because 
his suffering was severe ; after 
the fourth sitting he had severe 
fever, was much reduced, and 
slowly sank. Death. 
246 
| H. 
65 
J. M. 
Uric ; four. 
Lateral ; successful. 
247 
! » 
j 66 
w. c. 
Uric and 
phosphatic. 
Successful: seen with Mr. Hart, 
of Chesterfield. Opera! ion fol- 
lowed by some pyelitis; more- 
over, he cannot empty his 
bladder, and uses the catheter 
daily. 
24S 
1 
73 
J. H. 
T 2 
Uric ; three 
or four. 
Successful: much calculus re- 
moved in five sittings. Seen 
with Dr. Carlill. He has ro 
return of his complaint (1877), 
and in good health for eighty- 
j one years. He died in 1878. 276 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
249 
1870 
Vi 
W. L. 
Phosphatic. 
Successful: has passed all urin ; 
by catheter many years, an I 
has a very large and irregula r 
prostatic growth in the blad- 
der. Seen with Dr. Easton, 
of Connaught Square. I heard 
of him two years afterwards, 
as relieved, hut not since that 
time. 
250 
45 
W. G. 
Phosphatic. 
Successful; I saw him with Dr. 
Legouest, a Surgeon in Chief 
in French army. • Was perfectly 
well some years after, and 1 
have never heard of any re- 
turn. 
251 
1871 
70 
P. W. W. 
Uric. 
Successful: seen by Mr. Clover, 
who gave chloroform at each 
sitting. 
252 
57 
W. R. 
Oxalate. 
Successful: also seen by Mr. 
Clover. I saw this gentleman 
in 1878 ; he had no return of 
calculus, and was quite well. 
253 
82 
J. K. 
Uric ; large. 
Lateral: a very large uric acid 
calculus; a few weeks before 
I saw him, spontaneous frac- 
ture had taken place, and 
severe cystitis produced. I 
operated, great as his age was, 
to relieve him of his sufferings. 
He sank during the third week. 
1 saw him with Dr. C. Raj’, of 
Bishop’s Road. Death. 
254 
J? 
71 
P. I. 
Uric. 
Successful: was followed by 
some irritation of bladder, but 
he eventually became quite 
well. Seen with Dr. Southey, 
of Colebrook, Slough. 
255 
07 
J. H. 
Uric ; seve- 
ral small. 
A very stout man, who died sud- 
denly of heart disease a few 
days after first sitting, at 
which most were removed. 
Dr. R. Rej’nolds saw him with 
me, and stated that he had ad- 
vanced mitral disease. 
256 
04 
A. B. 
Uric. 
Calculus removed in three sit- 
tings ; symptoms not relieved : 
these chiefly depended on pye- 
litis, and he lived onh’ a month 
after the operation. Death. OPERATIONS FOR STONE IN MALE ADULTS. 
277 
No. 
I Hoso. or 
Private 
Date 
Age 
Litliotrity 
Lithotomy 
Calc. 
Eesults 
257 
1871 
47 
J. B. 
Urates and 
phosphates ; 
two. 
1 began by crushing, and did so 
four times, removing much. 
But the neck of the bladder 
was peculiarly rigid, without 
prostatic enlargement, and he 
could pass neither fragments 
nor urine. I therefore did 
lateral lithotomy, removing 
the second stone and portions 
of the first. I saw him with 
Mr. Quain.of Cavendish Square. 
He made a good recovery, and 
is quite well (1880). 
258 
50 
W. J. T. 
Uric; large. 
Successful: in eight sittings; 
seen with Dr. R. S. Mair, of 
Bayswater. He returned to 
India, was without symptoms 
for two years, but came over 
in 1874 with fresh symptoms ; 
I found another, and crushed it 
in three sittings, and he again 
left perfectly well. In July, 
1878, he returned, and I re- 
moved another large uric acid 
calculus, in two sittings, by 
crushing and aspirator; and 
he made a rapid recovery. I 
record three operations. 
259 
>> 
S6 
J. N. G. 
Phosphatic. 
Successful: seen with Dr. Har- 
ling, and remains well now 
(1880). 
260 
59 
S. S. 
Uric. 
Successful: seen with Dr. Ham- 
ilton, of Dublin. 
261 
H. 
49 
b. r. 
Uric; very 
large. 
Lateral: made an excellent re- 
covery. 
262 
II. 
60 
J. H. 
Uric. 
Lateral: leaving nothing to be 
desired in its ease and rapidity, 
yet he died of peritonitis on 
the seventh day. The autopsy 
showed sacculi of bladder, one 
inflamed and suppurating 
under surface of the peritoneum 
evidently occasioeing a fatal 
result. Death. 
263 
. 
61 
J. B. 
1 
Uric and 
phosphatic; 
large. 
Successful: in eight sittings, 
with difficulty, from inability 
to pass water without a 
catheter. Three years after he 
formed a phosphatic stone, re- 
quiring four sittings, also suc- 
cessful!y removed. He lived 
not quite two years after. I 
record two operations. 278 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
flosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Oalc. 
Results 
264 
1871 
31 
A. L. 
Phosphates 
and 
oxalates. 
Successful : seen with Dr. Owen 
Rees. He was for some time 
the subject of chronic pyelitis ; 
but leads an active life, with 
good general health (1880). 
265 
61 
A. T. H. 
Phosphatic; 
large. 
Successful ; six sittings : he is 
compelled by prostatic disease 
to pass all his urine by catheter. 
A year and a quarter after he 
came with another, which I 
removed in four sittings. A 
year later he came with an- 
other, removed in five sittings. 
Seen with Sir James Paget, 
and under the care of Dr. 
Bunny, of Newbury, Berks. 
He lived a few months after, 
and died worn out with disease 
of the prostate, &c. I record 
three operations. 
266 
99 
77 
T. B. P. 
Uric ; 
numerous. 
Successful: much debris in six 
sittings. Seen with Dr. 
Wright, of Clapham. I saw 
him a year after, with Dr. 
Wright; free from calculus. 
267 
99 
63 
J. S. 
Uric; 
several. 
Successful; from Orkneys ; seen 
here with Dr. Murray. I 
heard from him a year after 
that he was quite well. 
268 
55 
C. W. 
Uric. 
Successful: seen with Dr. Pal- 
frey. A year and a quarter 
after had a renal attack, and 
another descended from his 
kidney producing symptoms, 
which had before disappeared. 
I found a stone and proposed 
to crush. He declined, and 
commenced to drink ‘ constitu- 
tion water’ to dissolve it. 
During winter and spring he 
drank ‘ fifteen pounds’ worth,’ 
after which a large phosphatic 
calculus was produced. I re- 
moved an enormous quantity 
in five sittings by the lithotrite 
and Clover’s aspirator. He is 
now living and in good health 
(1879). I record two opera- 
tions. 
269 
H. 
99 
52 
J. E. 
Uric, large; 
two. 
Death from pyelitis after first 
sitting. 
270 
” 
66 
J. T. 
Uric. 
Successful: seen by Dr. Chep- 
mell. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
llojp. or 
Private 
Date 
Age 
Litliotrity 
Lithotomy 
Calc. 
Results 
271 
1871 
56 
F. H. 
Fhosphatic ; 
large. 
Successful: a case of unusual 
difficulty; seen with Dr. Chep- 
mell. He had been often 
sounded without discovery of 
the stone ; was unable to empty 
the bladder except by catheter : 
made a perfect recovery, and 
lived three or four years with 
no return : he died of pleurisy 
(1876). 
272 
H. 
99 
66 
T. H. 
Uric. 
The urethra was narrow and he 
passed no fragments by his 
own efforts ; much instrumen- 
ation necessary. After six 
sittings he died exhausted; 
the bladder having been 
throughout unusually irritable. 
Autopsy revealed sacculated 
bladder, chronic pyelitis both 
sides, with deposits of pus in 
one kidney. Death. 
273 
H. 
99 
57 
J. B. 
Uric. 
