Reprinted from the Transactions of the Medical and Chirnrgical Faculty 
of Maryland, April 1878. 
A REPORT 
OF 
Fifty-two Successful Cases 
OF 
LITHOTOMY. 
liY r 
ALAN P. SMITH, M. D„ 
Recently Professor of Operative Surgery in the University of Maryland. 
BALTIMORE: 
INNES & COMPANY, PRINTERS, 
No. 104 W. Baltimore St. 
1878. [Reprinted from the Transactions of the Medical and Chirurgical Faculty of Maryland, 
April, 1878.] 
REPORT OF SECTION ON SURGERY. 
A REPORT OF FIFTY-TWO SUCCESSFUL CASES' 
OF LITHOTOMY. / 
By ALAN P. SMITH, M. D., \ 
Recently Professor Operative Surgery in the University of Maryland. 
The Section on Surgery has prepared a single report, as required 
by our constitution ; but it is proposed that, if acceptable to the 
Faculty, each member shall read that portion contributed by him- 
self. It was at first supposed that the report from the Section 
should be a resume of the surgical history of the past year; but 
the old constitution required that we should confine ourselves to a 
description of the surgery occurring within our own State, and by 
that, to a certain extent, we have been guided. 
I have selected, to present to you to-day, an account of several 
cases of Lithotomy, one at least of which is of more than passing 
interest. 
Up to the present time (April 9th, 1878), I have performed 
the operation of Lithotomy fifty-two times, and in each instance 
without the loss of life. Of these, 16 were below five years of 
age, 13 between five and ten years, 11 between ten and twenty 
years, 5 between twenty and forty years, and 7 between forty and 
seventy-five. 4 were below two years of age; the youngest being 
twenty-one months. The oldest patient was seventy-one-years. 
Of the whole number, only two were negroes; these, curiously, 
were the youngest, of twenty-one months, and the oldest, seventy- 
one years. 
The ordinary grooved staff and knife was employed in only six 2 
of these cases, while in the remainder, the operation was performed 
with the Lithotome, devised by my father, the late lVof. N. R. 
Smith. To the use of this instrument I attribute the fact in a 
very great measure, that all of my operations have resulted so 
satisfactorily. My cases have not been selected, as I have operated 
in every instance where the opportunity offered, except one, in 
which the patient was brought into the hospital moribund, the man 
dying soon after admission. A post-mortem revealed two stones 
in his bladder. In all but four cases the calculus was found to be 
single; in three, there were two; in one case, four calculi were 
extracted. 
I have always observed certain rules, which have possibly been 
of some assistance in determining the result. I never operate 
when the barometer is low, preferring to postpone my work from 
day to day until the weather is bright and clear. This rule, I 
believe, applies equally to all grave surgical operations which will 
admit of delay. I have never used, except in some of my earliest 
cases, the drainage-tube passed into the bladder through the wound 
to facilitate the flow of urine, in the first twenty-four hours after 
the operation, because I have found that the presence of the tube 
gives rise to violent irritation of the already sensitive bladder. 
Instead of employing it, I prefer seeing my patient several times 
during that period; and if I find that the urine does not pass off 
freely through the cut, I introduce a gum catheter through the 
wound, and permit it to remain only sufficiently long to empty the 
bladder. This is rarely necessary in young subjects, but in adults 
there is almost always retention during the first twenty-four hours; 
rarely after that period. I always make my first incision ; that is, 
through the skin and subcutaneous cellular tissue, very free, so 
that there may be no pocket in which blood, urine, or pus may 
collect. After the operation I anoint the parts adjacent to the 
wound freely with carbolized oil. 
I have stated that I attribute most, if not all of my success to 
the use of the instrument conceived by my father. I have said so, 
because by its aid the only two difficult features in the cutting 
part of the operation are made perfectly easy and mathematically 
certain. I refer to the first incision made through the skin and FIG.I 
FIG.2 5 
cellular tissue down to the groove in the staff, and afterwards to 
the passage of the knife along the groove into the bladder. Dr. 
Smith in referring to these two steps of the operation says: “I 
know not how it may appear to other operators, but to me the 
cutting with the scalpel for the groove of the staff, the introduc- 
tion of the gorget or knife into the groove of that instrument, the 
anxiety which is felt in regard to its being properly fixed, and the 
means which are necessary to determine with certainty whether it 
may be pushed forward with safety, constitute the most painful 
and perplexing part of the operation.” The accompanying illus- 
trations show more clearly how easily and satisfactorily the two 
difficult steps of the operation are perfectly overcome. 
Fig. 1 exhibits the lithotome prepared for use, with the cutting 
director drawn back, and the index which works in the hollow of 
the grooved staff raised up. Fig. 2 represents the same instrument 
the moment after being used, with the cutting director, which has 
guided the knife into the staff, pressed down into the hollow of the 
staff, while the indicator above the handle has descended, demon- 
strating to the operator that his knife has remained in the groove. 
When the beaked point of the knife passes from the groove of the 
cutting director to the groove of the staff, it becomes engaged in 
the cup-shaped extremity of the indicator ; and as the knife is 
pushed forward in the groove, the indicator above the handle must 
descend. If on the contrary the knife leaves the groove of the 
staff, the indicator ceases to move, thus warning the surgeon that 
his incision is not being made in the desired direction. The 
instrument seems to me to be as nearly perfect as possible, and the 
only objection that I have ever heard urged against it fell from 
the lips of a distinguished professor of surgery, who rather com- 
plainingly said that “ with it any one could operate.” 
