:"^H^#
ill	■&	

..& 
<*i3$l't
UNITED STATES  OF AMERICA
WASHINGTON,  D.C.
GPO   16—67244-1 
 
 
     rJ\  *'a.i ■■'■,v   a:-










        STRICTURES











     « MR. PATTISON'S REPLY





               TO





CERTAIN ORAL AND WRITTEN CRITICISMS."
   BT






W. GIBSON.
  PHILADELPHIA:



PRINTED B* JAMKS MAXWEM"
1830. 
 
STRICTURES
"MR. PATTISON'S REPLY
CERTAIN ORAL AND WRITTEN CRITICISMS.'
BY
W. GIBSON.
* **^"fot
fcl
•  *   *
   PHILADELPHIA:
.&        PRINTED j|Y ^^fl MAXWELL.




     \       1820. 
X
™^ £&-<-4(L$

'fa-cU-   * 
STRICTURES,  &c.
'' Novelty captivates the superficial and thoughtless; vehemence delights
  the discontented and turbulent.  He  that contradicts acknowledged
  truth, will always have an audience; he that vilifies established authority
  will always find abettors."—Johnson.


  Mr. Granville Sharp Pattison has assailed my private and
professional reputation, in terms peculiarly rude and  disre-
spectful.  I am well aware that I have  ample scope for recri-
mination; but, while I have too much regard for public opinion
to indulge in  remarks  inconsistent with decorum, I hope to
show by incontrovertible evidence, that every thing I have
asserted in relation to this individual and his claims, is sub-
stantially true, and that my conduct, from beginning to end,
has been upright and honourable.
  Having had occasion to visit Philadelphia both before and
after my election to the Surgical chair, in the University of
Pennsylvania, I there heard from every quarter that Mr. Pat-
tison had avowed himself the author of a most brilliant dis-
covery'in anatomy,that several distinguished physicians in this
country, as well as some of the first anatomists and surgeons 
2
 in Europe, were not only satisfied with the equity of his claim,
 but convinced that highly beneficial consequences must result
 from the important change which would necessarily take place
 in the mode of performing one of the most difficult and dan-
 gerous operations in surgery.  It was natural that  I should
 feel a lively interest in the subject, believing, as I then did,
 that such reports were well founded;  but, I  had no opportu-
 nity of ascertaining  the precise nature of  the alleged dis-
 covery or the peculiar practical  inferences deduced  from it,
 until after the publication of an essay on  Lithotomy, in the
 ninth number of  the  Medical Recorder.  This  essay I read
 with great attention, but  I  was  grievously disappointed,
 for instead of finding  any thing  like  a discovery, or any
 important  directions for conducting  the  operation, I only
 met with an imperfect and awkward description of a structure,
 about which most  of the best anatomists  had said more or
 less, and views which no one but an  inexperienced surgeon
 would for a moment have entertained.
   About a fortnight before I delivered my lectures on Lith-
 otomy,  I  obtained at the book store of Collins  and Croft
the  "  Surgical Anatomy''''  of Mr.  Colles  of  Dublin,  an
anatomist and  surgeon with whose reputation  I had long
been familiar,  and who  for the last fifteen years has ranked
as the very first  in his  profession in  Ireland.   In looking
over the anatomy of the  perinssum I  found that Mr. Colles
had given an unusually full and well written account of those
very parts which  Mr. Pattison had claimed in  his essay as
his own discovery.  In conversation with Drs.  Physick, R.
Patterson, and  Horner, at the University, I mentioned these
circumstances, and showed them the work. After comparing
the descriptions of Mr. Colles" with dissections made by Dr.
Horner, on the spot, they all declared, without hesitation,
their thorough  conviction that Mr.  Pattison was  not only not
entitled in the slightest  degree to the discovery of any one 
3
part about the perineum, but that Mr. Colles's account of the
different structures was far more lucid and intelligible than
that of  Mr  Pattison, or of any other writer they had seen.
Dr. Physick then remarked, that he had gone through the
work  of Mr. Colles slightly,  some  months before, and had
stopped Dr. Dewees in  the street,  purposely to say  that be
believed Mr. Colles had  described  in a very clear manner,
the " prostate fascia'''' which Mr. Pattison had claimed as
his own discovery, but as  the weather was then too warm
to make an examination on the  dead subject, he would not
give a decided opinion until the ensuing winter.  Dr. Physick
added, that he made the  same observations to Drs. Chapman
and M'Clellan, and in confirmation of his opinion, had placed
the work of Mr. Colles in the hands of the latter gentleman,
in order that he might show it to Mr. Pattison.
   I commenced my lecture on lithotomy, by observing that
it was necessary  I should give a general view of the parts
directly and indirectly concerned in the operation. For this
purpose, I exhibited to the class some magnified and  uncom-
monly beautiful  drawings, by Mr.  Otis; some preparations
in wax,  and dissections  of the real  subject.  Among  other
things, I took occasion to say that Mr. Colles, of Dublin, had
described in a very circumstantial and perspicuous way, cer-
tain structures about the bladder and perineum to which I call-
ed the attention of the class, by reading several extracts from
his book. I then gave an account of the different operations of
lithotomy, which I conceived to be deserving of attention from
the earliest periods down to modern times.   I inculcated in
particular, a free  incision  of  the  prostate gland, and if ne-
cessary, of the neck of the bladder, and referred in a  pointed
manner repeatedly to the last and most approved operation
of Cheselden in  support of my opinion; I referred also to
the authority of Mr. John Bell, and  several other distin-
guished European surgeons,  and to the ample experience of
Dr. Physick; all of which tended to establish the position 
4
which my own experience had taught me to be true.  In ex-
hibiting the operation on the subject,  I remarked that it was
necessary to employ in the living body, a gorget of moderate
size, not from any apprehension or danger of making too large
an incision in the prostate, but to avoid wounding the pudic
artery, and pointed out in a particular manner, the neces-
sity  of afterwards enlarging the wound in the prostate and
neck of the bladder, by the bistoury, in case the stone should
be too large to come away without it.  I mentioned at the same
time, the difficulty of dividing completely the prostate gland,
even by a gorget of  considerable size, referred to an experi-
ment made by  Dr. Physick in the presence of his class a few
days before, in support of the same sentiment, and concluded
by passing a gorget of unusual magnitude, merely  to show how
large an instrument might be employed without the entire di-
vision of the gland being the consequence.
  Mr. Pattison attended my lecture  without invitation, and
immediately after, pasted  on the walls of our university an
address to my pupils, requesting them at a stated period, to
listen to a refutation of what I had advanced.
  Soon after my observations  on lithotomy were delivered
in the university, a  sort of quack bill or circumforaneous ad-
vertisement, emanating apparently from a Norfolk paper, was
published successively in most of the Philadelphia newspa-
pers, stating that Mr. Granville Sharp Pattison had written in
the Medical  Recorder, " without doubt  the  most important
paper, on the subject of lithotomy, that had appeared in any
country, for a  considerable time past.''''  The object of this
advertisement, was  at once easily understood by most of the
professional men, and its source readily guessed at by others.
  There was no difficulty in perceiving, both from previous
indications, and from the style of this particular panegyric,
that the  common European practice of wafting  one's self
along by puff, was about to be introduced into this country. It 
5
was evident, moreover, that the article alluded to was intend-
ed to do away any impression which might have been created
by my lecture respecting the validity of Mr. Pattison's claims
as a discoverer, or the importance of his practical deductions.*
I therefore requested Mr. Poulson to insert a short notice, in
which it was mentioned, that the praise lavished on Mr. Patti-
son, was not altogether merited. My name was left at the same
time, to be delivered to any one who should choose to call for
it. An answer appeared to my slight admonition, written at the
earnest solicitation of Mr. John Pattison, tending to support
the claims of his brother, and  protesting against newspaper
attacks.  I was thus placed under the necessity to publish a
rejoinder.
   It soon became apparent, that neither Mr. Pattison nor
his friends were satisfied with the course the affair had taken,
for they let no opportunity slip to stigmatize me as an anony-
mous writer, although perfectly acquainted, to use their own
words, with my " individuality," which indeed they could not
help knowing, as I  never myself, aimed at keeping it secret.
 It was  insinuated moreover, that I had made/a&e and garbled
 extracts from Mr.  Pattison's essay, in the newspaper discus-
 sion. To get rid of this imputation, and to convince my breth-
 ren who had no opportunity of reading Mr. Colles' work and
judging for themselves,  I determined to bring the matter be-
 fore them in a formal way, and accordingly published a review
 of the  anatomical part of Mr. Pattison's essay, under the
 signature of W. in the tenth number of the Recorder.
   This is  before the  profession, and  requires no comment.
 But it  will be necessary to reprint the articles which appeared
 in Mr. Poulson's paper, in order that  the public may ascer-