Successful. 
274 
H. 
» 
20 
J. S. 
Uric ; large. 
Lateral: successful. 
275 
1872 
60 
Col. St. C. 
Fhosphatic. 
Successful: seen with Dr. G. O. 
Bees. Living and in good 
health for several years, dying 
suddenly in 1879. 
276 
64 
W. B. 
Fhosphatic. 
Successful: seen with Mr. Jos. 
Bartlett, of Netting Hill; 
much relieved. He passes all 
urine by catheter; is subject 
to phosphatic deposits, often 
washing them out. A year 
after I removed a little debris 
he had been unable to get rid 
of. 
277 
99 
77 
D. C. 
Fhosphatic. 
Very infirm, and had used 
catheter habitually for years. 
Suffering so much from a phos- 
phatic stone that I ventured 
to remove it, and did so in 
three sittings: soon after 
pyaemia appeared and he died 
in a few days. I saw this 
case with Dr, Travers, of 
Kensington. Death. 
278 
99 
65 
Col. M. 
Uric. 
Successful; sent by Dr. Druitt, 
of Wimborne ; passes most of 
his urine by catheter, and is 
living now and in good health 
(1878). 280 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
279 
1872 
64 
w. c. 
Uric. 
Successful: seen with Mr. Gard- 
ner, of Gloucester Terrace. 
There has been no return, and 
he is enjoying good health (iu 
. 1880). 
280 
H. 
.. 
42 
D. M. 
Uric. 
Successful: sent by Dr. Squire. 
281 
77 
71 
W. P. 
Phosphatic. 
Succe ssful: sent by Mr. Gaskell, 
of St. Helen’s, Lancashire. 
282 
77 
74 
J. M. 
Phosphatic, 
oxalate; 
large. 
Successful: has long passed his 
urine by catheter. Seen with 
Mr. Gardner, of Gloucester 
Terrace. Two and a half years 
after I saw him again,' and 
found he had long been suffer- 
ing much. He had now a very 
large phosphatic stone, re- 
moved in ten sittings, leaving 
him in comfort. I heard that he 
lived a year after, very feeble, 
being then seventy-seven years 
of age. I record two operations. 
283 
77 
67 
J. J. 
Uric. 
Successful: sent by Mr. Snow, 
of Lincoln. 
284 
77 
74 
A. B. 
Uric. 
Successful: sent by Mr. Sweeting, 
of Basingstoke ; no symptoms 
for nearly two years. Two and 
a half years aftei, I crus: ed a 
second uric acid stone, since 
which he has had no return. 
1 record two operations. 
285 
H. 
77 
47 
W. J. M. 
Uric; large. 
Lateral: had albuminuria ; and 
sank after operation, which I 
did to mitigate his sufferings. 
Death. 
286 
77 
59 
J. S. 
Uric and 
phosphates; 
large. 
Successful: seen with Mr. J. B. 
Curtis, of Boston, U.S. He 
required constant cathelerism 
to empty his bladder, and some- 
what neglected this. Next 
year he had another large 
phosphatic stone, which I 
crushed; he then took greater 
care, and has been free ever 
since, being - iu good health 
until 1878, when he died of 
erysipelas. I record two opera- 
tions. 
287 
77 
66 
J. B. 
Uric and 
phosphates. 
Believed: but all his urine had 
long been removed by catheter, 
and he had constant cystitis ; 
no return of stone, but died of 
his urinary maladies next year. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
| Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
llesults 
288 
H. 
1872 
54 
J. M 
Uric and 
phosphates. 
Successful. 
289 
» 
74 
R. B. 
Uric. 
Relieved: seen with Dr. Osborne, 
of Bitterne, near Southampton. 
He had no return of the stone. 
I saw him a year and a half 
after with cystitis, but free 
from calculus. 
290 
yy 
63 
D. G. 
Uric. 
Successful: seen with Mr. T. B. 
Curtis, now of Boston, U.S. 
He had no return of the stone. 
A year after I taught him to 
empty the bladder by catheter, 
since which I have heard no 
more. 
291 
yy 
69 
C. T. 
Uric. 
Successful: seen with Mr. Deve- 
reux, of Tewkesbury. 
292 
yy 
58 
S. L. 
Uric. 
Successful: sent by Mr. Parsons, 
of Godaiming. 
293 
” 
70 
R. R. 
Uiic. 
Successful: Dr. Townshend, of 
Cork, saw this case with me. 
294 
yy 
75 
J. W. 
Uric. 
Feeble, and suffered greatly: 
after the second sitting had 
severe fever, and died ex- 
hausted a week after. Sent by 
Dr. Magrath, of Teignxncutb. 
Death. 
295 
H. 
yy 
66 
T. R. 
Uric. 
Successful. 
296 
» 
63 
W. W. R. 
Uric. 
Successful; sent by Dr. Gibson, 
of Dundee. 
297 
yy 
69 
W. D 
Phosphatic. 
Successful: sent by Mr. Morgan, 
of Stamford. 
298 
” 
79 
G. B. 
U ric. 
Successful: Mr. Clover gave 
chloroform for each of five 
sittings ; had no return, and I 
saw him in fair health in 1874. 
299 
70 
E. H. 0. 
Uric. 
Lateral: bled freely after opera- 
tion, notwithstanding a tube 
well plugged in the wound, 
which was insufficient to com- 
mand the haemorrhage suffici- 
ently. He did not recover the 
loss,' and died in three days. 
Death. 
300 
H. 
» 
70 
R. B. 
Uric. 
Successful: sent by Mr. G. C. 
Tayler, of Trowbridge. Living 
and in good health now (1880). 282 
No. 
Hosp. or 
Private 
Pate 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
301 
H. 
1872 
32 
T. M. 
Oxalate. 
Successful: a perfect result. It 
was the largest oxalate of lime 
calculus I h'd then crushed, 
being not less than an inch in 
diameter. 
302 
SOS 
304 
H. 
» 
60 
C. C. 
Phosphatic; 
large. 
Successful: had been cut by 
Keith, of Aberdeen, some years 
before; not emptying his 
bladder, I taught him to pass 
a catheter. Above a year 
after, he came with another 
rather large stone, which I 
crushed in seven sittings. Now 
quite well (1876). 1 record 
two operations. 
78 
H. P. 
Phosphatic. 
Lateral: I cut him at Brighton, 
with Mr. Turner. He did well 
for a few days, but died ex- 
hausted a week or two after. 
Death. 
62 
H. H. 
— 
Uric and 
phosphatic. 
Successful: seen with Mr. Har- 
rison, of Braintree. 
305 
” 
55 
K. W. A. 
Uric; seve- 
ral. 
Successful: but slow recovery ; 
seen with Mr. Gay Shute, of 
Greenwich. 
306 
57 
S. F. 
Uric; large. 
From Boston, U. S. I found a 
large stone, not before sus- 
pected ; bis health being very 
feeble, be went to the seaside 
for two months, advised also 
by Dr. Wilson Fox, who saw 
him with me. On his return 
two sittings were well borne 
and efficient; after a third he 
had abscess, a long illness, and 
died of exhaustion. Death. 
307 
H. 
» 
68 
W. B. 
Uric. 
Successful. 
308 
75 
D. T. 
Phosphatic. 
Successful; seen with Mr. Moul- 
lin, of Porcbester Terrace; 
passes all urine by catheter. 
I had formerly dilated a stric- 
ture, and had now to repeat 
this before passing a lithotrite. 
Two years later I divided his 
stricture, with great relief, to 
enable him to use a catheter. 
He was then seventy-eight, 
and had no return of stone. 
309 
69 
G. R. J. 
Uric. 
Successful: sent by Dr. Duigan, 
of Gainsborough. 
OPERATIONS FOR STONE IN MALE ADULTS. OPERATIONS FOR STONE IN MALE ADULTS. 
283 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
310 
1872 
36 
J. K. 
Uric. 
Successful: sent by Dr. Hep- 
worth, of Manchester. 
311 
1873 
65 
N. 
