Urinary Calculous and Lithotomy. 
-BY- 
Thos. W. Kay, M. D., 
SCRANTON, PA. 
REPRINTED FROM 
THE MARYLAND MEDICAL JOURNAL, 
OF MARCH 16TH, 
1889. URINARY CALCULUS ffl LITHOTOMY. 
-BY- 
THOMAS W. KA1/, M. D., 
Ex-Professor of Materia Medica and Therapeutics in the Medical Depart- 
ment of the Syrian Protestant College ; Ex-Surgeon to the Johanriter 
Hospital at Beyrout; Member of the Clinical Society of Maryland; 
Member of the Pennsylvania State Medical Society ; Member 
of the American Medical Association ; Member of the 
' Ninth International Congress, etc., etc. 
[Reprinted from Maryland Medical Journal of March IMh, 1889.] 
BALTIMORE: 
Journal Publishing Company Print 
No. 309 Park Avenue, 
1889, URINARY CALCULUS AND LITHOTOMY.* 
BY THOS. W. KAY, M. D. 
From the works of the early historians, we learn that vesical 
calculi were common in the East as early as the 2nd Century, 
B. C. They were so common, in fact, that specialists were 
recognized in Alexandria who were called lithotomists and who 
confined themselves entirely to the extraction of stone, an exist- 
ing law prohibiting all young practitioners from undertaking the 
operation. It is probable that lithotomy was practiced long 
before this period, for Hippocrates made his disciples swear never 
to perform the operation. Florus, the Roman historian, states 
that the usurper Tryphon caused the report to be circulated that 
Antiochus the 6th, son of Alexander Balas, King of Syria, suf- 
fered from stone, thereby procuring an operation on him, which 
caused his death, about the middle of the 2nd Century, B. C. 
Stone, in the East, is probably as common now as it was then, 
and in no section of the country is it more common than in Syria; 
for in spite of the native operators, the number of cases which 
fall into the hands of the regular practitioners is considerable. 
The native method differs from "le petit appareij" of the old 
French writers (first described by Celsus), in using the median 
incision and employing no scoop. The operator passes one or 
two fingers into the rectum, hooks the stone in front, and draw- 
ing it well against the perineum, cuts down on it at the most 
prominent point, after which he easily forces it out. f 
Of those operated upon who escape death, a large number 
suffer from urinary fistulse, which are hard to cure. As an ex- 
+See a paper by the author, on the "Native Treatment of Disease in Syria.'' read at 
the Ninth International Congress, and published in the transactions of the same. 
♦Read before the Baltimore Medical Association, December 17, 1888. 4 
ample of the frequency of stone in Syria, I will mention that my 
former colleague, Prof. Geo. E. Post, during a residence of 20 
years, has operated, over 250 times. This represents only a small 
part of the work done by the American, English, French, Ger- 
man, Syrian and Turkish surgeons. 
The frequency of stone in Syria is not due to the water, as has 
been thought by some to be the case, for it is as frequent in the 
Hauran, a volcanic district where rain-water is used, as it is in 
* 
the Lebanon mountains, where the source of water is nearly 
entirely limestone. Nor do I think the climate directly affects 
its frequency, but it is chiefly due to the large number of poor 
who are imperfectly protected by shelter and clothing, and who 
eat insufficient or improper food. It is true that certain villages 
furnish more calculi, proportionately, than others, but then we 
find their inhabitants poorer and more degraded than in the 
neighboring villages. This I think will also be found to be the 
case in other countries, though it is not uncommon for calculus 
to occur among the wealthy classes. Calculi originate most 
frequently in the kidney, but sometimes in the bladder, their 
relative frequency being, according to Heller, as 100 to 1. Their 
apparent nuclei are most frequently composed of uric acid, but 
they may be composed of urate of ammonia, oxalate of lime, 
triple phosphate of ammonia and magnesia, and phosphate of 
lime. I say apparent nuclei, for I incline to the opinion that in 
the majority of calculi some organic substance is the nucleus 
around which the inorganic substance accumulates. In Egypt, 
where hsematuria is very common, blood clots or the ova of the 
Bilharzia Haamatobia have been found to be the nuclei in many 
calculi. Stone occurs most commonly in children, and as the poor 
are frequently subject to catarrhal and febrile attacks, it is quite 
possible that small particles of blood, mucus or fibrin may find 
their way into the urinary system, thus furnishing a nucleus for 
the deposit of uric acid with which the urine is heavily loaded. 
This can be seen in many calculi when a careful section has been 
made, a small cavity being left from the decomposition or desic- 
cation of the animal substance. Colloid substances may be 
deposited between inorganic layers of a calculus, which, on 
changes taking place in the urine, swell and cause splitting of 
the stone. This was very prettily shown in one of my specimens, 5 
where four of the fractured pieces were found in the urethra. In 
another specimen the nucleus was lying almost free in a hollow 
calculus due to des^cation of a thick organic layer. 
Though calculi are composed, as a rule, of several layers, they 
are classified according to the outermost layer into two classes, 
the first being uric acid and the allied forms, and the second the 
phosphates. To these can be added a third class, containing car- 
bonate of lime, fibrious and other rarer forms. The first class 
is found most frequently in ill-nourished children in whom an 
imperfect change of proteids into urea takes place, with a result- 
ing increased production of uric acid. Stones of this kind are 
also found in persons of middle age who indulge in large quan- 
tities of nitrogenous food. Since uric acid is soluble in cold 
water only in the proportion of 1-14,000 to 1-15,000 parts, and 
slightly more so in warm water, we can readily see how a nucleus 
may increase in size in such individuals. The oxalate calcu- 
lus has its origin in the same way, oxalic acid being produced by 
changes taking place in uric acid or urates already existing in 
the urine. The phosphates are found most frequently in adults 
suffering from some disease of the bladder or kidneys. Here the 
nucleus may be phosphatic, but in the majority of cases it is com- 
posed of uric acid, which by its presence sets up a cystitus with 
subsequent phosphatic deposit. As a rule, only one stone is 
found in the bladder, but in two of 25 cases operated on by me, 
more than one was found. In the one case, there were two dis- 
tinct nuclei, but in the other it was due to the breaking up of 
the outer layers of the original stone. The calculus is generally 
round or oval in shape, but it varies according to circumstances. 