   * I had always inculcated in my lectures, principles adverse to those ad-
 vocated by Scarpa and by Mr. Pattison in  imitation of him.   If my ob-
 servations then applied indirectly to Mr. Pattison, it was surely not my
 fault, but his misfortune. 
6
tain how far Mr, Pattison's assertions with respect to matters
of fact can be depended on.
Mr.  Poulson,
   In  your paper of this morning, I  observe an article ex-
tracted from  the Norfolk Beacon, in which it is affirmed,
that the paper published  in the last number of Mr. Web-
ster's valuable  Medical Journal, by  Mr.  G. S. Pattison,  of
this city, a is without doubt, the most important on the sub-
ject of lithotomy, that  has appeared in any country for a
considerable time past." Without derogating in the slightest
degree, from the merits  of  Mr. Pattison, -which are respecta-
ble, I have no hesitation in declaring,  that the paper in ques-
tion, contains neither an Anatomical discovery, nor important
practical precept; as any one disposed to investigate the sub-
ject will find, by turning over the Surgical Anatomy of Mr.
Colles, of Dublin, published so far  back as the year 1811,
the Surgical Journal of Mr. Charles  Bell, and several other
anatomical  and surgical works.  I have  great  pleasure  in
bearing testimony to the general excellence of Mr. Webster's
Medical Recorder, which is circulated extensively throughout
the United  States, and is  unquestionably  the most valuable
periodical work of the  kind, in our country.    Aristides.
         " In nostros fabricata est machina muros."
Mr.  Poulson,
   I am very sensible that nothing short of the interests  of
humanity can authorise the discussion of a medical subject
in a  newspaper, and  if the  friends  of Mr. Pattison  had
entertained similar  sentiments, it  is probable that no in-
vestigation of his claim  to certain discoveries would have ap-
peared before the public  through such a  medium.__As the
affair now stands, however, it may be  deemed necessary  to
substantiate the assertions which have been  made, viz: " That
the paper of Mr. P. contains neither a discovery nor important
practical precept." 
7
  It is notorious that Mr. Pattison came to this city during
the last summer,  and proclaimed that he  had discovered a.
new fascia, and that some of the first anatomists of Europe
had acknowledged his claim.  But as this may be called " a
mere dictum of an anonymous writer,"  Mr. P. will excuse
the liberty I take of making him tell his  own story. In page
the 9th of the Medical Recorder, Mr. P. says, " I dissected
the parts  after a new method,  one which enabled me to dis-
cover a new  fascia."  Again,  he says, " This new fascia I
have named the fascia of the prostate gland."
   In page 22d,  Mr. P.  says,  "  I have demonstrated it to
some of the  first anatomists of Europe,  and  they have been
perfectly  convinced of its reality, and have believed it a dis-
covery.   I have since  demonstrated it before Drs. Physick,
Eberle and M'Clellan, who have all, without hesitation, ac-
knowledged  its existence.   I have since  demonstrated it be-
fore Drs. Parrish and Hartshorne, who have expressed equal-
ly strongly the conviction of its presence."
   " One  of my  friends was rather  unfortunate in the dis-
covery, he thought  he had made, that this  fascia had been
described by Mr. Collies (Colles) of Dublin, as the passage
in that author, in  which  he conceived  the  prostate fascia,
was  mentioned, referred  to  another—a fascia  universally
known and  demonstrated  by  anatomists.  But although in
the passage alluded to, Mr. Collies (Colles)  says nothing of
the fascia, still  I believe  from  an  attentive perusal of the
work,  that that anatomist had seen it.  He, however, only
saw it, and was neither aware of its connections, its import-
ance, or (nor) its uses."
   Here then we have, in the same paper—first, the discovery
 of a fascia—secondly, the existence or presence of a fascia,—
 and thirdly, no discovery of a fascia. We might, in the next
 place, go on to show that Mr. Colles not only  saw the " fascia
 of the prostate  gland,"  but has given a  more  minute, clear 
8
and satisfactory account of it than  even the discoverer him-
self, so much so, that it would be quite impossible, owing to
the extent of the information contained in his work, on the
subject, to introduce any extracts in this place; we refer those,
however, who are anxious for proofs, to the work itself.
  With respect to the precept deduced  from the discovery,
it may be stated, that the practice advocated by Mr. P. is in
direct opposition to that of most of the best  authorities of
Europe and of this country.  It would appear  too, from Mr.
P's. own acknowledgment, that  his experience in lithotomy
has not been very considerable, since we hear of two opera-
tions  only which he has performed, and from one of them,
the patient died, although contrary to the expectations of his
friends.—" As I left the  apartment with my esteemed friend
Dr. King, he shook me by the hand and said, Pattison it is
impossible this patient can die."
  I conclude by re-asserting,  that I have  no  inclination to
detract from the merits of Mr. Pattison, ^whatever they may
be, but his friend X. should be admonished to send no puffs
to the Norfolk Beacon, in order that they may find their way
progressively through  our country.  The American public
will not be imposed on with impunity.          Aristides.
  I shall next make some remarks on  the " Reply to certain
oral and written criticisms" published in the eleventh number
of the Recorder.
  Notwithstanding the gentle admonitions which Mr. Patti-
son had already received respecting his discoveries, we  find
him still  very unwilling to abandon his pretensions; for in the
very  outset he observes, " In a conversation which I had
with  Dr. Physick  shortly after my arrival  in America, I
took occasion to mention the prostate fascia as a discovery and
attempted to explain, from its connexions, the causes of urinal
infiltration."  Discovery, is in fact, the perpetual burthen of
his song, often repeated and always uppermost.  Omnia cum 
9
fecerit: Thaida Thais olet. In giving an account, however, of
the discovery of Mr. Colles' book, he would appear to be not
very accurate in his assertion  that an individual, meaning, it
is said, Dr. Horner,  " brought that work to Dr. Physick;" at
least I am authorised by Dr. Physick to say,  that  no  one
except the Hospital librarian ever put the work into his hands,
and then not  until he called for it of his own accord.
  Again, it is asserted that a leaf was turned down in the
work of  Mr. Colles, in order to designate the parts to which
Mr. Pattison had laid claim, but that the marked passages
referred  altogether to other parts. This assertion will perhaps
turn out  to be no better than the first, for it seems that neither
Dr. Physick nor Dr. Horner remembers that a leaf was turned
down at  all.  There  is no difficulty in perceiving the conclu-
sion which Mr. Pattison wished to be drawn from his modest
insinuation, that Dr. Physick could not distinguish the differ-
ence between those parts " regularly and constantly described
by anatomists,"  and his  discovery, when  he found so little
difficulty in convincing  his  friend Dr. MClellan they were
distinct.
  " Accompanied by Dr. M'Clellan," says Mr. Pattison, " I
visited Dr. Physick  with the book, and with  the most perfect
candour assured him that I  was satisfied Mr. Colles had seen
the fascia, and then went over with him that gentleman's
description.  Dr. Physick's observation was, that  it was so
confused, it was  impossible to understand exactly what the
author meant, and added most unequivocally, that his having
or not having seen  it, would in no measure take from the
honour which was  due  to  me, for being the first who had
brought  it before the profession in  a highly interesting and
important practical point of view." Unfortunately Dr. Phy-
sick does not recollect that he ever made any such observa-
tions, and  thinks  it  not  very probable he could have called
those passages in the work of Mr. Colles confused which he
                             B 
10
had previously told Drs. Dewees, Chapman, and M'Clellan
were very clear.  But I am quite sure from what I know of
Dr. Physick's views in relation to Mr. Pattison's discoveries
and practical conclusions, that he never could have^intended
to  convey  the impression  to him, or to any one else, that
they were entitled to that sort of regard which Mr. Pattison
has chosen to attach to them, and labours to make the public
believe.
   Mr. Pattison asserts that Dr. Physick, regulated by a love
of truth, when he came to the anatomy of the perinaeum, de-
monstrated the " prostate fascia." This is very true, and per-
haps more so than any other part of his whole essay, but it
does not follow that he demonstrated  Mr. Pattison to be the
discoverer of the fascia, which it is surprising, considering
his former good luck, he did not also assert. The fact is, Dr.
Physick  attached so little  importance to  the fascia, that he
merely showed the part, and read a passage or two from Mr.
Pattison's paper, without a single comment.
  The next part of the " reply," relates to the " anonymous
letters of Aristides"  These are now before the public, who
will judge whether they are really so infamous and ungentle-
manly as Mr. Pattison has chosen to represent.
  That Mr. Pattison was the author of the panegyric which
appeared originally in the Norfolk  Beacon, and subsequently
in many of the papers of the middle and southern states, I
cannot pretend to assert, for there are ways in which he could
manage such an affair, so as to remove the odium of it from
his own shoulders.  I can only say, I  verily believed him to
be  the author, and have yet had no  good reason to change
my opinion, on the subject, and  that the whole tenor of his
conduct, from his arrival in the country to the present time,
has been empirical in the extreme, and such as would justify
me, or any one else,  in concluding he was at the bottom of
the Norfolk advertisement, and of all the numerous puffs which
have appeared at different times in his favour.  The profession 
11
in general and many of the citizens of Philadelphia, will bear
testimony to the truth of what I have advanced.
  Notwithstanding Mr.  Pattison's extraordinary unwilling-
ness to " have his name brought forward, favourably or un-
favourably,  by anonymous writers," so much so that he de-
clares " that in the whole course of his life he never published a
syllable to which he did not affix his signature;" yet it appears
that he  has no particular objection his friends should take
this trouble  off his hands, by standing forward in his defence
while he remains behind the  curtain.  He will hardly ven-
ture to deny that it was at the particidar request of his bro-
ther, that the answer to Aristides was written.
  He may  not  find it  very easy, to convince  any one, not
devoid of common sense, that it is an outrage upon decency
and good fellowship, to publish  a nameless paragraph in Mr.
Poulson's,  or any  other newspaper, especially when it is
known as an answer to one manufactured by himself or some
of  his friends, and  for  the express purpose  of sounding his
own praise.
   In my review of  Mr. Pattison's essay, I endeavoured to
show, and trust I succeeded in proving, that he could not, with
the slightest propriety, lay claim to the discovery of the
" prostate fascia," which he had attempted to do in the most
unequivocal manner. But whether I  succeeded in convincing
the profession or not, it  is very  evident from  his subsequent
declarations in" his reply,"  that my arguments and proofs
were not altogether lost upon him, since we now find him
shifting his ground  with admirable  dexterity, and asserting
" that he had not claimed the fascia as a discovery."  Notwith-
standing his changeable nature, he cannot escape so easily as
he imagines, if  any credit is  due to his own previous asser-
tions, and to the unqualified testimony of some of the most
respectable professional characters of this city.
    But  there  is yet another view of the subject, the bearing
of  which He has not perhaps taken into full consideration. 
12
I presume that he cannot deny that it is stated in his reply
" I still continued to believe it was so (i. e. a discovery) until
I read Mr. Colles' book in  Philadelphia."   " 1 would de-
mand if there  was any thing disingenuous in my conduct
after I had read Mr. Colles' essay." Now it is certainly im-
plied  in  these  passages, that he had never read Mr. Colles'
work until he came to this country.  But this he had probably
so far forgotten as to state in his reply to my lecture that he
had been acquainted with the work in the city of Glasgow.
  This  acquaintance with  Mr. Colles' book, which it now
seems commenced in Scotland, was what I had long suspect-
ed, but which nothing except the unfortunate explosion which
took place at my lecture during the winter, would probably
ever have brought to light. As it is, we must give him credit
for his " most perfect candour:" he would have been a little
more  candid, however, if he had only taken the  trouble to
acknowledge the same in his former essay and in his late re-
ply. But such an acknowledgment, he well knew, would only
lead him into other difficulties, from which he may now extri-
cate himself as well as he  can.
  It is quite amusing,  to observe how this individual, after
having been driven from one  post to another, and forced to
confess that he was not the discoverer of the " prostate fascia"
attempts to escape, by taking to himself the merit of the
discovery, as he calls it, that Mr.  Colles had " really seen
the fascia"  " His book," says he, " had been pryed into by
those, who  were most  anxious to take from  me the honour
of the discovery, but they were unable to understand that he
had really seen the fascia.  It was left for me to make that
discovery, and when I did so, I was the first to proclaim it to
Drs. Physick, Eberle and M'Clellan."  This is as much as to
say, that although  he obtained the work of Mr. Colles from
Dr. Physick, through Dr. M'Clellan, that neither  Dr. Phy-
sick nor Dr. Horner, had penetration or sagacity  enough to 
13
perceive,  that  it contained  the  discovery of Mr. Pattison.
This is a fine specimen of his usual good luck and consisten-
cy, and corresponds very accurately with his declarations in
his first essay, and with certain passages in his reply, to this
effect," That excellent and enlightened surgeon, Dr. Physick,
a man who by his talents and professional enthusiasm, has de-
servedly raised himself to the very highest pinnacle of chirur-
gical eminence," &c. Again," Dr. Physick, professor of ana-
tomy in one of the first schools in the United States, a man who
deservedly  stands at the very head of his profession."  But
he might as well  have spared himself the  trouble of  pro-
claiming  Dr. Physick's culpable ignorance of the tl prostate
fascia" or his uncommon eminence in  his profession, since
no one would  ever think of taking his opinion of either.
   It certainly cannot be considered any thing less than sorry
logic, to affirm that the anatomists of Europe did not know
any thing about the existence of  the  prostate fascia,  until
his " demonstrations and publications," when he had already
been obliged  to   confess,  however  reluctantly,  that Mr.
 Colles  had  at least seen  it.    His  assertion,  that Dr.
Physick  was not  acquainted with the  structures about the
perinaeum,  which  he chose to call his discoveries, has no
better foundation.  But Dr.  Physick could never dream that
Mr. Pattison  or any one  else would venture to appropriate
to himself the anterior inferior ligaments of the bladder, and
the membranous expansion covering the surface of the obtu-
rator internus, and levator ani muscles, and took it for granted
that inasmuch as  a discovery  was claimed, the  merit of  a
discovery was deserved, until he had  an opportunity  of ex-
amining the parts, and satisfying himself to the contrary.
His declaration that I was  unacquainted  with what  all the
best anatomists had described, is another sample of his pre-
cious good  luck.  But he judged rightly perhaps, not to at-
tempt  to prove my ignorance, since his  bare assertion  would
no doubt be received, in the estimation of  all who had ever 
14
 looked into his writings, or heard any thing of him, be equal
 to any proof he could possibly bring.
   But how does it happen, since " this important discovery"
 was made before his arrival in this country, and known to
 the European anatomists eighteen months before the publica-
 tion of Mr. Charles BeWs Quarterly Reports, that he should
 have so  far indulged in languid supineness, as to forget  the
 honour of his native home, and reserve the publication of
 the " most important paper on lithotomy, which has ever ap-
peared in any  age"  for a country  like America, which he
 and some of his friends, if report say true, were disposed to
 consider as the Bceotia of the world? what documents more-
 over can he show to substantiate the assertion he has made,
 that some of the  first  anatomists of Europe  have acknow-
 ledged his  claim?
  Having asserted in my review of the anatomical part of
 Mr. Pattison's essay  that the "prostate fascia" which  he
 supposed to be a discovery, was well known to most if not
 to all of  the best anatomists long before the appearance of
 Mr. Colles' work, or the paper of Mr.  Pattison: I shall pro-
 ceed in the next place  to offer unquestionable evidence of
 the accuracy of the observation.
  Santorini in speaking of what he calls " ligamentum pros-
 tatas novum" says Igitur ex interiore pubis facie, qua ea ossa
 committuntur, latum circiter pollicem supra imam eorundem
 partem;  geminae, utrinque altera, ligamentosae productiones
 emergunt; qua interdum diductae, interdum latse in priorem
prostata faciem ac in proximum ani levatoris tendinem inse-
 runtur: unde utrinque provectse ad obtusum angulum, in sum-
 ma ejusdem prostates facie ac vesica,  vicinia concurrentes,
 firmissime cohserent. Si quis autem  de istius ligamenti natu-
 ra quod antenus dubitaret; turn  illius  albedinem, et firmi-
 tatem, turn fibrarum nexum, et positum exploret sedulo, ut
 quae proposuimus pernoscat.  Quantum vero com modi ex eo
 homini habendum sit, is facile intelliget, qui quantum hasce 
15
partes colligari, firmarique intersit, plane noverit.  Duplici
id potissimum  commodo,  preeter  tertium aliud,  quod mox
sumus allaturi constructum esse censemus. Ne recto scilicet
intestino alligata prostata, in vehementiori excernendarum
faecum nisu, suis e sedibus divellatur: atque id utrique sexui
commune est, quandoque  et utrique prospicit ligamentum.
In foeminis vero, in quibus et  urethrse et vaginae inseritur;
ne in diuturnis interdum, validisque edendorum  foetuum,
contentionibus, laxatee nimium dimoteeque partes incommode
aliquando prolaberentur."
  " Porro quod circa prostatam observatu dignum reputo,
atque  ad rem nostram paulo infra explicandam faciens, est
firmum expansumque involucrum; quod ad propriam intimi-
oremque circumfusam prostata menbranam is nihil spectare
intelliget, qui eo circumquaque diligenter exsecto, integram
prorsus, atque  suis circumdatam tunicis nihilominus compe-
riet: Quod si rem accuratius persequatur, eo etiam seminales
vesiculas arete concludi deprehendet.   Ad  ejus constructio-
nem nonnerveas dumtaxat,valentesquefibras caeterarum mem-
branarum in modum compingi, observavimus;  sed frequentes
interjectos lacertulos vidimus, quo ejusdem involucri compa-
ges, quando nihil ad  contractionem conferant, firmaretur am-
plius.  In cujus quidem priore facie, qua pectinis ossibus jun-
gitur, non exiguos muscular ium fibrarum fasciculos in lacer-
tosis praesertim cadaveribus intextos observasse meminimus:
quarum duplex incessus  erat.  Aliae  etenim lata  superne
basi in prostata imum  contrahebantur, ac velut  inversum
pyramidem exhibebant; aliae vero quasi transversim ductae
subjectas fere ad decussim secabant."
   " Observationes  Anatomicoe Jo.  Dominici  Santorini."
"Lugduni Batavorum." 1739.
   It still remains to be observed, that on each  side of the
bottom of the pelvis in both sexes, opposite  to the lower part
of the  bladder, there is an aponeurotic  or tendinous  liga-
ment which runs over the inner surface of the musculus obtur- 
16
 ator internus from before backwards. The anterior extremity
 of this ligament is fixed on one side of the middle portion of
 the symphisis of the ossa pubis, and the posterior extremity
 to the middle part of the ligamentum sacro sciaticum."
  " A little above the elongation called the neck of the blad-
 der there is another ligamentary expansion,  on each side of
 the bladder; the fore part of which is narrow and fixed to the
 anterior  extremity of the ligament already mentioned; and
 the broad posterior part to the side of the bladder.  These
 two lateral expansions may be looked  upon as proper liga-
 ments of the bladder, by which  it is  connected to the  inner
 side of both ossa pubis."
  Winslow's anatomical exposition of the human body.  Lon-
 don, 1776.
  " Besides these, the bladder has two other ligaments which
 are fixed at their forepart to the upper and inner side of the
 ossa pubis,  near the symphisis of these two bones;  from
 whence they  run back, becoming gradually broader to be
 fixed to the sides of the bladder."
  Monroes System of Anatomy, Edinburgh,  1807.
  " The firmest connexion is by means of a ligamentous ex-
pansion -which runs from each side of the neck of the bladder
 and prostate gland, to be  fixed to the inside of the arch of
 the ossa  pubis. It is connected also at this place to the penis,
 by the urethra.  It is composed of different coats joined to-
 gether by allular substance, the first of which is only a par-