Pbosphatic; 
rather 
large ; on 
small uric 
acid nuclei. 
Had suffered symptoms severely 
some years, and when urged to 
submit to examination had 
declined. I had advised sound- 
ing six months before, with 
same result. His health having 
become very feeble, and being 
now confined to the house, 
examination of the bladder 
was for the first time permitted. 
I sounded in presence of Dr. 
Conneau, Dr. Corvisart, and 
Sir Win. Gull, finding a phos- 
phatic stone of the form and 
size of a large date. It was 
agreed to operate by lithotrity. 
Two sittings under chloroform, 
given by Mr. Clover, were suc- 
cessful in removing half the 
stone. The day after he became 
drowsy, evidently from im- 
paired renal function, which 
condition gradually became 
more marked, and he died very 
suddenly the third day after 
the second sitting. The autopsy 
showed very unusual dilatation 
of the ureters and pelves of the 
kidneys, with recent purulent 
deposits in the latter. Death. 
312 
69 
S. D. M. 
Uric ; 
numerous. 
Successful: much removed in 
five sittings; seen with Dr. 
Newton, of Wimpole Street. 
He wrote two and a half years 
after that he was quite well. 
313 
99 
60 
T. C. 
Uric. 
Successful: sent by Dr. D. Man- 
son, of Chesterfield. 
314 
99 
71 
Dr. B. 
Uric. 
Successful: seen with Dr. Beatty, 
of Dublin. 
315 
» 
67 
VV. M. 
Uric. 
Successful: seen with Dr. C. 
Lovegrove,. Belgravia. He 
was free from all symptoms 
four years. He came again in 
Dec. 1878, passing his urine 
by catheter, from retention by 
enlarged prostate, and had a 
pbosphatic calculus, which I 
removed in one sitting. I 
record two operations. 
316 
99 
59 
*ir W.M. 
Oxalate. 
Successful: sent by Dr. Oldham, 
of Brighton. 284 
OPERATIONS FOR STONE IN MALE ADULTS. 
Jso. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
317 
1873 
79 
Sir W.H. 
Uric. 
Successful: seen -with Sir Win. 
Fergusson. He died a year 
after of some other affection. 
318 
64 
(i. M. 
Phosphatic. 
Successful: seen with Dr. Mur- 
chison. He was lunatic; all 
his urine was passed by catheter. 
About two years after I saw 
him with extravasation of 
urine, of which he died. There 
was no return of stone. 
319 
>> 
60 
E. W. 
Uric. 
Kelieved, but evidently has 
symptoms of renal disease, of 
which he died six months after. 
Sent by Dr. Evan Jones, of 
Aberdare. 
320 
>> 
41 
w. s. 
Oxalate. 
Successful: sent by Dr. Smith, 
of Belfast. I have seen him 
(1876) perfectly well. 
321 
H. 
„ 36 
T. W. 
Uric. 
Successful. 
322 
H. 
>> 
63 
W. B. II. 
Uric. 
Successful. 
323 
67 
Capt. E. 
Phosphate 
and car- 
bonate of 
lime. 
Has very severe symptoms; seen 
with Mr. Savory and others. 
Found a calculus imbedded 
between the rectum and the 
neck of the bladder, easily 
detected by finger introduced 
into the bowel. Lithotomy 
was proposed, but he wished it 
removed by lithotrity if pos- 
sible. I extracted it piecemeal 
from the sac in which it was 
lodged, in six sittings. It 
proved to be carbonate and 
phosphate of lime. He lived 
some time after, but the relief 
was only slight. 
324 
H. 
61 
J. M. 
Uric; large. 
Lateral: a little difficulty in 
removing the stone. He died 
next day, and at the autopsy I 
found a small opening in the 
top of the bladder, and some 
blood in the abdominal cavity*. 
I had used a staff, with a long 
curve, which 1 think must have 
gone through a very* fragile 
bladder. It was certainly* not 
done with the knife. See page 
70. Death. OPERATIONS FOR STONE IN MALE ADULTS. 
285 
No. 
Hosp. or 
i Private 
Date 
Age 
Lithotrity 
Lithotomy: Calc. 
Results 
325 
I 1873 
• 
) 56 
Viscomte 
de L. 
• 
Phosphatic. 
Successful: passes no urine but 
by catheter, and this at least 
twenty times a day; very 
feeble. I found a large stone, 
and removed it in six sittings. 
Chloroform given by Mr. 
Clover. He returned to the 
Brazils greatly relieved, pas- 
sing his catheter six times 
only in twenty-four hours. He 
remained thus for a year, and 
then came again with phos- 
phatic deposits which I re- 
moved, relieving him greatly. 
Two and a half years after he 
came again in a pitiable con- 
dition, passing his catheter 
every hour, having a quantity 
of phosphate in the bladder. 
Being now in the last stage of 
chronic cystitis and pyelitis, I 
endeavoured to relieve him by 
removing and washing away 
some of the mortar-like material 
which choked the neck of the 
bladder, so as to enable him to 
use his catheter, but could not 
attempt more. He died ex- 
hausted in a few weeks. 
326 
?> 
36 
K. D. S. 
Uric. 
Successful: chloroform given by 
Mr. Clover ; has had no other 
re urn than a small oxalate of 
lime calculus, impacted in the 
urethra at Nice in 1876, which 
sent him in great haste, suffer- 
ing from retention, to London, 
when I removed it with the 
long urethral forceps. Is quite 
well (1878). 
327 
H. 
66 
W. W. 
Phosphatic. 
He had no albumen in his urine, 
and no signs besides those of 
calculus. After a short and 
easy sitting, had severe rigors, 
and died in five days. The 
autopsy revealed large dilata- 
tion of both ureters. Right 
kidney and ureter much in- 
flamed, as well as tissues sur- 
rounding. Death. 
328 
>> 
65 
E. L. 
Uric. 
Successful: chloroform given by 
Mr. Clover. Mr. Lund, of 
Manchester, present at one 
sitting. 
329 
67 
Prof. C. 
Phosphatic. 
Successful: chloroform by Clover. 
From Philadelphia. OPERATIONS FOR STONE IN MALE ADULTS. 
286 
— 
— 
— 
— 
— 
. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
330 
1873 
()0 
W.N. 
Uric. 
Successful: sent by Mr. Dixon, 
of VVatlington. 
331 
99 
77 
Capt. A. 
Uric. 
Successful: from Chambery, in 
France; chloroform given by 
Mr. Clover and by Mr. Bailey. 
I saw him quite well in 1875. 
332 
99 
67 
Rev. 
C. B. 
Uric. 
Relieved: still symptoms which 
were evidently due to some 
cerebral condition, which con- 
tinued two years after tne 
operation. I saw him with 
Mr. Lund, of Manchester. 
333 
99 
56 
R.S. 
Phosphatic. 
Relieved: symptoms returned 
and grew worse, but no more 
calculus ever found : had now 
signs of tumour of the bladder, 
and died a year and quarter 
after operation from malignant 
disease of the bladder. I saw 
him with Dr. Pearson, of 
Manchester. 
334 
99 
78 
F. C. 
Uric. 
Successful: he persisted in leav- 
ing too soon, as lie felt quite 
well, although I desired him 
to stay and learn to pass a 
catheter, as I believed he did 
not empty his bladder. This 
proved to be the case, for he 
came to me six months after 
with a phosphatic calculus, 
crushed in four sittings, since 
which he has been quite well, 
passing his catheter daily. 
Sent by Dr. Paley, of York, 
and Dr. Hick, of Easingwold. 
I record two operations. 
335 
99 
76 
A. E. 
Uric. 
Successful: but requires to use 
his catheter twice a day. There 
was no return in the summer 
of 1875, when I last saw him : 
with Dr. Griffiths, of Camber- 
well. 
338 
99 
72 
Lord B. 
Oxalate. 
Successful: seen with Dr. Bed- 
dard, of Nottingham. Perfectly 
well (1880). 