The dumb-bell shape is due to the lodging of a small calculus in 
the urethra, which as it grows becomes constricted by the neck 
of the bladder, as prettily shown in one of my specimens. Facets 
are not unfrequently found in calculi where several exist in the 
bladder at the same time. In a short paper I cannot dwell on 
the symptoms of stone, but for its diagnosis I will remark that 
I have found no searcher as valuable as a thin flexible uterine 
sound. It does for all ages and both sexes, and can be bent to 
any curve before its introduction, or after its introduction, with 
a finger in the rectum. It is true that it does not give as dis- 
tinct "click" as Thompson's sound, but this is no more essential 6 
for diagnosis of stone than it is for the diagnosis of necrosed 
bone. It is also true that some of the best surgeons have been 
mistaken and cut for stone when none existed, but most cases 
reported were probably those of "missed stone." I was called 
in to a case of this kind some three days after the operation was 
performed, and was almost on the point of pronouncing no stone 
present when I detected a small hard substance between the fin- 
gers of my two hands as I made a bimanual examination. The 
bladder had been missed at the neck and my finger was then in 
a cavity, closely resembling the bladder, which had been hollowed 
out in the loose tissue in front of the rectum. 
It is not my purpose to speak of the relative merits of lithola- 
paxy and lithotomy, nor of the different methods of lithotomy. 
Each has its field, and a choice must be made on the merits of 
each individual case-the age of the patient, the size of the stone, 
the condition of the genito-urinary apparatus, and the general 
health. Of my 25 cases, 17 were lithotomies in children, with 
one death from cellulitis in a child of 4 years of age, from whom 
I removed a | oz. stone; 4 were litholapaxies in adults without 
a bad symptom ; 1 was a lithotomy in a debilitated adult who 
died ten days later from diarrhoea ; and three were suprapubic 
cystotomies, one dying from peritonitis and a second from cys- 
titis.* 
The chief dangers to be feared in operating are wounding the 
artery of the bulb or the internal pudic, missing the bladder by 
the knife slipping from the groove of the staff, or by the assist- 
ant withdrawing the staff too soon ; opening up the recto-vesical 
fascia; wounding the rectum or bladder, and finally tearing 
across the urethra or pushing the bladder up out of the way while 
attempting to introduce the finger. Many instruments have 
been devised to overcome these dangers, but they are all expen- 
sive, and none of them, in my estimation, come up to the scalpel 
when in a careful and skillful hand. In my first three cases I 
used a double lithotome and lost one of my patients ; since that 
time I have only used the scalpel, and have had the most satis- 
factory results-14 cases, without a bad symptom. In operating, 
I follow the left lateral method, but as there are several points 
♦See a paper by the author on "Supra-Pubic Cystotomy, with a Report of Three 
Cases," Medical Times, July, 1888. 7 
in which I do not follow the rules laid down in text-books, I will 
describe it briefly : The patient having been prepared for the 
operation and put in the proper position, a good-sized staff is 
introduced till it comes in contact with the stone, and then with- 
drawn so that its apex just rests in the bladder. This is then 
given to an assistant and the first incision, 2 to 3 inches in length, 
made through the skin and fascia down to the muscles. Then 
taking the staff in the left hand, the scalpel is made to transfix 
the perineal muscles from about the level of the anus to the apex 
of the prostate gland. The transfixion is done slowly, a slight 
lateral motion being kept up until I am sure that the point of 
the scalpel is in the groove of the staff, after which both knife 
and staff are slid into the bladder. The staff is now left in the 
bladder and the knife Withdrawn, the incision in the prostate 
and urethra not being enlarged, and that in the muscles only to 
the extent of about an inch. A second staff or sound is now in- 
troduced into the perineal wound and run along the groove of 
the first until it reaches the bladder, when it is turned over so 
that the convex surfaces are in contact. The condition now very 
much resembles that of a female bladder with two curved retrac- 
tors introduced through the urethra. The first staff is now held 
by the assistant, and the second one in the operator's right hand, 
while the left index finger is wedged between the two, until it 
overcomes the resistance of the sphincter vesicae and enters the 
bladder. The opening is now large enough to allow most stones 
to be extracted, but if it is not, a probe-pointed bistoury can be 
used to enlarge the incision, or to convert it into a bilateral 
operation, according to the requirements of the case. The staves 
can be withdrawn as soon as the finger enters the bladder, but 
their presence is found to materially aid the introduction of the 
forceps, after which the stone is extracted and the patient is 
treated on general principles. 
The advantages of this method of operating can be readily 
seen. In transfixing the perineal muscles, the blood vessels are 
better avoided, the urethra is opened well back of the bulb by a 
small incision, and the perineal incision is small, favoring rapid 
healing. 
By passing staff and knife simultaneously into the bladder, the 
dangers of missing the bladder, of incising the prostate to too 8 
great an extent, or of wounding the bladder or rectum, are 
avoided. With the two staves in the bladder as retractors, there is 
no danger of rupturing the urethra across, of pushing the blad- 
der up out of the way of the finger, of passing the finger between 
the bladder and rectum, or of injuring the neck of the bladder 
in introducing the forceps. 
A method offering so many advantages has no doubt been 
adopted by others before, but as yet I have seen no description 
of it.