 tial one continued from the peritoneum."
  Fyfes' compendium of anatomy, Edinburgh,  1807.
  La vessie est  retenue dans le lieu  quelle occupe par plu-
 sieurs ligamens, dont deux sont inferieurs et anterieurs, un
 moyen et posterior, et un quatrieme  superieur.  Les pre-
 mier sortent  de  la  partie interne and superieure des pubis
 pres la jonction de ces os.  lis sont  etroits and rapproches
 l'un de l'autre en devant;  mais ils s'elargissent et s'ecartent 
17
en arriere, pour se jeter sur les parties laterales d'un corps
glanduleux  qui embrasse le col de la vessie et que Ton nom-
me la prostate.  La prostate sert  d'attache a la plus grande
partie des fibres musculeuses de la vessie; elle est soutenue
par les ligamens  anterieurs de cette poche,  lesquels de la
partie posterieure et  interne  de  chacun  des os pubis, vout
se porter sur ses parties laterales."
   Traite complet D'anatomie par M. Sabatier, Paris, 1791.
   " Par des ligaments anterieurs qui attachent la vessie a la
partie interne et superieur  de l'arcade du pubis, lesquels li-
gaments apres avoir donne attache a quelques fibres muscu-
laires de la vessie, se  terminent sur les parties laterales de la
prostate. Les parties  laterales de la prostate donnent attache
aux ligamens anterieur de  la  vessie et ne sont pas eloignees
du muscle releveur de l'anus."
   " Le prostate est soutenue par des trousseaux ligamenteux
qui sont attaches  a la partie  posterieure et  externe des os
pubis."
   Cours d'anatomie medicate par Antoine Portal. Paris, 1803.
   "Du bas  de cette  region ou voit  naitre un petit faisceau
fibreux aplati de haut en bas, qui  de la se porte horizontale-
ment au dessous et derriere la symphyse pubienne a laquelle
il se fixe sous le nom de ligament anterieur de la vessie.  II
 est presque immediatement applique sur  le gland prostate."
 Bjchat p. 140.
   Speaking of the prostate gland, the author remarks
   " Sa surface superieure  qui regarde un peu en avant, est
 immediatement recouverte par ^expansion fibreuse appelle
 ligament inferieur de  la vessie.  La face opposee  est unie au
 rectum par  un tissu cellulaire extremement dense et serre,
 surtout vers le sommet: ce  dernier rapport de la prostate est
 d'autant plus etendue que  le  rectum est plus dilate par les
                              c 
18
 excremens; delal'indespensablenecessite d'evacuer cetintestin
 chez les sujets sur lesquels on sa pratiquer la tailie."
                   Anatomie descriptive par X. Bichat,
                                         Tom, 5. p. 205.
                                               Paris, 1803.
   " La Region anterieure, legerement inclinee  en  bas est
 bornee en haut par l'ouraque, et en bas par le col de la ves-
 sie.  On remarque a sa partie la plus inferieure deux petits
faisceaux fibreuse,  appeles  ligamens anterieurs  de la vessie.
 lis ont une direction  horizontale et se fixent d'une part a la
 partie posterieure de la symphise du  pubis et  de  l'autre a
 la partie superieure  du col  de la  vessie ou il sont appliques
 sur la glande prostate."
                        Traite complet d'Anatomie,
                                par M. Le  Baron Boyer,
                                              Paris, 1815.
   Du bas de cette region on voit naitre  un petit faisceau
fibreux, deprime, qui  se porte  horizontalement derriere la
symphyse des pubis, a laquelle il s'implante, et que Ton ap-
pelle  ligament  anterieur de la vessie.   II est immediatement
applique sur la prostate."
                   Traite D' Anatomie Descriptive
                                   par J. H. Cloquet.
                                           Paris, 1816.
   After these  extracts from  some of the  best  Scotch and
Continental anatomists it may be deemed proper to insert the
description of the " Prostate Fascia,"  given by Mr. Pattison
in his " observations on lithotomy."
   " The prostate fascia when superficially looked at," says
he, " would appear to take its origin from the inner margins
of the rami of the os ischium and pubis.  If we, however
come to examine it more  attentively, we may remark, that,
although, it has here a connexion with the bone,  that here it
does not terminate, but that in fact it is continuous with the 
19
aponeurosis which covers the obturator internus muscle. The
best description, perhaps, which can be given of it, would be
to state, that the fascia which  covers  the  internal obturator
muscle, having reached the rami of  the ischium and pubis,
forms there a connexion with the inner margin of these pro-
cesses; and that from this it runs and  is at last lost by becom-
ing inserted into the basis of the prostate and into the rectum
where lying below, and exterior to the gland. From this des-
cription the two following important facts are to be observed:
   1st. That the prostate fascia separates the perinceum from
the cavity of the pelvis.
   2nd. That  from  the  manner, in which the fascia passes
from the rami of the ischium and pubis to its insertion, that
a triangular space must be formed betwixt  its pelvic aspect
and the shoulder of the bladder; the apex of the triangle be-
ing formed by the union of the fascia with the basis of the gland
and the base by the  lateral boundary of the pelvis."
   Mr. Pattison with  his  accustomed  prevarication  will
doubtless deny  the applicability of the passages  quoted to
the " prostate facia."  A very moderate acquaintance howev-
er with anatomy will enable any one to determine that the
structure  alluded to, differs from his " discovery" in  no-
thing so much as in the name, and that even this is not very
far  removed  from the appellation employed by  Santorini
and others to designate the same thing.  But I have charity
enough to suppose that Mr. Pattison  as a private teacher of
anatomy in Glasgow, was unaccustomed  to  peruse such
works as Winslow, Monro, Fyfe, Sabatier, Portal, Bichat,
Boyer, and never heard of their contents until his arrival in
America, where he first  ascertained  through  Dr. Physick
that Mr. Colles " had seen the prostate fascia."
   I shall go on the next place to show, although I think there
can be very little necessity for so doing, so far at least as
intelligent and experienced lithotomists are concerned, that 
20
Mr. Pattison's  practical deductions founded on the basis oi
his alleged discovery, if not incorrect or useless, are certain-
ly gratuitous.
  It is commonly believed that the celebrated Rau of Am-
sterdam, by observing the operations of Frere Jacques, and
by dissecting his patients after  death, was  enabled to ascer-
tain a mode of extracting the stone attended with unparallel-
ed success, so much so that out of 1540 patients upon whom
he operated, it  is said every one  recovered, leaving thereby
no opportunity  for investigating the parts actually cut.  Go-
verned by the most sordid motives Rau was induced to con-
ceal the nature of  his operation  from the public, and even
from his private pupils, who were unable to determine with
certainty whether the prostate  gland  and  neck  of the blad-
der were alone divided or whether these parts were left un-
touched and an opening made  into the body of the bladder
itself.  Albinus, the favourite pupil and assistant of Rau, en-
tertained the latter opinion, and  ventured to publish an ac-
count of the operation.  This attracted the particular atten-
tion of the profession; and the  distinguished Mr.  Cheselden
of London was the first to put  the plan in  execution, by dis-
tending the bladder with an injection and opening it between
the tuber ischii and vesiculee seminales without injuring its
neck or the prostate gland.  The result, however, was unfa-
vourable, for he lost four out of  ten patients in consequence
of urinal infiltration, and  the operation was  therefore aban-
doned. Mr. Cheselden next turned his attention to the divi-
sion of the prostate gland and  neck of the  bladder, which he
accomplished by pushing a knife through the membranous
part of the urethra, and carrying it backwards and outwards
 with its edge directed towards the tuberosity of the ischium.
 By following this practice he was eminently  successful, but
 he found that the rectum was liable to be wounded from the
 edge of the knife being necessarily turned  towards it; and in 
21
consequence of this circumstance, was  induced to change
not the principle of his operation but the mode of executing
it. Accordingly in his third and most approved operation, in-
stead of cutting, in the first place, the membranous portion of
the urethra, he made a free  dissection of the  parts adjoin-
ing the  prostate  gland and  neck of the bladder,  and then
plunging his knife into the body  of  the  viscus immediately
above the gland, he drew it downwards towards him, and di-
vided the prostate as far as  the  urethra.   In  pursuing this
method he succeeded in saving fifty patients out of fifty-two,
and out of two hundred and thirteen operations performed
within a period of twenty years,  it is said, only twenty were
lost, making about two in every  twenty-one.
   I have given this short history of the lateral operation, to
point out the principles  by  which Cheselden was governed,
inasmuch as his second  or third operations are practised by
all modern surgeons of eminence at the present day.   But
since Mr. Pattison  has  ventured to  affirm that it is  " not
consistent with truth" to declare that in his third operation
he did fg^ divide  the prostate  and neck of the bladder, I
must proceed a little further, and show that such an assertion
is altogether  without foundation.
   " The  internal wound," says  Dr. Douglass, " is through
the bladder, prostate gland and urethra."
   1st." The vesica urinaria covered with the membrana cellu-
laris, is cut in two places, viz:  first a small portion of it a
little above the prostate gland,  on the left side, where he
enters the knife, first into the groove of his staff, and then
part of the bladder  which lies  round the orifice upon the
upper part of that gland."
   2dly. " The substance of  one  half of the prostate gland is
likewise  divided laterally from  without, inwards in the di-
rection of the urethra that lies within it, through  the whole
length of that part of the canal." 
22
   3dly. " The iter urina, or canal of the urethra is divided
in two places, and both laterally.  First, the beginning of it,
which runs through the substance of the prostate lengthwise,
at the same time the  incision  is  made through it and the
urethra into the groove of the staff."
   " The next is  the  membranous part of the urethra  with
the circular muscle that surrounds it, beginning at the infe-
rior apex of the prostate, and ending a little beyond the hole
in the septum tendineum, under the pendulous  part of the
bulb."
   " In  England," says Mr. Allan Burns, " Cheselden  im-
proved the  operation of lithotomy,  but not  until repeated
failure had taught him the  necessity of making a free divi-
sion of the prostate gland and neck of the bladder."
   But it would be useless to quote authority  on the subject,
inasmuch as the  testimony in  favour of  Mr,  Che'selden's
particular mode of operating is universal, and as well esta-
blished as any thing else in surgery.  Notwithstanding this,
Mr. Pattison has brought forward some extracts from Mr.
Sharp's Treatise  on  the operations,  in  proof of<fc suppo-
sition, that  Cheselden  did not divide  the neck of the
bladder.  It is  very  true,  that Sharp recommends  " the
whole length of the gland to be cut, from within outwards;"
but it does not follow that Mr. Pattison's logical conclusion,
that the base of the gland must therefore remain uncut,  is
altogether correct.  I  presume  it will  be  admitted that the
base of the prostate forms a part of its length, and ergo that
if Mr. Sharp  cut the whole length, he must also have cut
the base.   Mr.  Sharp's declaration,  that a dilatation  is
necessary both in the Marian and Lateral operations, would
seem  to establish  not the conclusion  which Mr. Pattison has
drawn from it, viz: " if the base of the prostate and shoul-
der of the bladder were divided, there could be no occasion
for laceration," but rather the reverse, that a free division of 
23
the prostate and neck of the  bladder was sometimes neces-
sary,  and if not made, that  laceration would be the conse-
quence.   I am well convinced  from reading  Mr,  Sharp's
chapter on the stone,  in  the  work referred to, that although
he does not say in direct terms  as Douglass and others do,
that the neck of  the bladder  must be divided, he took  it for
granted the surgeon would conclude, inasmuch as the  knife
was to be entered  at  the base of the gland, that the neck of
the bladder must unavoidably be cut, and in corroboration of
this sentiment, I extract the following passage from his " Cri-
tical Enquiry" where speaking of the form of the knife that
should be used in lithotomy, he  says " besides  that the back
being blunt is a security against wounding the rectum,  when
we cut the neck of the bladder from below upwards."
   Mr. Pattison  conceives it is  proved  that Cheselden did
not divide the neck of the bladder, " from the difficulties
opposed to the operation."   What these difficulties are,
he  does not venture to say.  If he means that the  neck
of the bladder is too  remote to  be reached by the knife, he
will recollect that Mr. Cheselden in  his first  operation,
opened the body of the bladder as he says,  " very readily;"
and since the bladder  itself is deeper seated than the  pros-
tate gland, it follows  it  cannot be so easily cut; but if cut,
that its neck and the prostate may  also and with greater fa-
cility.
   It  has  been insinuated  by Mr.  Pattison, that although
Cheselden may  have  intended  possibly to  cut the neck of
the bladder,  yet he never accomplished it except in  a few
cases, and " that the fatal cases were the  ones where this oc-
curred."  This is an admirable specimen  of his  " sound logic
and pure philosophy;" but he will not find it very easy per-
haps to make other people suppose that Cheselden, the great-
est anatomist and surgeon of the age in which he lived, was
so ignorant of his  own operation  as not to cut the parts he 
24
 intended to cut, especially as he must have had some oppor-
 tunities, notwithstanding his great success of examining them
 after death.    Any  one who has  read Scarpa's  Memoir,
 will readily  perceive where  Mr.  Pattison obtained  the
 idea of the difficulty of cutting the  neck of  the bladder be-
 hind the prostate. " But, in fact, it is not so easy, says Scarpa,
 as some not sufficiently acquainted with this operation might
 perhaps imagine, to  conduct a knife through  the neck of the
 urethra, beyond the orifice of the bladder," &c.   It is plain,
 however, from  what soon follows, that Scarpa never intended
 to insinuate  that  Mr. Cheselden  found any difficulty, for,
 says he,  " To  facilitate  to intelligent surgeons,  but not so
 dexterous as Cheselden, the performance of the lateral in-
 cision was the laudable motive which led Hawkins to propose
his cutting gorget."   It remained then for Mr. Pattison to
make this  discovery, but as he has  admitted  that  if Mr.
 Cheselden did  in  reality execute his  own operation, " the
very root of his  reasonings  must be torn up," there can  be
no  necessity  I  hope for following him any further, since
every one must  be fully prepared to acknowledge by this time,
that the neck of the bladder and  the whole prostate Were com-
pletely divided in Mr. CheseXdLevfs second and third operations.
   Mr. Pattison, in  speaking of Cheselden's  operations as a
strong and unanswerable objection to his maxims,  remarks,
" So satisfied do  I  feel of the  justness of this observation,
that I am unwilling to take leave of my critical friends with-
out assisting them, with  at least one observation, which cer-
tainly carries with it a much more powerful inference against
my maxims, than any of those puerile objections with which
their minds have furnished them."  It certainly required no
uncommon penetration  to  discover, that if  Cheselden, by
making an extensive incision of the prostate and neck of the
bladder was enabled to  save 193 patients out of  213, that
his  operation  must stand  as  an objection  to  a  contrary
 mode of proceeding, which had not been subjected to the 
25
test of the same  extensive experience.   This Mr. Pattison
might easily have inferred from what he heard in my lec-
ture, or from a perusal of more than one passage in the dic-
tionary of his favourite author, Mr. S. Cooper, to this effect:
" Every practitioner who will take the trouble to look over
the history of the lateral operation will find, that such litho-
tomists as have  particularly distinguished themselves by
their  unparalleled  success, as  Frere Jacques, Cheselden,
Cosme, &c, all made a free incision into the bladder.  This
fact alone, is enough to raise doubts of the goodness of the
advice delivered upon this subject by Callisen and Scarpa,
especially, as neither they nor  any other  modern surgeon,
can boast of having cut patients for the stone with a degree
of success, at all equal to that of the above  mentioned ope-
rators."
  I have already had occasion to state, that the operation of
Rau was unknown  to  his contemporaries,  and was so care-
fully concealed by him, that even his own assistant, the cele-
brated Albinus,  an excellent  anatomist, and most expert
surgeon, could not discover his particular mode.  Mr. Pat-
tison is also aware it appears, " that Rau made a secret of
the parts he divided," but he is so well pleased with Rau's
success in saving 1500 patients, and with the declarations of
those who saw him operate, and the principles of the opera-
tion correspond so  exactly with his own, that he is induced
to believe  that Rau must have operated precisely after his
method.   If he means, as  I  presume he does, that Sabatier
was  one of those  " who saw Rau operate,"  I may  observe
that, according to historians, Rau was born in the year 1668,
and died in 1719; and that Sabitier was born just about the
time of his death, and died in  France within the last ten
or twelve years.  It is natural to conclude therefore, that he
had no more opportunity of seeing Rau operate,  than the
fcetus in utero had, and must have been fully as well qualified
to describe his particular mode, which it seems  Albinus
> 
                           26
could not comprehend, although an eye witness to the whole
scene.
  It is stated, that " Foubert invented or rather revived the
practice of Franco and introduced  a  gum catheter into the
bladder."  It is not easy to perceive the impression intended
to be conveyed by the particular and unnecessary mention of
such an instrument. I may therefore observe, that Dr. Physick
has for many years employed a gum  catheter after the opera-
tion for lithotomy, and that Mr. Pattison wishes to insinu-
ate  he was not the first to put the plan in execution. Although
it is well known that Franco, the Collots, Foubert, and several
of the old lithotomists employed  metallic canulce,  yet the
gum elastic catheter was invented by Theden in 1782, while
the memoir of Foubert was published in  1743, in which he
says, " cet accident sur lequel j'avois deja beaucoup reflechi
quand je  pratiquois le grand appareil, reveilla d'avantage
mon attention, lorsque je reconnus qu'il avoit ete la  cause de
la mort de quelques  malades tailles selon ma methode et je
pensai que je pourrois le prevenir en placant dans la plaie
une canule  pour  entretenir autant de temps qu'il  seroit
necessaire."   In a  note Foubert adds, " Qouique  les can-
nules d'argent ou le plomb puissent  servir en pared  cas, je
prefere cependant celles  d^argent qui sont flexibles que je
couvre de  linge fort doux  et  use."  Thus it appears from
Foubert's own words, that he used ^flexible silver  catheter,
and not a gum catheter as Mr.  Pattison has asserted.  I have
mentioned these circumstances, to show that  Dr.  Physick
was, in all  probability, the first who used a gum  catheter
to  draw the urine  from  the bladder after the operation of
lithotomy;—and to  expose Mr. Pattison's disingenuous at-
tempt to take that merit from him, which is especially due, as
the instruments used by the ancients, and by Foubert, must
have increased the  very difficulties they were intended to re-
move; as any one will be able to determine by examination, or 
27
by referring to the plates in which they are represented in the
old writers.*
  Mr. Pattison has remarked " one of the assertions, deli-
vered by Dr. Gibson in his lecture was, that no gorget was
made sufficiently large to cut the  whole body or base of the
prostate gland."  I never made an assertion of the kind.  The
extent of   my  observation, was,  that  the prostate gland
was  not so  easily  divided, , as some  imagined; that in
fact  a  gorget from three quarters  of an inch, to  an inch
in breadth, might be employed in most full grown subjects,
without  producing such  an  effect.   I  did not  suffer the
observation to rest upon my assertion, for I performed the
operation in presence of the  class, with a gorget, upwards of
an inch  in the blade, merely to put the matter to the test, and
upon examination of the parts after lecture, while several of
the gentlemen were looking  on, it was  distinctly seen  that
the gland was not divided by the eighth of an inch.
   But the gratuitous assertion as it is called, did not rest
upon my authority alone.  Dr. Physick demonstrated to his
class, by actual experiment,  that a gorget  much larger than
the  one usually   employed  in the  operation on  the living
body, would not  divide the prostate,  and  Dr.  Horner
repeated  the experiment   so  frequently  in  the practical
rooms,  as  to convince  the  most sceptical inquirer, and in
fact to leave very little doubt on the subject, as the following
statement will show.