337 
99 
63 
J. P. 
Uric. 
Successful: sent by Mr. Parker, 
of Newton-Malpas, Cheshire. 
I heard from Mr. Parker, in 
summer of 1875, that he was 
perfectly well. OPERATIONS FOR STONE IN MALE ADULTS. 
287 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
338 
1873 
70 
Capt. F. 
Uric. 
Successful: sent by Dr. Watson, 
of Dundee. 
339 
H. 
>> 
59 
J. c. 
Uric. 
Lateral; successful. 
340 
75 
T. G. 
Uric. 
Lateral; successful. Clover gave 
chloroform. He died next 
year of diseased liver. 
341 
1874 
GO 
Col. H. 
Uric. 
After removing one, I found a 
second stone, the existence of 
which I had not suspected, and 
so had rather too much to dis- 
pose of by lithotrity. However, 
I emptied the bladder com- 
pletely in ten sittings. Much 
irritation remained for some 
time, slowly diminishing. He 
now withdraws all his urine 
by catheter. Seen with Mr. 
Blaker, of Brighton. See also 
No. 431. 
342 
Gl 
Rev. J. I’. 
Uric. 
Successful: sent by Dr. Roberts, 
of Carnarvon. 
343 
„ 
70 
VV. A. A. 
Uric. 
A small calculus successfully re- 
moved, but much irritation 
continued, from inability to 
empty the bladder, &c. He 
died in little less than a year, 
when much sacculation was 
found, hut no remains of the 
calculus existed. Seen with 
Mr. Ellis, of Sloane Street. 
344 
„ j 62 
J. N. 
Uric. 
Successful: seen with Dr. Mac- 
donald, of Inverary. 
34& 
H. 
36 
J. L. 
Rhospliatic. 
Lateral: recovering rapidly, eat- 
ing his chop daily and sitting 
up, when he was attacked with 
erysipelas, which prevailed in 
the Hospital. He was recover- 
ing from this and regaining 
appetite, when he had a second 
attack, from which he never 
rallied, and he died six weeks 
after operation. I cannot re- 
gard this as a death due in any 
way to the operation. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Litliotrity 
Lithotomy 
Calc. 
Results 
346 
1874 
67 
H. B. 
Uric; 
oxalate. 
Mr. Clover gave chloroform, but 
with especial care, since he was 
subject to ‘angina pectoris,’ 
and it was a question whether 
he should have chloroform on 
this account. A few days after 
the second sitting, being as 
well as usual and seated in bed, 
he was seized with one of his 
attacks and died in a few 
minutes. 
347 
72 
Sir R. C. 
Uric. 
Successful: seen with Dr. Sibley. 
Xo return, and is perfectly well 
now (1880). 
348 
64 
Sir F. S. 
Phosphatic; 
large- 
Successful: seen with Dr. Hol- 
man, of Reigate. Xo return, 
and is quite well now (1880). 
He passes all urine by catheter. 
349 
51 
F. C. 
Uric. 
Successful: seen with Dr. Allan, 
of Islington. Was perfectly 
well when last heard of, 1875. 
350 
>> 
50 
c. c. 
Uric. 
Successful: Mr. Lawrence, of 
Hammersmith, was present at 
the operation: no return in 
1875. 
351 
V 
65 
T. M. 
Phosphatic. 
Successful: he continues to pass 
all urine by catheter, as for 
several j ears past. A year 
and quarter after I removed 
phosphatic matter from the 
bladder, and he continued well 
long afterwards. Sent by 
Mr. Meadows, of Ipswich. 
352 
60 
Rev. W. 
P. M. 
U ric. 
Successful: seen bv Dr. Lambert, 
of Sunderland. Xo return when 
I saw him last, 1877. 
353 
>> 
68 
J. L. 
Uric ; large. 
Successful : seen with Dr. Lam- 
bert, of Sunderland, who wrote 
a year and a quarter after that, 
his condition was ‘ perfectly 
satisfactory.’ 
354 
61 
G. W. S. 
Uric. 
Successful: seen with Dr. Helks- 
ham, of Brixton, who wrote 
me next year he was quite 
well. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
355 
1874 
69 
J. A. L. 
• 
Uric and 
phosphates ; 
large. 
Successful: sent by Mr. Free- 
man, of Stowraarket, Suffolk. 
He continued in excellent 
health and without return', 
using the catheter daily, as the 
bladder could not empty itself. 
A year after he had a paralytic 
seizure, and died. 
356 
yy 
59 
G. S. 
Uric. 
Successful: known to Mr. Hick, 
surgeon, of Easing wold, York- 
shire. 
357 
yy 
57 
J. C. 
Uric. 
Successful: sent by Mr. G. 
Grewcock, ofFolkingham, Lin- 
colnshire. I saw him in sum- 
mer of 1875, perfectly well. 
358 
yy 
73 
Dr. V, 
Phosphatic; 
large. 
Relieved : he has long been the 
subject of enlarged prostate 
and chronic cystitis, and fre- 
quent catheterism is necessary. 
Seen with Dr. Evershead, of 
Arundel. 
359 
63 
J. R. 
Uric and 
phosphatic. 
Successful: seen with Dr. Jami- 
son, of St. Helen’s. He passes 
all urine by catheter from 
hypertrophied prostate. A 
year and half after (Nov. 1875) 
he came with a rather large 
phosphatic calculus ; removed 
in four sittings : the pain dis- 
appeared, but necessity for 
catheterism exists as before 
(1876). Subsequently his 
bladder was more irritable, the 
use of the catheter more fre- 
quent, and I removed twice a 
small concretion, which he had 
failed to wash out. He died, 
in 1878, with chronic disease 
of the ureters and kidney, 
but without any further stone 
formation or operations. I re- 
cord two operations. 
360 
yy 
55 
Rev. 
G. B. M. 
Uric. 
Successful; sent by Dr. Grif- 
fiths. 290 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Oalc. 
Eesults 
361 
1871 
59 
R. S. 
Uric. 
But little relief followed: severe 
cystitis continued; he re- 
turned to the country, and 
improved for a time. A few 
months after I went there to 
see him, meeting Mr. George, 
of North Thoresby, Lincoln- 
shire; he was suffering from 
advanced renal disease, and he 
died not long after. The stone 
had been removed, but he died 
of disease of the kidneys. 
362 
43 
E. W. R. 
Uric. 
Successful : but he made a rather 
slow recovery. Seen with Mr. 
Bainbridge, of St. Martin’s 
Lane. 
363 
H. 
67 
T. W. 
Uric. 
Successful. 
364 
?> 
71 
— T, 
Uric. 
Successful: seen with Mr. 
Roberts, of St. John’s Wood. 
365 
” 
72 
Sir A. A. 
Uric. 
Successful: seen with Mr. Tjder, 
of Devonshire Street. 
366 
H. 
59 
Wm. A. 
Uric; large. 
Lateral; a good recovery: he 
was a very stout man, ■weigh- 
ing 19 stone. 
367 
69 
P. G. 
Uric and 
phosphates. 
Successful: Mr. Clover gave 
chloroform on each of his three 
sittings, and he made a rather 
slow but sound recovery. 
368 
60 
R. P. 
Uric. 
Successful: slow recovery, hut 
ultimately became free from 
symptoms : seen by Mr. Cadge, 
of Norwich. 
369 
64 
Capt. T. 
Uric. 
Successful: seen with Mr. 
Roughton, of Kettering. Is 
living now and in fair health 
(1876). 
370 
» 
61 
A. G. H. 
Phosphatic ; 
large. 
Lateral: died the fourth day 
after, with symptoms of urae- 
mic poisoning. Death. 
371 
81 
Gen. S. 
Uric : two 
or three. 
Prostate very large; notwith- 
standing which and his age, 1 
consented to operate, his pain 
being very considerable : had 
retention after first sitting; 
severe fever, and died of ex- 
haustion a few days after 
second sitting. Death. OPERATIONS FOR STONE IN MALE ADULTS. 