Some of my friends say that luck has helped me much, and the 
following illustrative case would seem to prove the truth of the 
assertion. Several years since a little boy with calculus was 
brought from Virginia to my father, and he not feeling well on 
the appointed day, requested me to do the operation for him. 
Chloroform had been administered, and I was about to proceed, 
when the father of the child interrupted me, saying that he had 6 
brought the case to Dr. N. R. Smith, and desired that he should 
do the operation. I of course at once made way for him, and he, 
with his accustomed skill and dexterity, soon removed the calculus. 
The patient was placed in bed and left doing perfectly well, but in 
the course of two or three hours was seized with convulsions, and 
died before either of 11s could reach him. 
The calculi which I have removed varied in composition; some 
of them were of phosphate of lime, surrounding in concentric 
layers an uric acid nucleus; others were of uric acid, and a few of 
oxalate of lime, constituting the mulberry variety. One large 
phosphatic calculus had for its nucleus a white hominy-bean, and no 
amount of cross-examination could extract from the patient, a man 
of about fifty years, any explanation of the curious phenomenon, 
-'Cir.5/4 Inches, weight 1.005 grains!. 
Fig. 5 represents the natural size and appearance of a large 
mulberry calculus removed from the bladder of a young man from 
Virginia, aged nineteen years. This patient had suffered from the 
presence of calculus since birth, and presented a most emaciated 
and wan appearance. H6, however, made an extremely rapid 
recovery. 
Almost the only trouble lhat I have experienced after the 
operation has been from hemorrhage, and that only in a few 
instances. I have always used opium freely in my after- 
treatment. In every instance but one, the patient was placed under FIG. 3 9 
the influence of an anaesthetic; in that case there were reasons why- 
nothing of the kind could be used, and upon the assurance being 
given that it would be done quickly the patient submitted, and the 
operation from the first incision to the extraction of the stone was 
accomplished in a few seconds less than a minute. In two 
instances partial non-retention of urine was the result, and in one 
case there remained a small fistulous opening in the perineum, 
through which the urine occasionally dribbled. These occurred 
in ill-nourished and weakly children, who did not receive proper 
nursing or care, and who were allowed to be up and about before 
the wound had properly healed. 
The most interesting case of the whole series, on account of the 
peculiar deformity which it presents, is illustrated by Figs. 3 and 4. 
A middle-aged gentleman from a distance, suffering from well- 
marked symptoms of stone in the bladder, consulted me some 
time ago. Upon uncovering the organ in order to introduce the 
sound, I was amazed to discover that the penis was double. The 
organs were separated from each other above by a deep sulcus, 
below which they were closely united. They were slightly under 
the average normal size, and were unprovided with any prepuce. 
The one upon the right of the median line was normal in every 
respect, being traversed by an urethra beginning at the extremity 
of the glans, while the one on the left had the urethral opening 
below and just in advance of the scrotum. From this point for- 
ward to the glans the organ was perfectly solid. On the surface 
of the organ, and midway betweeh the umbilicus and the pubes, 
appeared an irregular smooth patch with a slightly concave sur- 
face uncovered by true skin. This was afterward found to be 
formed by the wall of a partially extroverted bladder. The scrotum 
was natural in every respect, and contained two testes of normal 
size. Upon making an examination, I of course passed the sound 
into the urethra of the right-hand penis. The instrument slipped 
readily into the bladder, but I could not detect by its aid the 
slightest symptom of calculus. Very much surprised at this, I 
asked the patient through which opening he passed his urine, and 
was informed that he used both; and, what was more curious still, 
that he could use either at will, or that he could first pass a 10 
quantity of urine through one, and immediately after discharge 
about the same amount through the other. Then for the first time 
it occurred to me that there were two bladders; and calling for two 
utensils, I desired him to first discharge from the right-hand 
organ. From this there flowed a quantity of clear, amber-colored, 
healthy urine; while, when directly afterward the same act was 
performed by the one on the left in a separate vessel, the fluid 
was ammoniacal and turbid with mucus and pus. At once the 
case was clear; he had two bladders. The one which I had not 
yet examined contained the stone sought for. I then attempted 
to pass my sound into the second urethra, but found the canal 
contracted and tortuous. Substituting, however, a bougie tipped 
with steel, I was rewarded by striking immediately a large cal- 
culus. Several days were spent in dilating and straightening this 
canal by means of sea-tangle tents. The removal of the stone was 
readily effected, the incision being made from within outward with 
a bistourie cachet. Violent hemorrhage ensued after the opera- 
tion, and continued very profuse in spite of the most strenuous 
efforts to arrest it, till he became almost perfectly exsanguine. The 
pulse ceased to beat at the wrist after the bleeding had continued 
several hours, and only slight' heart-sounds could be detected. 
However, after almost every drop of blood had escaped, the hem- 
orrhage ceased ; he commenced slowly to react, and progressed to 
perfect recovery. For some time after my patient’s discharge I 
believed that there was no case on record like his, till one day ] 
discovered its facsimile in Van Buren and Keyes’ work on the 
Genito-Urinary Organs, page 5. There I found my case so well 
and accurately described, even in the minutest detail, that I came 
to the conclusion that Dr. Van Buren had seen him before me. I 
could not believe that there existed two such remarkable instances 
of deformity of the genital organs. Upon writing to my patient 
and questioning him about it, he assured me in the most positive 
terms that lie did not know Dr. Van Buren, that he had never 
consulted him, and that no physician had ever examined him but 
myself. FIG,4