  * Dr. Physick has never asserted that he first employed a gum catheter,
after the operation  of lithotomy,  although not aware of its having been
used by any one before him for such purpose. I believe that the profession
 is entirely indebted to him for its introduction, as I have not been able, after
 the most diligent research, to find it noticed, except in thj; tenth volume
 of the Edinburgh Journal, published in 1814; where its use is theoretically
 proposed by a Mr. IMhell who says, " among the many eminent writers on
lithotomy, I cannot find such a practice mentioned." 
28
                             Philadelphia, July, 28, 1820.
Dear Sir,
  Being much interested last winter in the discussion which
took place concerning the injury done to  the prostate gland
by passing a common gorget,  and hearing Dr. Physick  say
that this body was seldom entirely divided, I performed five
operations with a gorget, the blade of which was three quar-
ters of an inch in breadth, with  a view of ascertaining the
fact.  In none  of these  experiments was the  side of the
prostate gland divided; on the contrary, upwards of one eighth
of an inch remained uncut.
  I also found  that the  membranous  expansion  described
by most of the old as  well as the late anatomists, is  connec-
ted  to the bladder so high up, that an incision may be made
through the whole side of the prostate, and into the lower fun-
dus of the bladder,  without dividing the membrane itself.
If this arrangement holds  in  all subjects, it appears to me,
that the fears entertained  by  Mr. Pattison, of cutting this
membrane (even allowing it capable of resisting urinal infil-
tration) are groundless.
  I am prepared, at all times, to demonstrate by dissection,
to persons whose opinions are unsettled on the subject, the
correctness of the statements  I have  advanced, and in cor-
roboration of my assertions, I appeal to the  numerous class
of medical gentlemen, who attended my winter and spring
courses of practical anatomy, on whose minds I believe there
can be little doubt, at this moment.  I remain with much respect
                 Your obedient Servant,
                           W.  E.  Horner,
                        Demonstrator of Anatomy.
       Dr. W. Gibson.
  In addition to the experiments  made by Dr. Physick, Dr.
Horner, and  myself, during the  winter  at the University,
I may state that  I have performed the operation on the dead
body  under  different circumstances repeatedly since the 
                           29
                         •
publication of  Mr.  Pattison's  reply, and that in  one in-
stance only,  has the base of the gland been cut through as
the following circumstances will show.
  On Sunday, the 30th of  July, 1820, in the presence of
Drs. Colhoun,  Edward  Barton, and  Lawrence;  I divided
the prostate gland in two subjects.   In one I used a  gorget
of  three quarters of an inch in the  blade, and the gland
was not divided  by upwards of a quarter of an  inch.  In
the other, I  employed a  gorget of a full inch  without the
division of the  gland by  nearly the eighth of an inch.  In
both  instances  the " prostate fascia" was untouched,  and
was connected  to the  bladder,  by  its posterior  attach-
ment so  far back that  it  could  not  have been divided,
except  by a very  extensive incision,  and was  not inju-
red  even when the gland  was afterwards cut through by
the knife.  Upon  measuring the divided part of  the gland
in both subjects at its base, from  its  external boundary to
the edge of the urethra, it was upwards of eight in one, and
fully nine lines in  breadth in the other.  The breadth of the
urethra, also  exceeded in both subjects, nine lines, making in
the whole, including the urethra and gland, more than eigh-
teen lines in one,  and nearly the same in the other subject.
  Thursday, August the  3d, 1820,  Drs. Horner, Harlan,
Wilstack, and Lawrence being present, I opened  the mem-
branous part of the urethra with  a knife, and  introduced
a gorget, an inch  in breadth into  the staff, and  divided the
prostate gland,  in two different subjects.   In neither  in-
stance was the  gland cut through by the eighth of an inch,
nor was the  fascia within the reach of  a gorget considera-
bly wider in the blade,  than the  one  I  used.  In both
cases the  divided glands and urethra, measured each nine
lines  at their base, making together eighteen lines.
   On  the 26th of August, 1820, I performed the operation
of Lithotomy, with a gorget  exactly  thirteen lines wide in
the blade.  Drs.  Harlan,  Lawrence,  and three intelligent 
                             30