291 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
372 
1874 
65 
J. T. L. 
Uric and 
phosphates. 
Successful: seen with Mr. Butt, 
of Mayfair: passes his catheter 
daily from enlarged prostate 
and continues to do so. Next 
year had symptoms due to 
some phosphatic matter, which 
I removed. All urine is now 
passed by catheter, using it 
eight times in twenty-four 
hours. Subsequently, he had 
a paralytic attack, but he still 
enjoys fair health. I saw him 
last with Dr. Jackson, of Net- 
ting Hill (1879), with irri- 
tability of bladder, but there 
is no return of calculus. 
373 
57 
Dr. 
R. H. P. 
Uric. 
Successful: from Danville, Illi- 
nois, U.S. Mr. Clover gave 
chloroform for each of five sit- 
tings : heard subsequently that 
he is perfectly well. 
374 
H. 
61 
C. M. 
Uric. 
Health bad ; suffering severe: 
urine clear, but always albu- 
men : lithotrity has been twice 
lately attempted without suc- 
cess. I crushed twice ; ddbris 
freely passed. After second 
sitting he gradually failed, 
and died in a few days. Au- 
topsy showed both ureters 
much dilated and left kidney 
large. Death. 
375 
>> 
62 
A. R. 
Uric and 
phosphates. 
Successful: Dr. Levis, of Phila- 
delphia, saw this patient with 
me. 
376 
1875 
70 
E. C. 
Phosphatic; 
large 
Lateral; successful: Mr. Clover 
gave chloroform. Heard from 
him a year after that he was 
quite well. 
377 
69 
T. B. 
Uric ; large. 
Lateral: recovery slow, but went 
home well: lived a year after, 
and died of some affection not 
connected with the bladder. 
Mr. Clover gave ether. 
378 
62 
M. H. 
Oxalate. 
Successful: Dr. Colegate, of 
Eastbourne, was present. 
379 
>> 
83 
J.T. 
Phosphatic. 
Successful: seen with Dr. Ac- 
land, of Oxford ; requires 
catheterism daily: has been 
greatly relieved. Died in the 
summer of 1877 from ol 1 age, 
without return of stone. 292 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
380 
1875 
Cl 
C. M. 
Uric ; two. 
Successfully and easily removed, 
but he did not empty the 
bladder by his own efforts, and 
deliberately neglected my in- 
structions to pass a catheter 
regularly. Hence he had 
phosphatic deposits frequently, 
which I removed with the 
lithotrite, and he had chronic 
cystitis during the year. But 
he persisted in his neglect, and 
I lost sight of him. 
381 
11 
22 
A. B. 
' ■ 
Oxalates and 
urates. 
Improved: the subject of chronic 
pyelitis, and often forms phos- 
phatic deposits, which I re- 
moved. Sent by Mr. Diver, of 
Warlingham. I last saw him 
in 1879 ; he has recovered from 
the tendency to produce de- 
posit, and is almost well. 
382 
11 
80 
Capt. D. 
Uric* 
Lateral: saw him with Sir 
James Paget, who agreed with 
me that lithotomy would be 
better than lithotrity. Made 
a rapid recovery, left London 
(for Exeter) three weeks after 
operation, and is living and 
active in 1880. 
383 
73 
Rev. J. E. 
Uric. 
Successful: seen with Dr. Evans, 
of Gloucester. 
384 
11 
71 
E. W. 
Uric ; two. 
Successful: has been recently 
under the care of Mr. Van 
Buren, of New York, who sent 
him to me. 
385 
11 
C3 
R. Gr. 
Uric; large. 
Successful: sent by Dr. Boyd, of 
Durham; heard that he died 
of malignant disease of blad- 
der, 1879. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
386 
1875 
66 
J. D. 
Uric; two ; 
one large. 
After six sittings much fever ; 
and it was obvious that he is 
the subject also of disease of 
the kidneys. He left town for 
Tottenham. He took daily 
exercise, and next month was 
able to call on me. Soon after 
had symptoms of uraemia and 
died. The autopsy showed 
that the bladder had been 
completely emptied ; it was 
sacculated, and in one of the 
sacs two small calculi were 
found: the ureters much 
dilated, both kidneys diseased, 
one almost disorganised. It 
is impossible to consider this 
death due to operation. 
387 
70 
VY. S. 
Uric; large. 
Successful; sent by Mr. G. 
Evans, of Seaton, Axminster, 
Devon. 
388 
» 
70 
General 
M. 
Uric; large. 
Four days after the last sitting, 
a swelling appeared over right 
hip; another in the neck; 
others afterwards, during 
nearly a month ; he died of 
pyaemia, twenty-eight days 
after last sitting. Seen with 
Dr. Maclean, of Netley. Death. 
389 
70 
M. D. 
Uric and 
phosphates. 
He was obliged to use the 
catheter daily, and much irri- 
tation always present. He 
left my care the 1st of June 
for his house in the suburbs, 
where he was doing well. On 
the 13th he worked in his gar- 
den, came in chilled, had 
severe bleeding, which greatly 
weakened him, and died on 
the 17th. I saw him with Dr. 
Yintras, who made an autopsy 
and wrote as follows:—‘ The 
left kidney much atrophied, 
not weighing more than 1 \ 
oz.: the right weighing over 
a pound, and extensively 
diseased, with traces of recent 
haemorrhage. The bladder 
bore no signs of recent inflam- 
mation, the prostate much en- 
larged, and prostatic portion 
of the urethra quite free from 
any trace of recent irrita- 
tion.’ The death was in no 
degree due to the operation, 
from which he had completely 
recovered. 294 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
390 
1875 
22 
J. M. 
Uric ; large. 
Lateral: much bleeding, and I 
used a tube tightly plugged. 
He made a good recovery. 
391 
” 
68 
Rev. H. 
W. 
Uric; two. 
Successful: sent by Dr. Gram- 
shaw, of Walton, Suffolk. 
392 
” 
71 
J. D. 
Uric; large. 
Successful; seen with Dr. Jack- 
son, of Islington. 
393 
65 
G. T. K. 
Uric, 
Greatly improved: seen with 
Dr. Slack, of Leamington. 
394 
63 
J. G. G. 
Uric. 
Successful: sent by Dr. Ander- 
son, of Coventry. 
395 
66 
S. S. 
Large mass, 
of three 
uric cal- 
culi, hound 
together, 
phosphatic. 
Lateral: excellent recovery ; 
seen with Dr. Tuke, of Chis- 
wick. In perfect health (1880). 
396 
65 
J. F. B. 
Uric; three. 
Successful, after a severe and 
prolonged attack of pyasmic 
deposits in various parts, end- 
ing in recovery; seen with 
Dr. Sibson. Lithotomy in 
J uly 1878, with Mr. P. Hewett; 
and now well (1880). 
397 
69 
T. H. 
Uric. 
Successful: seen by Mr. Clover. 
Saw him, summer of 1876, 
perfectly well. 
398 
62 
C.T. 
Uric. 
Successful: Dr. Joseph Luke, of 
Newington, present; a rapid 
recovery. Quite well (1878). 
399 
yy 
70 
T P. 
Uric. 
Left too soon, and returned with 
chronic cystitis ; improved by 
removal of phosphatic matter 
and by learning to wash out 
his bladder. He is now much 
better and fairly active. Sent 
by Dr. Gibb, of Newcastle. 
400 
” 
26 
F. C. 
Uric. 
Median : he made an excellent 
recovery; was sent by Dr. 
Watts, of Frampton-on- 
Severn. 
401 
yy 
67 
J. T. R. 
Uric and 
phosphates. 
Successful: passes his water by 
catheter : seen with Dr. Luke, 
of Newington, No return 
(1876). OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
402 
1875 
66 
H. 0. N. 
Uric; nu- 
merous. 
For years has passed all urine by 
catheter, and small calculi 
have accumulated in bladder ; 
amount of debris very large. 
Five long sittings, under ether 
by Clover. Much irritation 
after ; chronic cystitis severe, 
and catheterism frequent. 
Next year he got worse, and 
during my absence from town 
was cut by Mr. C. Heath, who 
removed a phosphatic cal- 
culus. 
403 
99 
64 
H. H. 
Uric. 
Successful: uses catheter to 
empty bladder, and has chronic 
cystitis. Seen with Dr. E. 
Marten, of Paris. 
404 
99 
61 
A. F. 
Uric. 
Relieved: uses catheter to empty 
bladder. Clover gave ether, 
and has done so since to re- 
move phosphatic matter, which 
formed for some time. But 
he is in excellent health now 
(1878). 
405 
1876 
71 
R. Q. 
Uric ; seve- 
ral. 
Successful: seen with Sir Wil- 
liam Jenner; quite well 1880. 
406 
99 
62 
E. B. W. 
Uric. 
Successful: seen with Mr. Wal- 
ford, of Ramsgate ; saw him 
quite well in summer 1877. 
407 
99 
68 
B. W. 
Uric; very 
large. 
Lateral: a rapid recovery : seen 
with Dr. Mitchell, of New 
Cross ; was in good health in 
1878. 
408 
99 
63 
J. A. 
Oxalate. 
Successful: seen with Surgeon- 
Major Harris, Indian Army. 
409 
73 
64 
T. B. 
Phosphatic. 
Successful: seen with Dr. Buz- 
zard, of Grosvenor Street: 
passes all urine by catheter ; 
occasionally forms phosphatic 
matter which requires to be 
removed. In excellent health, 
and no return during last two 
years (1880). 
410 
99 
Rev. D. 
M. 
Uric. 
Successful; seen by Surgeon- 
Major Harris; much irritation 
for some time after. Then 
had excellent health, and little 
trouble. I washed out a small 
concretion, 1879. Heard of 
his death 1880. 
295 296 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
411 
1876 
64 
W. J. D. 
Phosphatic; 
very large. 
He passes all urine by catheter, 
twelve times in twenty-four 
hours; health very bad. I 
removed a large quantity in 
eight sittings, under ether by 
Mr. Clover; and at length 
verified existence of an encys- 
ted portion at the side of the 
bladder, which I can seize but 
not move. Much relieved; 
but unfit for further operation. 
Seen by Dr. Harris and 
others. 
412 
68 
G. J. 
Uric. 
Successful: Dr. J. A. Pepper 
saw him -with me. 
413 
40 
R. F, 
Oxalate. 
Lateral: seen with Dr. F. N. 
Hall, of Bermondsey ; recovery 
rapid. 
414 
68 
J. C. F. 
Oxalate. 
Successful: seen with Mr. A. R. 
Martin, of Chatham. 
415 
69 
— E. 
Uric; one 
very large 
and one 
small. 
Lateral; seen with Mr. T. L. 
Read, of Kensington; capital 
recovery. Living and in good 
health (1879). 
416 
60 
J. J. G. 
Uric. 
Successful: a year and half ago 
Mr. B. Holt crushed a stone 
for him. Another has formed, 
requiring four sittings. 
417 
” 
53 
T. W. 
Uric. 
Lateral: very stout; weighs 20 
stone; seen by Mr. Knox, of 
Bakewell; an excellent reco- 
very. 
418 
47 
J. S. 
Oxalate and 
phosphate. 
Successful: sent by Dr. Mather, 
of Glasgow. 
419 
55 
E. R. 
Uric. 
Lateral: Mr. Henry Smith, of 
King’s College, saw the case 
with me; healing almost by 
first intention ; no urine by 
wound after second day. Ex- 
cellent recovery. 
420 
65 
F. 0. H. 
Oxalate. 
Lateral: Mr. Henry Spencer 
Smith saw the case with me ; 
little or no water after opera- 
tion, except by catheter. On 
seventh day after a little urine 
passed by rectum, and urethro- 
rectal fistula since (1877), 
now greatly improved (1880) ; 
he is in excellent health, and 
takes horse exercise. OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
421 
1876 
55 
Dr. C. 
Oxalate. 
Successful: sent by Mr. Bow- 
man, of Clifford" Street; be- 
longs to the Indian service, 
and has done many operations 
for stone there. Saw him 
summer 1880, in perfect health. 
422 
yy 
55 
Gen. S. 
Uric. 
Successful. 
423 
yy 
72 
Lord H. 
Phosphatic. 
Successful: passes no urine 
except by catheter ; seen with 
me by Sir William Jenner. 
424 
yy 
58 
G. B. 
Uric. 
Repeated rigors ; organic disease 
of the kidneys present. He 
died in a week; autopsy 
showed dilated ureters and 
pus in the pelves of the kid- 
neys. Sent by Mr. Maling, of 
Sunderland. 
425 
yy 
60 
H. J. P, 
Phosphatic. 
Successful: seen by Mr. Wor- 
thington, of Lowestoft; has 
passed all urine by catheter. 
426 
yy 
79 
The Mar- 
quess of 
G. 
Uric; large. 
Lateral: performed as a last re- 
source, in consequence of great 
suffering; had declined it 
when advised at an earlier 
period. He sank on the fifth 
day from exhaustion: seen 
with Sir W. Jenner, Mr. P. 
Hewett, and Mr. Tagart. 
Death. 
427 
yy 
59 
W. S. 
Uric. 
Successful: sent by Mr. H. G. 
Moore, of Ipswich. 
428 
yy 
66 
W. F. B. 
Uric. 
Successful: seen with Dr. Bisset 
Smith, of Birmingham, and 
Mr. J. Morgan ; passes urine 
by catheter. In September, 
1877, a second stone (phos- 
phatic) removed in three sit- 
tings : passes all urine by 
catheter. Had no return, and 
died suddenly of some other 
malady in 1879. I record two 
operations. 
429 
| 
64 
E.B. P. 
Uric. 
Successful: sent by Dr. Palfrey. 298 
OPERATIONS FOR STONE IN MALE ADULTS. 
No. 
Hosp. or 
Private 
Date 
Age 
Lithotrity 
Lithotomy 
Calc. 
Results 
430 
1876 
74 
— F. 
Foreign 
body, 
coated with 
phosphates. 
The last inch of a vulcanized 
catheter broke oft- in his blad- 
der ; severe symptoms since. 
I removed a quantity of phos- 
phatic matter; then seized a 
yielding mass, and after a few 
trials withdrew the fragment 
by the urethra ; success com- 
plete. 
431 
63 
Col. H. 
Phosphatic. 
Lateral: successful; seen with 
Mr. Blaker, of Brighton. 
Same as No. 341, for whom I 
performed lithotrity two and a 
quarter years before. He is 
quite well (1877), passing 
urine by catheter as before. 
432 
433 
66 
R. E. M. 
Uric. 
Successful: Dr. Miller, of 
Chicago, present on each of 
two sittings ; excellent health, 
and no return (1879). 
70 
T. A. 
Uric. 
Lateral: excellent recovery. 
Seen with Mr. Wakefield, of 
Nottingham Place; passes all 
urine by catheter. In good 
health (1880). 
434 
75 
N. G. 
Urates and 
oxalates. 
Very feeble, and died soon after 
an attack of fever. Death. 
435 
71 
Dr. J. F. 
M. 
Phosphatic. 
Successful: seen with Dr. A. S. 
Heaton, of Detroit; requires 
frequent use of the catheter 
from enlarged prostate. 
436 
64 
W. L. 
Uric. 
Successful: seen with Dr. E. 
Lynes, of Coventry. 
437 
?• 
72 
G. I. W. 
F. 
Uric. 
Lateral: from pyaemia in a few 
days. Death. 
The above is the number (437) of individuals, on whom the 500 operations were 
performed; viz., 422 of Lithotrity, and 78 of Lithotomy. See pages 206-8. INDEX. 