medical  students;  Messrs.  Wilson,  Cuthbert, and  Stod-
dart,  were present.  \ small portion of the prostate, ad-
joining the urethra,  where it opens into the bladder, was found
undivided.  The rest of the gland, together with a part  of
the neck of the bladder was cut  through.  " The  prostate
fascia"  was not touched, and it  appeared  to every one  that
the incision might have been carried to  the extent of three
quarters of an inch  further into the side of the  bladder,
without wounding it.   The gland in this subject was uncom-
monly small, measuring only six lines.   This was probably
owing to the extreme emaciation of the body, the patient ha-
ving laboured for several years under  Pthisis  Pulmonalis.*
   By all these results,   I am  strongly fortified in  the po-
sition  advanced  in my  lecture, that  a  gorget  of three
quarters of an inch to an inch in breadth, will not complete-
ly divide the prostate gland in most full grown subjects, and
have therefore a  right to conclude that the anatomical fact,
insisted  upon  by Mr.  Pattison, is no fact at all.  But up-
on whose authority does this " anatomical fact" rest, that the
prostate gland,  does  not  exceed seven  lines  in  breadth;
not surely upon the authority of Scarpa, for he expressly de-
 clares that " the size or thickness of  the  prostate as its ap-
 pex, is a little more than two lines, four at its body and  six
 or even eight at its  base,  where it surrounds  the  orifice of
 the bladder."
   It rests then upon the  authority alone, of  Mr.  Pattison,
 who, as far as I can ascertain from his essays, has never made