PAGE 
Addekbrooke’s Hospital cases . 112 
Adherent calculus . . .99 
After-treatment: Lithotomy . 39 
„ „ Lithotrity . 166 
Age, influence of . . .114, 224 
Ages of stone patients . .113 
Ages of 422 cases of Lithotrity , 204 
Allarton’s operation . . .48 
Analysis of Lithotrity cases . 204 
Anaesthesia in Lithotrity . 176-182 
Anatomy of perineum ... 6 
Angular staff . . . .51 
Anklets for Lithotomy , ,18 
Aspirator, Clover’s . . .165 
„ author’s . . .186 
„ how to use . . . 187 
„ value of, for last frag- 
ments .... 163, 188 
Assistants in Lithotomy . . 21 
Atony of bladder . . ,197 
Author’s cases of Lithotomy . 118 
„ „ Lithotrity 71, 238 
Bell (John) on the gorget . 31 
Bigelow’s modifications of Litho- 
trity. . . . . .183 
Bilateral operation . . 45, 119 
Birmingham Hospital cases . 112 
Bistouries cachees . • 33, 46 
Bladder, atony of . . .197 
„ sacculation of . ,197 
„ tumours of . . .197 
Bleeding after Lithotomy , . 37 
Blizard’s knife . . . .28 
Brodie on first incision . . 25 
„ his knife . . . .31 
PAGE 
Brodie on small incisions . . 66 
,, on spasms of the bladder 98 
Brodie’s cases of Lithotrity 202-205 
Brown’s tampon for haemor- 
rhage 19 
Bryant (Mr. T.), cases from . 112 
Buchanan’s operation . .51 
Cadge (Mr.) on encysted calcu- 
lus . . . .95 
„ record of cases from . 119 
Calculi left after Lithotomy . 102 
„ different modes of frac- 
ture . . . .222 
„ of large size . . 86-90 
„ modes of removing . 87-91 
„ brittle . . . .93 
„ multiple .... 199 
„ encysted . . .94, 97 
„ adhering . . . .99 
Calculous incrustation . . 108 
Calculus, recurrence of . . 213 
Case of encysted calculus . . 94 
Cases of Lithotrity at a single 
sitting . , .190 
„ operation by author, 
five hundred . 71, 238 
„ composition of calculi . 216 
Catheters, evacuating . . 164, 187 
Causes of death after Lithotomy, 
„ „ in the adult . 63 
„ „ in children . 74 
„ „ Lithotrity . 208 
Central operations ... 4 
Characters of stone . . .221 300 
INDEX, 
PAGE 
Cheselden on injecting bladder . 21 
„ on first incision . . 25 
„ his gorget . . .30 
„ on dilating neck of 
bladder . . .67 
„ practice of. . .115 
Children, Lithotomy for . .56 
,, median operation for . 57 
,, causes of death in .74 
„ difficulties peculiar to . 79 
„ Lithotrity for . .177 
Chloroform in Lithotrity . 177, 182 
Choice of operation . . . 230 
Civiale on medio-bilateral Litho- 
tomy 46 
Civiale, his trilabe for exploring 162 
„ his practice . . 203, 233 
Cline’s gorget . . . .30 
Clover’s apparatus . . . 165 
Compact calculi .... 222 
Composition of calculi . 216-222 
Conclusions, final . . 180, 229 
Condition of patients after Litho- 
trity 212 
Conditions necessary to Litho- 
trity 124 
„ „ to a good 
lithotrite . . . . .129 
Construction of lithotrites . . 128 
Coulson on first incision , . 25 
Crichton on first incision . . 25 
„ his use of the gorget 32, 86 
„ bn healing by first in- 
tention , . 40 
„ on encysted calculus . 95 
„ on large calculi . . 86 
Crosse (Mr.) on Norwich Museum 111 
Crushing the stone in Lithotomy 87,92 
Cutting and crushing combined . 55 
Cylindrical lithotrite 137,148,153,161 
„ sound . . . 220 
Cystitis after Lithotrity . .173 
Danger of violence in extract- 
ing 64-69 
Death, causes of, after Lithotomy 62 
„ „ in Lithotrity . 208 
Deaths, table of . . . . 209 
PAGE 
Deaths, from errors in the opera- 
tion . . .63 
„ „ defects in the pa- 
tient’s system . 71 
„ causes of, in children . 74 
Deep incision in Lithotomy . 76 
Details of lateral operation . 20 
„ of instruments for . .14 
Detecting the stone early . . 234 
Diagnosis of sacculated bladder . 197 
„ „ stone . . . 217 
Diagrams of incisions :— 
Lateral Lithotomy . . ,34 
Bilateral Lithotomy . . 46 
Medio-Bilateral Lithotomy . 47 
Median Lithotomy . . .49 
Buchanan’s operation , . 52 
Diagram of pelvic outlet . . 7 
Different modes of Lithotomy 
necessary 2 
Difficulties in Lithotomy . . 78 
„ „ infancy . . .79 
„ „ old age . . .81 
„ from malformation . 83 
„ „ large stone . 85 
Dilatability of neck of bladder . 67 
Dissection of pelvic outlet . . 6 
Double-current catheters super- 
seded 164 
Double incision of the prostate . 82 
Early detection of the stone . 234 
Encysted’ calculi . . . 94-97 
English and French lithotrites 136-8 
Enlarged prostate in Lithotomy 82 
„ „ „ Lithotrity 195 
Erichsen on first incision . . 25 
Evacuating catheters . . 164, 187 
Exceptional position in Litho- 
trity. . . . . .154 
Exhaustion, a cause of death . 72 
Exploration of bladder . 161, 220 
Fenestrated lithotrites . .130 
Fergusson on first incision . . 25 
„ his practice, results of 117 
Fever after Lithotrity . .173 
Final conclusions . .180, 229 INDEX 
301 
PAGE 
Fistula after Lithotomy . .104 
Forceps for Lithotomy . .17 
„ introduction of . 35, 68 
„ urethral. . . ,167 
Foreign bodies in bladder . .169 
„ „ „ cases of 171 
„ „ „ instru- 
ments for .... 170 
Form of pelvic outlet ... 7 
Fracture of calculi, modes of . 222 
Fragments in urethra . . .167 
French and English lithotrites 136-8 
Friable calculi .... 222 
Glasgow Infirmary . . .Ill 
Gorgets for Lithotomy . 16, 30 
„ history of 29 
Granulation of the calculus . 158 
Gross on first incision . . .25 
„ his syringe . . .15 
„ „ compressing forceps . 37 
Gutteridge (Mr.), remarks by . 108 
Guy’s Hospital cases . . .112 
Haemorrhage after Lithotomy. 37 
„ death by ,73 
„ and exhaustion . 73 
„ secondary . . 103 
„ after Lithotrity . 174 
Hair-pins in bladder . . . 171 
Handling the lithotrite . . 148 
Hawkins’s gorget . . .31 
Healing by first intention . . 40 
Heurteloup . . . . .122 
High operation . . . .58 
History of the gorget . . .29 
Holding the staff . . 21, 23 
Humphry (Dr.) on high opera- 
tion . .119 
„ „ on care in extract- 
ing stone . 69 
„ „ on dangers in Li- 
thotomy in 
children . . 80 
„ „ on encysted cal- 
culus . , . . .94 
Hunter’s (John) knife . , 31 
Hussey (Mr.), cases from . .112 
PAGE 
Hypertrophied prostate, Litho- 
tomy in 82 
„ „ Litho- 
trity in 195 
Impaction of fragments . . 167 
Importance of preliminary treat- 
ment 123 
Importance of finding stone early 234 
„ „ diagnosis , .217 
Improved lithotrite of Charrilre. 136 
„ „ cylindrical, modi- 
fied by author . 137, 148, 153, 161 
Incisions in Lateral Lithotomy 24, 28 
Incontinence of urine . . .106 
Infiltration of urine after Litho- 
tomy 63 
Influence of age . . 224 
„ „ disease . . . 230 