   * Since some of these experiments were made, I have perused with
 great pleasure an essay, published in the last number of the Recorder,
 by Dr. Jameson, of Baltimore, replete with sound observation and correct
 anatomical views.  It is very evident from the account which Dr. James-
 on has given, of the situation and connections of the " prostate fascia"
 that he must have been aware, it could not be cut even by the " entire
 division of the prostate gland, but I do  not find that he has drawn such a
 conclusion. At any rate he is entitled to full credit, and his remarks general-
 ly confirm in a pointed manner, the experiments of Dr. Horner and myself. 
31
a single experiment to substantiate  the  assertion  which he
brings forward with so imposing an  air.*  But even admit-
ting his declaration to be true, that " the gland very rarely
measures above seven lines," does it follow that a gorget of
greater breadth than the gland  itself,  must of necessity di-
vide the gland completely? It certainly does not, and for the
very best reason in the world, that a considerable portion of
the blade next to the beak of the instrument passes through the
urethra, and does not touch the gland at all. What this pro-
portion is cannot perhaps be exactly ascertained, since it will,
in some measure,  depend  upon the size of the staff and its
groove, and upon the size of the beak of the gorget.  But
it is reasonable to  conclude, since I have been able in the
experiments detailed, to carry a gorget of an inch in breadth
into the bladder,  without dividing  the gland entirely which
was found in numerous  instances to equal nine lines, 'that
the cavity of the urethra must have exceeded at least three
lines, otherwise the gland would have been cut to  mathema-
tical certainty.  It is here then that Mr.  Pattison has erred,
and it is proper  the mistake  should rest with him  and not
with Scarpa,  who allows that the urethra measures general-
ly five lines.  The assertion that  many gorgets " are made
of fourteen  lines in  breadth,"  I will not  pretend to dispute.
I can only say, that I have never met with such, either in this
country or in Europe, or in any book on lithotomy, ancient
or modern.
   But I shall proceed in the next place to show upon other
authority than that of Dr. Physick, Dr. Horner and myself,
that the prostate gland is not only not cut so easily as Mr.
Pattison supposes, but that in fact the difficulty of dividing
   * The idea of measuring the extent of the prostate gland in subjects oJ
different ages did not originate with Scarpa, for we find Deschamps in
his " Traite Historique de 1'operation de la Taille," the best work on li-
thotomy in the French language, entering minutely into the investigation,
and confirming in a particular manner im assertion, that the gland mea-
sures generally, in a full grown subject, upwards of nine lines. 
32
 it even by a gorget of large size, is considered as the strong-
 est possible objection to the use of that instrument.  " The
 gorget ought to be," says Mr. Charles Bell, " of that breadth
 in the sharp edge, that it may cut through the left side of
 the prostate gland.  If the prostate gland and the  stronger
 fibres of the sphincter vesicae be completely cut, the wound of
 the bladder will enlarge  to transmit the largest stone.   But
 if the base of the gland  be not entirely  cut through, there
 will be a bridling and stricture on the forceps.  As the  gor-
 get is uniformly of one size (and  indeed cannot be made
 broader without endangering the cutting of the pudic artery,
 it has the fault of not entirely cutting through the prostate
 gland and neck of the bladder.  In operating with the knife
 in place of the gorget,  the incision can be adapted to circum-
 stances."
   Mr. John Bell in his " principles of surgery" speaking of
the gorget says, "but there is one paramount objection inde-
pendent of the many dangers  which  attend this push of the
gorget; the instrument, guide it is you will, makes an incision
inadequate to the  easy  extraction of the stone! I have often
compared the incisions I have made with the knife and with
the gorget upon the dead body.  I have observed also, in the
 time of operating, how difficultly the opening of the prostate
admits even the forceps, how impossible that such an imperfect
incision should easily allow the extraction of the stone.   In
all cases of particular difficulty, where using the  privilege
of an assistant, I  have  introduced my finger, I have felt dis-
tinctly the stricture of the gland, the greater part of it being
left entire.  The  incision of the  gland often  admits the for-
ceps so difficultly, that I  am well assured the gland itself has
sometimes by the mere pushing of the forceps against this
firm, and narrow opening been entirely separated'from the  ure-
thra! and after the forceps are pushed successfully  through
this  narrow opening,  and the stone  caught betwixt their
blades, all that remains pf the gland  is inevitably lacerated 
33
with much danger and  pain.  But I would more willingly
quote any authority than that of my own dissections or ex-
perience.   Camper who has studied the subject, says " In-
credibile est quam parva plaga ab omnibus etiam dexterrimis
infligatur; nunquam forcipem robustam exciperet nisi dilata-
retur.   Hawkensius solo conductore, cujus margo dexter in
aciem assurgit idem prsestat; omnes plagam dilatant ut calcu-
lum  extrahant dilaceretur  igitur semper vesicae ostium et
prostata."
  " But higher and better authority remains behind. Dease
was, if I judged rightly of his talents, a stern  and rude sur-
geon, but perfect  in all the  theory and  practice of his art;
he was not very  explicit  in  his  communications  with  me,
but from the manner and  the movement of his hand in de-
monstrating  to me, rather than from  what he said, I con-
clude that he cut after the manner of Rau, making the inci-
sion with the right hand, while he held the staff with his left,
" In all the trials," says Dease, " that I have made with the
gorget on the dead subject, I  have  never found the opening
into the bladder sufficiently large for the extraction of a stone
of middling  size, without a  considerable laceration of the
parts.   I have frequently taken the largest sized gorget, and
could not find that in the adult subject, I ever entirely divid-
ed the prostate  gland, if it was any way large; and in the
operations that were performed  here on the  living subject,
the extraction was painfully tedious, and effected with great
difficulty, and in some cases not at all."
  Other authority might be quoted to the same amount, but
I have said  enough to convince  any one that the prostate
gland cannot be cut in most full grown  subjects, by passing
a gorget of three  quarters, to an inch  in breadth  along the
urethra;—that a comparatively small opening is made, even
by an instrument of the largest size;— that the  " prostate fas-
cia" of Mr. Pattison cannot be divided, by cutting through
the gland, and even  prolonging  the incision  some distance
                            E 
34
  into the body of the bladder;—and that, therefore, its influ-
  ence upon the operation of lithotomy must be inconsiderable,
  if not nugatory.
    After these observations, I conceive it quite unnecessary to
  argue with  Mr. Pattison about D'Alembert's proposition,
  t% that there is no analogy  between living matter, which is
  active, and dead matter which is inert," for according to his own
  principles, the opening  made  by the  gorget in the prostate
  gland of the living body, should be larger than the same in-
  strument could produce in the dead, which, even admitting
  to be true, we find  not  sufficiently  large, according to Mr.
  John Bell, Mr. Dease and others,  to effect a complete divi-
  sion of the gland, or to  permit a stone of small  size to pass
  through without difficulty.
    But suppose that the principles I have inculcated are incor-
 rect, and those advanced by Scarpa and reechoed by Mr. Pat-
 tison are true, what becomes of their position that urinal in-
 filtration  is a necessary  consequence of the division of the
 neck of the bladder, when it is ascertained  that the greater
 number, if not all, of the most celebrated lithotomists, from the
 time of Cheselden down  to the present day, have made a free
 incision of the prostate and bladder, and yet have been able
 to save at least seven patients out of eight?
   The most successful lithotomists, in  this country and in
 Europe, are in  the habit  of removing  from the bladder
 stones of uncommon, and even of enormous magnitude, which
 cannot be extracted without a very extensive division of the
 prostate and bladder,  and the patients generally recover.  Can
 any man at all acquainted with  the subject, believe then that
there is really so much danger  as Scarpa and Mr. Pattison
contend from dividing these parts? " Mr. Orford, aged 56,"
says Dease, " calculous for many years, resolved in  1773 to
undergo the operation, which Mr. Morris performed with Mr.
Daunts' instruments, and happily extracted a stone which
weighed fifteen ounces and a half. The operation was not at- 
35
tended with any alarming hemorrage.  The patient recovered
in the course of two months, and after some time could retain
his urine as well as ever."
  We are told by Gooch, that Mr. Harmer, of Norwich,
extracted  a stone from a patient aged 48, which weighed fif-
teen  ounces,  and the man afterwards recovered.  " It was
found impracticable," says Gooch," to extract the stone through
a wound of the common size, which the operator had made,
or to break it by the force of the forceps;  therefore, at his
desire, I divided the parts occasionally, as he  continued a
gentle extraction."
   Klein, a celebrated German lithotomist, lately extracted a
stone, by the lateral operation performed by the knife, weigh-
ing, without the fragments, twenty-six ounces and thirtygrains.
   Dr. Physick, some years ago, in Virginia, took from a boy of
four years of age, a stone measuring an inch and three  quar-
ters in its  smallest diameter, and his patient  speedily reco-
vered. I operated six or seven years ago upon a child of the
same age, in the Baltimore hospital,  and  extracted a stone
nearly as large, and he  recovered  in two weeks, without a
bad symptom.  I  operated  three  or four years ago upon a
gentleman at Washington, who had two stones in his bladder,
each as large as a  hen's  egg of common  size, to extract
which I was under the necessity  of dividing the prostate and
neck of the bladder, to a considerable extent by the bistoury,
after I had made an opening with a gorget of three-quarters
of an inch; and who, notwithstanding, got well  without any
difficulty whatever.  It will be said, perhaps, that these were
uncommon cases, that under the  same circumstances the
patient would generally die.  I  appeal to the whole profes-
 sion, whether the most successful lithotomists of ancient and
modern times, have not inculcated a free incision of the pros-
tate gland and neck of the bladder, and whether  any surgeons
 of eminence, except Scarpa and Callisen, have advised a con-
 trary practice. It is stated, I know, by Mr. Pattison, that Le 
36
Cat, Mr. Astley Cooper, and Dupuytren of Paris, are in
favour of small incisions; but have we any other than Mr.
Pattison's assertion on the subject? to which I may perhaps
with propriety oppose my own by  declaring,  that during
my residence in London in 1809 and 1810, I had an oppor-
tunity of seeing Mr. Cooper operate for the stone two or
three times, with a beaked knife, and chiefly  with  a view,
as he  said  at that period in his  lectures, of  making an
ample  incision of the  prostate and neck of the bladder.
Have we not  also  the  authority of  several late  surgical
writers that Mr.  Cooper, within the last five or six years,
has employed the bistoure cachee of Frere Cosme, an instru-
ment better  calculated than any other to make a  large open-
ing into the  gland and neck of the  bladder?   I  have more-
over the authority of Roux, a celebrated French surgeon, who
in his  " Relation  D' un voyage fait a Londres en 1814,"
says, " Le seul chirurgien de Londres a qui je 1' aie vu pra-
tiquer, est M. Cooper: je la lui ai vu faire deux fois.  Dans
les deux cas, le col de la vessie et la prostate, furent incises avec
un gorgeret tranchant."
   Of the practice of Dupuytren  I  cannot speak, from ex-
perience; but I am  informed by Drs. J. G. Nancrede  and
Price,  two most intelligent  and able Surgeons  of this city,
who have witnessed his operations for  the stone, in a great
many  instances  within  a  short time,  that  he  invariably
made extensive incisions of the prostate and bladder.  I may
add that my  friend Dr. W. Howard,  of  Baltimore,  has
confirmed these statements.   As to the authority of Le  Cat,
I do not conceive that it can weigh in favour, or against any
mode of practice.  " Le Cat's talents," says his biographer,
" were lost to himself and the public; he never became a  dis-
tinguished operator;  it was his fate to  continue through life,
writing volumes/^// of ingenious theories, the pages of which
were never soiled by any finger, and  to invent instruments,
still more ingenious,  which were never sharpened by any 
37
hand but his  own: even in France where every novelty has
its admirers,  Le Cat found no one to praise or follow him.
After a turbulent  life, embittered by perpetual warfare, all
his  brilliant  expectations ended in utter disappointment.
His innumerable improvements had so accumulated, that his
method of Lithotomy was such as no one would be at the
trouble  of learning or the habit of performing."
  Independently  of the  difficulty of extracting a stone of
large size, through a small wound of the  prostate, is there
no  other objection  to  the practice?  I would  ask  those
operators, who for fear of wounding the pudic artery, or of
cutting  through the prostate gland, have used a very narrow
gorget,  whether they have been able readily to find the open-
ing they have made, and whether they have not, during the
operation, forced the forceps  between  the  bladder  and
rectum, and  made unavailing  efforts to extract the stone?
 I need  hardly ask the question, for I  am  convinced  that
every Surgeon who has  performed the operation half a
dozen times, must have  encountered  more or less resis-
tance from the gland, even where he has employed a gorget
of considerable size. It cannot be said that the  gorget has
slipped between the  bladder and the gut, and left  the gland
undivided, as sometimes happens, because the flow of  urine
follows so speedily  the thrust  of the instrument, as to give
the Surgeon   convincing proof, that he  has opened the  blad-
der, and leaves him to wonder why his forceps  or finger
will not follow the same route.   " In one unfortunate case,"
says Mr. John Bell, " the Surgeon groping thus on the out-
side of the bladder, actually grasped with the point of his
forceps and   twisted away the greater part of the prostate
 gland, which when he had thrown down among his feet was
picked  up by a professor of anatomy, who assisted at the
 operation; and when the gentleman died the parts were dis-
 sected  out,  and  are preserved."  If such is the  difficul-
 ty of finding an opening, made into the prostate, or  if the 
38
 forceps will not easily enter after it is once found, how can
 the Surgeon expect to remove a stone even of small dimen-
 sions, through such an opening, without lacerating the parts
 to a considerable extent, and without exposing the patient
 to danger  and agony, a thousand times worse than the dis-
 ease itself.  It would be said by Pouteau, in answer to this,
 and  perhaps by Scarpa, who has taken many of his notions
 from  him,  that   the  opening  in   the  prostate,  would
 dilate gradually, and expand  like the neck  of the  uterus
 in proportion to the pain  which the patient  suffered, or
 the efforts of  the  operator.   But does not the history of