Injecting prior to Lithotomy . 21 
„ „ Lithotrity ... 143 
Instruments for Lateral Litho- 
tomy . . 14 
„ „ bilateral „ 46 
„ „ supra-pubic „ 58 
,, „ Lithotrity , 130 
„ „ foreign bodies. 170 
Insufficient incisions dangerous . 64 
Introduction of forceps . 27, 35 
„ „ lithotrite . .145 
Keith on first incision . . 25 
„ his gorget . . .31 
„ careful use of forceps , 69 
„ his practice, results of .117 
Key’s operation . . . .41 
Knives for Lithotomy . ,32 
Langenbeck’s knife . . .32 
Large calculi . . . .86 
„ „ difficult to detect . 92 
„ lithotrites rarely necessary 189 
Lateral Lithotomy, 1827 cases, 
table of . . . . .113 
Lateral and Central Lithotomy 3, 44 
Lawson (Mr.), case by . ,95 
Leeds Infirmary cases . . .112 
Leicester Infirmary cases . .112 
Liston’s knife . . , .33 302 
INDEX 
PAGE 
Liston’s double incision of the 
prostate 82 
Lithotomy, lateral . . .20 
„ bilateral . . .45 
„ medio-bilateral. . 46 
„ median . , .48 
„ by angular staff . 51 
„ recto-vesical . . 54 
„ pre-rectal . . .55 
„ super-pubic . . 58 
„ various forms of . 44 
„ without a stone . 106, 108 
Lithotomes . . . . .33 
Lithotrites, principles of con- 
structing . . 128 
„ varieties of . ,129 
,, fenestrated . , 130 
„ non-fenestrated . 132 
„ intermediate con- 
struction . .134 
„ old screw. . 136 
„ improved screw . 136 
„ cylindrical 137, 148, 
153, 161 
„ mode of passing . 145 
Lithotrity, rise of . . .121 
„ treatment, prelimin- 
ary .... 123 
„ for children . .177 
„ at a single sitting . 182 
„ for adults, healthy . 230 
„ „ diseased . 231 
„ cases of single sitting 190 
„ in cases of stricture . 194 
„ in hypertrophied pros- 
tate . . . 195 
„ in sacculated bladder 197 
„ in tumours of bladder 197 
„ in renal disease . 199, 211 
„ with multiple calculi. 199 
„ at a single sitting . 182 
Male pelvic outlet . . . 7, 8 
„ measurements ... 8 
„ dissection of . . 10, 12 
Management of lithotrite in blad- 
der 147-156 
Martineau’s practice . . .116 
Maxims in Lithotrity . . .180 
PAGE 
Measurements of pelvic outlet . 8 
Mechanical violence, its dangers 64 
Median operation . . .48 
Medio-bilateral operation . . 46 
Minor varieties of Lithotomy . 55 
Mode of seizing the stone . 147, 150 
„ crushing the stone . 156 
„ introducing lithotrite . 145 
„ employing cylindrical 
lithotrite . 148, 149, 161 
„ sounding for stone . 220, 221 
Mortality after lateral Lithotomy 114 
„ at different ages . .114 
„ in children . . 75, 114 
„ after median Lithotomy 119 
„ „ Buchanan’s opera- 
tion . . .119 
„ „ bilateral „ .119 
„ „ recto-vesical „ .119 
„ „ supra-pubic „ . 120 
„ „ Lithotrity . . 208 
Multiple calculi . . . .199 
Museum of College of Surgeons . 99 
„ „ of Norwich . 236 
Narrow pelvic outlet . , 84 
Neck of bladder very dilatable . 81 
No stone discovered at operation 107 
Non-fenestrated lithotrites . . 132 
Norwich Hospital cases . .Ill 
„ Museum . . . 236 
Nunneley (Mr.), cases from . 112 
Objects of Lithotrity . .126 
Old screw Lithotrite . . . 136 
Operating table . . . .20 
Ordinary position in Lithotrity . 142 
Origin of lateral operation . . 4 
Paget (Mr. Thos.), remarks by . 108 
„ „ cases from . 112 
Parallelism of incisions . . 34 
Parts cut in lateral Lithotomy . 12 
,, central „ .12 
Parts avoided in lateral Litho- 
tomy 13 
„ „ central „ .13 
Pemberton (Mr.), cases from . 112 
Perforated lithotrite . . 133-5 INDEX, 
303 
PAGE 
Pelvis, dissection of . . .10 
Perforation of bladder by staff • 70 
Perineum, region of . . .6 
Peritonitis in children . .76 
Phlebitis and pyaemia . . .73 
Pince a trois branches . .162 
Position of hands in last incision 27 
Position for Lithotomy . .23 
Position in Lithotrity. . . 139 
„ „ ordinary . 142 
„ „ excep- 
tional . . . . ,154 
Pouteau on careful use of forceps 68 
Practical maxims in Lithotrity . 180 
Preliminary treatment, Litho- 
tomy 20 
„ „ Litho- 
trity 123 
Prichard (Mr.), his anklets . 18 
Probe-pointed knives . . 16, 32 
Prostate, size of, in children . 77 
„ gland, portions re- 
moved . . .101 
„ rigidity of . . .82 
Prostatic disease, Lithotrity in . 195 
„ „ Lithotomy in . 82 
Pulverising the fragments . .158 
Pyaemia following Lithotrity . 210 
Pyelitis (chronic) and Lithotrity 
211, 227 
RA.DCLIFPE Infirmary cases . 112 
Rates of mortality . . .113 
Recovery rate after Lithotrity . 208 
Recto-vesical operation . . 54 
Rectum, wound of . . .100 
Recurrence of calcrrlus . .213 
Refusal to operate . . . 232 
Removal of debris . 158, 163, 187 
„ last fragments . .167 
„ portion of prostate . 101 
„ foreign bodies . .169 
Renal disease and Lithotrity 199, 211 
Results of Lithotomy . . .110 
„ Lithotrity . . . 201 
„ author’s cases . .118 
Retention after Lithotrity . . 175 
Rigidity of prostate . . .82 
PAGE 
Rules for use of aspirator . .187 
,, crushing the stone . 150 
Sacculated bladder, operation 
for stone in . . . 197, 211 
Safety of Lithotrity . . , 235 
Scarpa’s gorget . . . .80 
Small lithotrites for fragments . 160 
Secondary haemorrhage . .103 
Seizing the stone . . 147, 150 
Septicaemia . . . .73 
Series of 500 cases by author . 71 
Sexual impotence . . .105 
Shock, death by . . . .77 
Single sitting, Lithotrity at a .182 
„ cases of . .190 
Situation of calculus . . , 155 
„ incisions in Lateral 
Lithotomy . . . .24 
Skey on first incision . . .25 
Slipping of the gorget . .31 
Smith (of Leeds), his knife . 32 
Solvents of stone . . . 236 
Sound, best form of . . 220-1 
Sounding for stone . . 220-1 
Sounds for detecting stone 14, 220 
„ the bladder . 14, 220 
Sound with cylindrical handle 221 
Spasm of the bladder . . .98 
St. Thomas’s Hospital cases . 112 
Staffs for Lithotomy . . .15 
„ the straight . . 42 
„ perforation by .70 
Stone to be struck with the staff 21 
Stricture and stone . . .194 
Supra-pubic Lithotomy . . 58 
„ „ results of 119 
System of seizing and crushing 
150-2 
Table of 1827 cases . . .113 
Tampon, air . . . .19 
Tenaculum . . . . 19, 37 
Tetanus 74 
Tonicity of bladder . . .144 
Treatment after Lithotomy . 39 
„ „ Lithotrity. .116 
Triticum repens, value of . 124, 174 304 
INDEX. 
PAGE 
Tube for Lithotomy . . 19, 38 
Tumours of the bladder . ,198 
University College Hospital 
cases 113 
Urethral forceps . . . .167 
„ lithotrite . . .168 
„ scoop . . 169 
PAGE 
Urinary infiltration after Litho- 
tomy 63 
Urine, retention of 175 
Value of aspirator . . 168, 188 
When not to operate . . . 232 
Wound of the rectum . . . 100