 the art  furnish a sufficient number of examples  of patients
 mutilated, and destroyed, by the tortures of the Marian ope-
 ration, to dissuade any modern Surgeon  from the revival of
 so horrible a practice.  And yet this is the very doctrine
 inculcated by Scarpa. " Therefore," says he, " in the present
 day the lateralizing ofthe great apparatuses justly considered
 as the greatest degree of  perfection to which the operation
 of Lithotomy, in the  perineum can be brought."  Any one
who  has encountered a large stone in  the bladder, knows by
experience that the prostate does not  dilate in the manner
we are taught by some to believe; he finds that the prostate
is tough and unyielding, and resists the utmost efforts he can
use, that his forceps bend under his exertions to extract the
 stone, that the cries of the patient bear testimony to the vio-
lence  committed,  and   finally,  when  the stone  is  ex-
tracted, that it is by main force and by the laceration of parts
 which nothing less  than  the strength of  a Cyclops  could
rend asunder.  We  are told  by Mr. Pattison himself, that
the " prostate  gland  is composed of a very tough substance,
 one which is not easy of division."  How can it be  expected
 then, that this gland is to dilate to the extent  of eight lines,
 as Scarpa says, and permit a large stone to pass without dif-
 ficulty. 
39
   There  is another  objection  to  a  small  incision  of the
prostate, independently of the pain which the patient suffers,
from the passing of the stone;—the stone itself is liable to be
broken by the pressure of the  forceps,  during  the  forcible
attempts, to get it away.  If such an accident should hap-
pen,  the operator has necessarily  to  encounter  a vast deal
of trouble, and the patient is exposed to danger, from  in-
flammation of the bladder, or, if he survives, to  the forma-
tion of another  stone, from fragments left behind.
   But the great  apprehension of  Scarpa, and Mr. Pattison,
relates to urinal infiltration.  Let us see, therefore, whether
the  urine, which  escapes  very  readily,  after  a  large
wound of  the prostate and  neck of the bladder, is really
productive of those  injurious and fatal effects which these
writers are inclined to believe.   I  do not know  the  ex-
tent of Scarpa's  experience in  lithotomy, however high
his reputation  in  some other  departments of his  profes-
sion, but I have reason to think that  the  stone in  Italy, is
not  a very  common complaint,  and that his  opportuni-
ties of operating have consequently been a good deal limited.
Mr. Pattison's experience is  confined to two cases in his own
practice, and those in young children, and to three dissections
in the practice of others.
   Let us examine then  the  testimony  of those who teach
a doctrine adverse to the views of Scarpa and his followers,
and in the first place, that of  Mr. Samuel Cooper, " who, ac-
cording to Mr. Pattison, is perhaps better acquainted with the
writings of ancient and modern  Surgeons, than  any other in
Britain," and  see how far his notions of the dangers of urinal
infiltration, correspond with their own. " With respect to the
degree of importance," says he," which ought to be attached to
the fear of effusion of urine,  between  the bladder and  rec-
tum,  gangrene fistula, &c. I can  only say that they are in-
conveniences which are not  commonly observed after lithot- 
40
 omy in this country.   In two  or  three instances only I have
 known the urine come through the wound longer than usual,
 and these  cases ended well.  As for the extravasation of
 urine, and sloughing,  I shall merely remark, that  although
 there cannot be a doubt of their occasional occurrence, they
 have not taken place after any of the  numerous operations,
 with the results of which I have been acquainted."
  " All these  facts and considerations, therefore, incline me
 to doubt whether the apprehension of the effusion of urine,
 fistula?, &c. be sufficiently  serious and well founded to make
 it advisable for surgeons to relinquish the plan of making a
 complete division of the side  of the prostate gland and neck
 of the bladder  in the operation of  lithotomy.  Nor is it at all
 clear to my mind,  that effusion of urine and sloughing are
 likely to be the effect of practising a free opening.   Indeed,
whenever  they do happen, I believe they proceed from a to-
tally different  cause, viz:  from the  incision in the skin  and
 muscles being too small, and too  high up, and from  the axis
 of the  internal parts of the incision,  not corresponding with
that of the external wound.   Hence  the urine  does not rea-
dily find its way outwards,  and  some of  it passes  into  the
neighbouring cellular membrane."  It is stated by Mr. Pat-
tison, in his former essay, while  speaking of urinal infiltra-
tion, that " Mr.  John  Bell is most decided in asserting that
the inflammation which produces death,  arises from urinal
 infiltration." " It is indeed," continues Mr. Pattison," the ge-
 nerally received opinion."  In answer to this I may state,
that I have not been able to find,  after a patient investigation
 of Mr. Bell's work, a single expression which would induce
 me to draw such a  conclusion.  His observations respecting
 urinal infiltration, are exceedingly limited, and when he does
 mention it at all,  it is not in  reference to  Cheselden's  last
 operation, but to his first, which  he  and every  one acknow-
 ledges to  have proved fatal, chiefly on that account, for rea-
 sons which I shall presently endeavour to  explain.   If any 
41
positive inference can be drawn, respecting Mr. Bell's opi-
nion from his own writings, as to the most common cause of
death, after the operation, I am disposed to think that he con-
siders it owing to loss of blood, either from a wound of the
pudic artery, or of the deeper seated parts, in consequence of
which the cellular tissue is injected with blood; or to violence
done the bladder and prostate, in getting out the stone through
a small opening.  Mr.  Allan of Edinburgh, the friend and
assistant of Mr. Bell, expressly  says, in his Treatise  on
Lithotomy, " the two great dangers to which the patient is
exposed, and which chiefly claim the attention of the surgeon,
after the operation of lithotomy, are hemorrhagy and abdomi-
nal inflammation."  The effusion of urine is not referred to
by Mr. Allan  as the cause  of death, and is only spoken of as
occasionally productive of excoriation.
  That urinal infiltration is not generally considered, as Mr.
Pattison asserts, as  the cause of the inflammation which pro-
duces death, I may mention that very few, either of the En-
glish or French surgeons speak of it, as a consequence of the
lateral operation as usually performed by the modern surgeon;
on the contrary, when spoken of, it is in relation to the High
operation, the operation of Foubert, of Thomas, and to Chesel-
den's first operation, as may be ascertained by any one who will
take the trouble to look  over the works of Cheselden, Doug-
lass, Sharp, Daunt, Dease,  Sir James Earle, John Bell, Dr.
Thompson, Allan  Burns, Charles  Bell, Allan,  Dionis, Le
Dran, Dechamps, Sabatier,  Boyer, Bertrandi, Desault, all of
whom recommend  a free incision of the prostate gland and
neck of the bladder, with a  gorget,  knife, or bistoury.  It is
well known that almost all, if not the whole, of the best sur-
geons  in England,  Scotland and Ireland, follow the  same
practice, and generally with a happy result. In proof of this,
I may mention the  names of Hunter, Cline, Carlisle, Lynn,
Abernethy, Home, S. Cooper, Lawrence, Blick, Blizzard,
Pearson, Benjamin  Gibson, Hey, Brown, Newbigging, Rus-
                           F 
42
sel, Inglis, George Bell, Colles, Barlow, Foster, Chevalier,
&c.  In Italy, Nannoni and Flajani, who have as much re-
putation as Scarpa, always make large incisions.   In France,
Pelletan, Percy, Richerand, Patrise, Lallemand, Roux, Clo-
quet, Les Frank, Serrurier, Merat, Guille,  Le  Roux, Be-
clard, Delpech, Nicod, Beauchene, &c, follow the same prac-
tice.  In Germany, Klein and Langenbeck, two surgeons of
the first eminence, both  of whom have written copiously on
lithotomy,  say nothing  of the dangers of urinal  infiltration,
although they have constantly made extensive  incisions of
the prostate and neck of the bladder.  " In a work of more
recent date," says Mr. S\ Cooper, in the second volume'of
his first lines of the practice of surgery, " Klein lays down
as the basis of his method,  the necessity of always dividing
not only the prostate gland completely through, but also a
portion of the bladder itself.  Upon this basis (says he) rests
the success of my operations,  and hence I invariably make
it a rule rather to make the  incision too large than too small,
and never  to dilate it with any blunt instrument when  it
happens to be too diminutive,  but to enlarge it with  a knife
introduced, if necessary, several  times."  Again, " in proof
of the success of his method, he tells us that, in 1816, he had
cut into the bladder seventy-nine times, (for he almost always
cut more or less of that  yiscus) and not one patient had died;
unless  when the prostate, bladder,  kidneys  or ureters were
diseased.   Notwithstanding the free division of the bladder,
most of the patients got well in from eight to fourteen days; a
few in a month; and one alone was three months in  recovering.
Though the sphincter of the  bladder -was divided, no para-
lysis of it was the result."
   Deschamps, in speaking of suppuration of the bladder, says
" L'inflammation dont  la vessie est frappee, est  quelquefois
si vive qu'elle  fait   perir le  malade  tres promptement;  7/
est rare alors qu'on observe des  absces a Vouverture des ca-
davres."   Again, in  speaking of gangrene  the same author 
43
 remarks, " J'en ai cherche dans les vessies de plusieurs cal-
 culeux morts dans les trois premiers jours, a la suite de l'in-
 flammation, et je n'en ai point trouve: une seule vessie m'a
 presente trois points veritablement gangreneux; mais ayant
 ete temoin de Poperation, je les ai attribues au choc des in-
 strumens qui avoient violemment contu ce viscere."
   If urinal infiltration was so common a cause of death after
 the operation of lithotomy, by the lateral operation, as now
 performed by  the gorget and knife, , ought  we not to have
 some mention of the circumstance?—instead of which almost
 every writer I have met with, has passed it by as if no such
 consequence had ever ensued. That it cannot be of so much
 importance as has been attached to it even in the High ope-
 ration,  we have the  authority of Sabatier, who in his  essay,
 published in Fourcroy's  " Medecine Eclaire," says  " La col-
 lection  de  pieces sur  la taille au haut appareil, publiee en
 1730  par M.  Morand, a l'occasion d'une operation de cette
 espece qu'il venoit de pratiquer, presente plusieurs  exemples
 de guerison malgre la blessure du peritoine, et celui-ci ajoute
 a la certitude  qui en  resulte, que  les epanchemens  d'une
 quantite mediocre d'urine dans le ventre, ne sont pas mor-
 tels," Morand, in speaking of the high operation as perform-
 ed by Bernier, states that thirty-five out of forty patients re-
 covered.
  Bromfield, in operating for the stone upon a boy between
 six and seven  years of age, thrust  his gorget through the
 fundus of the bladder among the intestines,  which,  descend-
 ing through the opening  to  the  external wound, were with
 difficulty kept from the grasp of the forceps. " Contrary to ex-
 pectation," says he, " the child had a very good night, and was
 perfectly well in a little more than a fortnight, without  one
 alarming symptom  during the process of cure; neither did
the intestines ever once descend through the ruptured peri-
toneum  after they had been returned when the operation was
 finished." 
44
   Dr. Willison, in the Edinburgh essays, says in the begin-
 ning of March 1735, " a smith pushed a red hot iron with such
 force  into the buttock, an inch  and a half from the anus, of
 a young man of twenty years of age, that the point of it came
 out through the linea alba, about an  inch above the ossa pu-
 bis, having pierced through the  pelvis.  He had violent bili-
 ous vomitings, from time to time, great pains  in his belly,
 thirst, watchings, cold sweats and faintings.  He passed no
 urine until thirty hours  after the wound.   In six weeks he
 was  cured."
  Larrey,  also, in  his  Surgical  Memoirs, relates several
 cases in which the  bladder  and rectum were penetrated by
 musket balls, where the  patient  recovered, notwithstanding
 urinal infiltration to a great extent, was the necessary result.
 If urinal infiltration is  really so dangerous as represented,
how  does  it  happen that so few  inconveniences  followed
the extraction of stones from females through the vagina and
fundus of the bladder, as practised by Hildanus,  Mery, and
others, the  success of whose operation  has given rise to the
observation of  Dupuytren,  that wounds of  the  bas fond of
the bladder are not so  dangerous  as  has been supposed.
 Qu'on rapproche des faits, observes par Fabrice, par Rousset
et Tolet, 1' idee emise  par Mery et renouvelee  depuis par
Louis, de pratiquer chez les femmes la lithotomie par le vagin;
et si  l'on n'est pas persuade qu'on doive preferer cette methode
a celles que nous avons, expos e s plus haut, on sera du moins con-
vaincu les plaices qui establissent une communication entre le
vagin et le corps de la vessie, ne sont pas incurables comme on
Pa pense, et commepeutetre on le pense generalement encore.''
Lithotomie. p. 55.
  If effusion of urine is necessarily attended with such dread-
ful consequences as Mr. Pattison conceives, what  is to be-
come of those patients operated on by Sansom, who removes
the stone by cutting the prostate gland and bladder, through
the rectum?  But volumes  of examples might  be  cited, if 
45
necessary, all of which tend to subvert the positions advanc-
ed by Scarpa, and subscribed to by Mr. Pattison.
  When Cheselden opened the bladder above the prostate in
his first operation, he was so unsuccessful as to be obliged to
abandon his mode on account of effusion of urine.  " My
patients," says he, " for some days after the operation seemed
out of danger, but the urine which  came out of the bladder,
continually lodging upon the cellular membrane on the out-
side of the rectum, made foetid ulcers, attended with a vast
discharge ot stinking matter; and from this cause, I lost four
patients out often." Mr. Pattison, inquoting Camper, through
the medium of Scarpa, makes  it appear that Cheselden lost
eight out of ten patients by following this method.   But the
result was not  so unfavourable  it will be seen, as Camper
has  chosen to  represent, as four  instead of eight out  of
ten were lost. Even this is a convincing proof that urinal in-
filtration is not so hazardous as we have been led to believe,
since the greater number  recovered.  The ill success of
Cheselden, however,  is  satisfactorily explained by Sharp,
in  the  following manner.   In  order to make the  open-
ing above the prostate with greater facility,  he distended
the bladder to the  utmost  by  an  injection; so soon as the
instrument entered, the fluid was discharged, and the blad-
der suddenly retired  in such a way as to place the opening so
far back in the pelvis, as not to correspond with the axis  of the
external wound,  and  the  urine of necessity accumulated in
the cellular membrane for want of a free egress. If the pros-
tate gland and  the urethra had been divided along with the
bladder, would such consequences  have taken place? I think
not;  and for the following reasons; when an  opening is
made through all these parts, the urine will continue to pass
off in a small stream  or guttatim,  as fast as it is secreted,
without ever accumulating  in such  quantity as to fill the
cellular  membrane at the upper part of the wound.  On the
contrary, if the prostate and urethra remain entire, it is very 
                           46

evident that it cannot escape in this gradual manner, but must
collect in greater or less quantity. When the bladder contracts
for its expulsion, it is forced through a wound which does not
correspond with the external one, and effusion is the necessary
result.   If these principles  are correct,  it  must  follow
that a large and free incision of the perinseum, of the urethra,
prostate gland, and neck of the bladder will permit the urine
to pass out with comparative freedom, but if the incision in
any of those parts be confined, and especially if there be not
a complete debridement of the gland, then the urine  will be
detained,  and  by creating more or  less  irritation may, in
some instances, give rise to sloughing of the parts.   That a
more extensive sloughing would be the  consequence of the
lodgment of urine above the neck of the bladder, than would
happen from its infiltration below the neck I can easily con-
ceive, but that the division of the neck of the bladder, and of
the " prostate fascia" will contribute to such an effect so long
as the urethra and prostate are at the same time freely divid-
ed, I cannot believe.   I would  ask  if it was not  upon  the
principles inculcated, that Frere Cosme  was enabled to suc-
ceed, in saving an immense number of patients after the High
operation, by making an opening in the perinaeum, introduc-
ing a catheter, and suffering the urine constantly to  dribble
away by a  depending outlet? Is not the  success of Dr. Sou-
berbielle of Paris, (represented by Carpue  to  exceed  that
of any modern operator,)  owing to  the  same circumstance;
and would not Cheselden have  met with similar success in
his first operation if he had opened the urethra and gland,
and  permitted the urine to flow continually  through  the
wound or  through a  catheter?  The result of his second
and third operations amply demonstrate the truth of the pro-
position.
   But, I would ask what circumstance can possibly give rise
to effusion of  urine behind the fascia, before or  after its di-
vision, and that of the whole  gland? 
47
  Is it a fair experiment to prove the danger of urinal infil-
tration,  and to show that the cellular  membrane about  the
bladder is capable of restraining the course of the  urine, to
pour water into the cavity of the pelvis, and ask  if it will
run out without the division  of the fascia? Does not the ex-
periment prove, in fact, directly the reverse; that as soon as
the fascia is  cut, the water  flows  in  a full  stream  out of
the opening in the perineeum? If Mr. Pattison had  filled the
bladder with water, and  then cut the  prostate and neck of
the bladder and fascia,  his class would have had a full  and
very satisfactory  demonstration  of the  fallacy of his  princi-
ples, as the urine would have escaped  pleno rivo, and could
not possibly have been detained by the fascia, or any simi-
lar structure.
   After repeated perusal of  the memoir of Scarpa, I do not
find that he has brought forward a single case to substantiate
his assertion, that  " gangrenous suppuration"  takes place
after the operation by the gorget or knife, or after any other
operation, and have a right  to conclude that he is  not over-
stocked with materials  for establishing a general  practice.
As I have  not the work of Callisen  before me,  I  cannot
speak of its particular contents.    Only one case is adduced
by Mr.  Pattison as having occurred in his own practice where
the patient died, not from peritoneal inflammation,  but from
the collection, he supposes, of two drachms of pus " betwixt
the bas  fond of the bladder,   and  vesiculse  seminales."   In
three  cases where he had an opportunity of making  dissec-
tions of patients, operated upon by some of his " brethren"
the symptoms, says he, which preceded death in all of these,
bore a considerable resemblance to those which had  occurred
in my own case, and in all, pus was found betwixt the bladder
and the  rectum.
  I would  ask those surgeons who have witnessed  the ef-
fusion of urine into the  cellular membrane  of the  scrotum,
or into  the cavity of the abdomen, from wounds  or from
sloughing of the fundus of the bladder, from over distension 
48
 of its coats, if they have ever discovered any purulent mat-
 ter upon dissection? They will answer, that whenever urine
 is extravasated  in  such  quantity as to produce the patient s
 death, gangrene has speedily ensued, and the parts have been
 discharged like  wet  tow, and that  true  suppuration has
 not taken place.*   But, admitting that true pus  was actu-
 ally formed in the cases  related by Mr. Pattison, to the ex-
 tent of two drachms between the bladder and rectum, would
 this be sufficient to cause the patient's death, when it is ex-
 pressly declared, there was nothing like peritoneal inflam-
 mation present?  If a simple lodgment of  matter about the
 rectum were  capable of  destroying the  patient, should we
 not expect the same thing from a similar  accumulation, in
 cases of abscess  preceding the formation of fistula in ano,
 or fistula in perinfeo?  That a  thin offensive  discharge ac-
 companies gangrene or  sphascelus, cannot be  denied;  but
 as this is very different from pus, and as no marks of gan-
 grene but simply " a considerable matting and thickening of
 the parts," together with two drachms of pus were found, I
 conclude that the patients of Mr. Pattison, and those " of
 his brethren" did not die from this cause, but some other.
 In all probability, Mr, Pattison became aware after the pub-
 lication of his first  essay, that  pus could not arise from the
 cause he pointed out; and therefore, in imitation of Scarpa,
he observes in his reply  that he found '"''gangrenous suppu-
ration" between the bladder and  rectum of his patient, al-
though previously,  in  giving an account of his dissections,
 he had not said  one word about gangrene.
  At any rate, I think we are justified in concluding, that  if
no worse effects  than the accumulation " of two drachms of
 pus" between the bladder and rectum succeed the operation
 of lithotomy, that  ninety-nine out of  one  hundred patients
 ought to recover.
* This circumstance was first noticed by Dr. Physick. 
49
   It  may  be asked, since  I do  not  allow  that urinal infil-
tration,  is attended with so much danger  as  Scarpa and
Mr. Pattison conceive,  what I  suppose  to be the cause
of death  in  most cases, after  the  operation of  lithoto-
my?  I  answer,  without hesitation,  that I  believe  it  to
proceed, in  nine  out of ten  cases,  from  violence  done
to  the  bladder^  prostate  gland,  and adjoining  parts  by
protracted and forcible efforts to remove the stone;—that this
difficulty  of  getting out the stone, arises either from an
opening not being made into the  bladder or from its being
made so  small as not to  be  found, or if found,  insuffi-
cient to admit the finger  or the forceps,—that after the for-
ceps are introduced, so many fruitless attempts are made  to
grasp the  stone,  and so much  force employed in  pulling
it  away after it is seized, that  the parts are lacerated and
mangled, and the bladder, probably, in many instances in a
state of inflammation, before the patient is removed from the
table,—that in consequence of all this rudeness on the part  of
the operator, peritoneal inflammation is speedily induced, and
the patient dies in a very few  days.  This is  not only my
opinion, but the opinion of nine tenths of the best informed
and most experienced operators  in the  world.   It is the
particular  opinion  of  Mr.  Pattison's best authority, Mr.
Samuel Cooper  who says, "In the course of the nineteen
years, that I have  been in the profession of Surgery, I have
seen the lateral operation performed more than fifty times ei-
ther with various kinds of gorgets, beaked  knives, the litho-
tome cache, or common scalpels.   In all these examples, the
avowed intention of the surgeon, was to make a  free open-
ing into the bladder.  I do not  mean, however, to say that
this was actually  accomplished, since the bad construction
of the instruments employed, and other  causes, sometimes
frustrated the wise design of the operator.   But what was 
50
 the consequence?  Generally speaking, those surgeons wh».
 made only a small incision into the bladder, and kept their
 patients a long while upon the  operating table, ere they suc-
 ceeded in getting out the stone, by the repeated and forcible
 use of the forceps, had the mortification to see  very few of
 their patients recover, a large proportion of them being car-
 ried off by peritonitis, on the third  or fourth  day after the
 operation.  On  the  contrary, when the incision was ample
 and direct, so that  the calculus could be easily and gently
 removed, the patients  were almost always saved."
   That patients sometimes die  from violence alone,  in a few
 hours  after the operation, and before peritoneal inflammation
 could  have taken place, or before  effusion  of  urine could
 have produced suppuration, or gangrene, there can be no doubt.
 They  die in  such cases, from absolute  irritation,  or from
 the shock communicated to the nervous system, by the oper-
 ation,  in the same way that patients are lost in many instan-
 ces, from amputation and other severe operations.
   On  the other hand,  I  have known  persons  die in the
 course of eight or ten hours after  the operation, where no
 sort of delay  or difficulty  was  experienced in getting the
 stone away, where the patients  suffered  comparatively little
 pain, and where no  vestige of suppuration or of gangrene,
 or  of  abdominal inflammation  could be  discovered after
 death.   A case of this  sort occurred in the Edinburgh In-
 firmary, under the  care of Professor Thompson,  while I
 was a  student.
  Again, there  are  cases,  where  patients are kept on the
table for hours, during which the utmost violence is commit-
ted  where the bladder is torn and shockingly mangled, either
by the instruments, or  by the passage of rough stones, and
yet recover almost without  a bad symptom.   This I have
also  seen in  Europe,  and  Dr. Physick  has  witnessed
similar examples in  this country.   Surely  then we have
  ngnt to conclude,  that  there  is something inexplica- 
51
\
ble in many instances, as to the cause of the patient's death
or recovery after the operation;  and that what  will quickly
destroy one, will have no effect on another.
   That death is a very frequent  consequence of hemorrage,
after lithotomy, I do  not believe, but that it sometimes oc-
curs is very  certain; for  upon dissection, the bladder has
been found filled with blood, and all the neighbouring parts
extensively injected and separated from their connexions.
In such cases the blood may flow either  from the internal
pudic, or from the artery of the bulb, or from the transversa-
lis perenei  artery.  I  believe  that  it  may proceed occa-
sionally from an  extensive  incision  through  the  prostate
gland, into the body of the bladder;—in consequence of the
large veins,  the vence  vesicates, which  are  distributed in
great profusion about these parts, being cut across.   This I
would  consider then a stronger objection  to a prolonged
incision into  the  neck  of the bladder, than  the  fear of
urinal infiltration  from the  division of the " prostate fas-
cia"  or as  it  is better called  by Carpue and others, the
" obturator  fascia."   It   was  probably owing to the di-
vision of some of these vessels, that Boyer  experienced so
much trouble in stopping  the hemorrage in the interesting
ease detailed in Fourcroy's  journal;  as the  blood procee-
ded evidently from  the cavity of the pelvis, and not from
the pudic  artery.   I do not believe that the pudic is cut so
often as is imagined, but I am very sure that it may be divi-
ded, and bleed for hours, in some cases, without the opera-
tor being  aware of it. If the  surgeon were to follow the
advice given by Mr. Pattison, in his first essay, to " continue
the incision down boldly  from three  to  four inches, in a
line which runs  betwixt the tuber ischii  and the anus, incli-
ning it considerably towards the former," lam confident that
in six out of ten cases the pudic would be  cut across, and
the patient's life endangered. Mr. Charles Bell, in speaking
of hemorrage after lithotomy remarks:  " The internal pudic 
52
 is often cut, and the patient dies.   Three of our first opera-
 tors, have each within the last year lost a patient, by hemorr-
 hagy."  It is surprising under such circumstances that the
 English, and  French surgeons, should  continue to employ
 the   canula  and  sponge, instead  of  Dr.  Physick's for-
 ceps and needle, an instrument calculated with certainty, to
 suppress the bleeding.
   I   have said enough to  convince any one, that the  as-
 sertion delivered  in  my  review  of Mr.  Pattison's essay,
 that  the practice  recommended by him, is adverse to the
 best European authority,  has  been proved  beyond the pos-
 sibility of contradiction.   I shall therefore endeavour to sub-
 stantiate the remaining assertion, that  it is  equally repug-
 nant to the principles and practice  of the  best authority  of
 this  country. For this purpose I  submit the sentiments of one
 whose knowledge  of  the  subject, and extensive  experience
 can never for a moment be called in question.
  Dr. Physick has performed  the  operation of lithotomy,
 generally every year, and sometimes three or four times a
 year, ever since 1797.  He has always made a free division
 of the  muscles, and other  soft  parts  of  the   perinseum.
 To  avoid  wounding  the pudic artery, and  not  from fear
 of making  too large an  incision  in the   prostate  gland,
 he has employed a  gorget from  a  half  to three  quar-
 ters  of  an inch in breadth.  Whenever the stone has been
 found so large, as not  to be extracted without difficulty
 he has divided the neck of the bladder with a bistoury, and
 never found any inconvenience  to  result from the practice.
 He is convinced that many patients  have been lost in conse-
 quence of the opening in the prostate and bladder being
 made so small as to require  forcible efforts to remove the
stone, which has  not been extracted without considerable
laceration.
  As regards  the  cause  of death after the operation, Dr.
 Physick is inclined to believe, that it is owing frequently  to 
53
the shock communicated to the  system,  sometimes to he-
morrage, sometimes, though rarely, to violent inflammation
of the internal coat of the bladder, sometimes to mortifica-
tion of this viscus and of all the parts in its neighbourhood,
and never to urinal infiltration, so far as he has been able to
ascertain by dissection, or by other means.  In one instance, in
his practice, the urine did not come away through the wound
or urethra after the operation, and he concluded that it must
have been effused into the cavity of the pelvis.  Under this
impression a gum elastic catheter  was introduced into the
bladder, through the wound, but not a drop of urine  flow-
ed.   He then conceived that the action of the kidneys was
suspended, and that the urine did not escape, because none
was secreted.  His suspicion was confirmed by dissection,
for the bladder,  rectum, and all  the adjoining  parts,  were
found dry, without a  vestige of suppuration, of gangrene or
of effused urine.
   Mr. Pattison  in his  " observations on lithotomy," says,
" Dr. Physick has observed to  me, that  for a considerable
number of years  back, he has  been in the habit of introdu-
cing, from the wound  into the  bladder, a piece of a gum
catheter, which he allows  to remain, and that the success of
his operations had been much  increased by the introduction
of this instrument.   The superiority of success attending
those operations, where the catheter was introduced over those
where it was not employed is a strong argument in proof of
 the justice of my observations."
   Upon inquiry  I find Dr. Physick  has been in the  habit
 of saying that since the use of the gum catheter his  patients
 had been rendered more comfortable  than  before, in conse-
 quence  of the urine being deposited in a vessel,  kept in
 bed for the purpose  of receiving it;  thereby obviating ex-
 coriation of  the  edges of the wound,  and preventing the
 bed  clothes from being soiled and wet. 
54
    It  was  this circumstance, that  induced  Dr. Physick  to
  continue the  use  of the gum elastic catheter.  But he has
  found it useful in  another point of view;—viz. in the  sup-
  pression of hemorrage, from  the  deeper  seated  parts.  In
  this case, the catheter is introduced through the wound into
 the bladder, and insures an outlet  for the urine, while com-
 pression is  made by filling the wound with lint. It is obvious,
 without such a contrivance, that  the urine could not flow,
 but would be detained by the lint, and give rise to inflamma-
 tion, and other ill  consequences.   Dr. Physick does not in-
 troduce  " a piece of catheter," but uses the entire instrument.
   In addition to the authority of Dr. Physick,  I may state,
 that other distinguished surgeons in the United States, are
 in the  habit of making  free incisions  of the prostate gland
 and neck of the bladder, and with the happiest result.   I am
 informed by  my  friend,  Dr.  Stevens  of New  York,
 that Drs. Post, Kissam, and  Mott  invariably  aim  at the
 complete division of the prostate, and that their success has
 been very considerable.  In two instances  where  Dr. Ste-
 vens had occasion to  operate,  extensive  incisions  were
 made,  and in  one  case a stone was extracted,  the smallest
 diameter of which measured two inches and a quarter. Both
 patients recovered without difficulty.  None of these gentle-
 men (as  I am authorised by Dr. Stevens to say)  believe uri-
 nal infiltration to be a common occurrence, or the cause of
 death after  the  operation  of lithotomy, but are persuaded
 that patients die from hemorrage, more  frequently  than
 from any other circumstance.
  Professor Caldwell, of  the Transylvania University, du-
 ring his  late  visit to Philadelphia,  informed me that Dr.
 Dudley,  well known throughout the western country, as an
 able anatomist, and accomplished surgeon, had operated for
the stone fourteen times without having lost a patient, and
was induced to attribute his success  in  a great  measure to
 ample incisions of the prostate gland, and neck of the blad- 
55
der.  The late professor Dorsey, who was particularly dis-
tinguished as a lithotomist, preferred an extensive to a small
incision.  In speaking of two cases where  the neck  of the
bladder healed by  the first intension, he remarks, I have no
hesitation in ascribing the successful  termination of these
cases to the  use of a gorget which is so perfectly keen, as  to
pass without any  resistance through the prostate gland and
neck of the  bladder."  Dr. Dorsey, in speaking of the cause
of death, after the operation, barely mentions, " sometimes
gangrene results from the escape of urine into the surround-
ing cellular  texture, and sometimes the bladder inflames vio-
lently and death results from this cause."
   A surgeon well acquainted with the principles upon which
lithotomy should be performed, may operate with almost any
instrument.   But he will prefer such as will enable him to
execute his purpose with the least trouble to himself and dan-
ger to the patient.  Even an experienced lithotomist, or ex-
pert artist  will find it no easy matter  to understand the
design or shape of the weapon figured upon a plate in Mr.
Pattison's essay.  If the awkward thing  exhibited in one
of the shops of this city under the name of " Pattison's Gor-
get," be a faithful copy of the  original, it  certainly cannot
answer conveniently the purpose for which  it was designed
by its inexperienced projector.  It is professedly  an im-
provement on the instrument of Peile of Dublin.  Peile's in-
strument, I may remark, was copied, with a slight alteration,
from that of Dease, and Dease simply modified the lithotome
of Daunt; Daunt probably copied Pouteau, and Pouteau the
older French surgeons. However varied, the straight handle
was always  left as more convenient for introducing the blade
into the bladder.  Mr.  Pattison has  given the finishing touch
to the instrument, and rendered the handle crooked, for the
purpose, no  doubt,  of adapting it to his own practice.  An
additional beak or protruding peg, is  fixed near the  shoul-
der of the blade, to prevent it from leaving the groove of tfye 
56
 director, which, in imitation of Mr. Allan Burns' instrument
 and that of some of the older lithotomists, is straight instead
 of curved.
   Any one who has leisure to examine  tjtfese lithotomie cu-
 riosities, will find that the ungainly handle can answer no other
 purpose than to encounter the ischium, which  by reacting
 will dislodge it from the groove of the conductor in spite of
 its double beak.  These beaks, moreover, must  of necessity
 hitch, and  prevent  the blade from moving with facility in
 the groove.
   It is advised by Mr. Pattison, to introduce a bistoury and
 cut a portion of the right side of the prostate, in case the
 opening made by his gorget, be not large enough for the stone
 to pass through.  Dr. Physick, many years ago,  employed a
 gorget with a beak in the  centre,  and an edge on each side,
 for the purpose of putting to a certain extent both sides of
the gland.  He  used it once only, and the patient died.  Mr.
 Astley Cooper has employed a similar instrument, in several
cases, but with no better  success.  Scarpa has  contrived a
 gorget of the same kind.
   Now I take leave of Mr. Pattison forever. If his essays are
 full of sound doctrine and useful practical information, my
censure will prove harmless.   But there is a criticism from
which no work is secure.  If I have been unjust I should
regret it.   Mr. Pattison's merit I have  no desire to under-
 value.   That he is a good anatomist it gives me  pleasure to
allow, that he may become, in time, an intelligent surgeon I
am willing to hope. But I never should have placed him where
he has ventured  always to place himself.  His  petulant in-
vectives I have disregarded.   His vain  and abortive efforts
at sarcasm, I have not  deigned to notice.  " If any coarse
 expressions have escaped me, I am ready to agree that they
 are unfit for me to make use of, but I see no reason to admit
that  they have been improperly applied." 
 
 
M&'aL. Hist,
    WZ
  J170
 G-tr/s