SECT. LX.—ON CALCULUS.
The cause of the formation of stones, and that in children they are formed most readily in the bladder, and in adults in the kidneys,—all this having been explained in another place, we now proceed to the method of performing lithotomy, but shall first give the symptoms of stones lodged in the bladder. The patients then void urine of a watery consistence with a sandy sediment; and from constant itching the member is now relaxed and again stretched in an uncommon degree, because, owing to the irritation, they are perpetually handling it, more especially in the case of children. When the stone falls into the neck of the bladder a sudden retention of urine takes place. Of those cut for the stone, children to the age of fourteen are the best subjects for the operation, on account of the softness of their bodies: old men are difficult to cure because ulcers of their bodies do not readily heal; and the intermediate ages have an intermediate chance of recovery. And again, those who have larger stones recover best because they have become habituated to the inflammation, whereas those who have smaller recover with difficulty for the opposite cause. These things being so, when we proceed to the operation, we first have recourse to shaking the patient, sometimes by means of assistants, and sometimes by making him jump from a height, in order that the stone may be forced down to the neck of the bladder. We have then to place him sitting in an erect posture, with his hands under his thighs, in order that the bladder may be forced down into a small space. If then we ascertain by feeling externally that the stone with the shaking has fallen down to the perineum, we proceed immediately to the operation; but if it has not descended, we must introduce the index finger of the left hand well oiled, or, if an adult, the middle also, into the anus, and with the fingers in a supine direction we search with them for the stone, and, bringing it down gradually to the neck of the bladder, we fix it there, pushing it out with the finger or fingers when so fixed; and having given directions to the assistant to press down the bladder with his hands, and ordering another assistant to raise the testicles in his right hand, and with the other to stretch the perineum to the other side from that upon which the incision is to be made, we take the instrument called a lithotome, and between the anus and the testicles, not, however, in the middle of the perineum, but on one side, towards the left buttock, we make an oblique incision, cutting down direct upon the stone where it protrudes, so that the external incision may be wider, but the internal not larger than just to allow the stone to fall through it. Sometimes, from the pressure of the finger or fingers at the anus, the stone starts out readily at the same time that the incision is made, without requiring extraction; but if it does not start out of itself we must extract it with the forceps called the stone-extractor. After the removal of the stone, having stopped the bleeding by manna of frankincense and aloes, comfrey, misy, and such like styptic powders, and having dipped wool or compresses in wine and oil, we apply them; and also apply the bandages for calculous diseases, namely, that having six legs. But if there be any apprehension of hemorrhage we must apply a compress which had been soaked in oxycrate, or water and rose-oil, and placing the patient in a reclining posture, bathe the parts frequently. After the third day, having loosed the bandages, and poured much water and oil into the wound, we may dress it with the ointment called tetrapharmacon (basilicon) on a pledget, removing them and dressing often on account of the acrimony of the urine. If inflammation come on, we must have recourse to the cataplasms and fomentations proper for it. And we may also inject into the bladder oil of roses, oil of camomile, or butter, unless some inflammation prevent. In like manner, if the sore become spreading, or otherwise malignant, we must suit the applications to the state of it. When the ulcer is freed from inflammation we may loose the dressings, and use diachylon plaster to the groins and bottom of the belly. During the whole time of the treatment, the thighs must be bound together, which contributes to the cure with the other remedies. If the stone, being small, fall into the penis, and cannot be voided with the urine, we may draw the prepuce strongly forwards, and bind it at the extremity of the glans. We must next apply another ligature round the penis behind the member, making the constriction at its extremity next the bladder, and then make an incision down upon the stone, and bending the penis we eject the stone, and undoing the ligatures we clear away the coagula from the wound. The posterior ligature is applied lest the calculus should retreat backwards, and the anterior, in order that, when untied, after the extraction of the stone, the skin of the prepuce may slide backwards and cover the incision.
Commentary. We will now attempt to explain all the ancient descriptions of lithotomy.
Hippocrates in his Oath binds his pupils not to perform this operation, but to leave it to those who made it their business. It appears then that in his days lithotomy was a separate branch of the profession. Celsus is the earliest author who describes lithotomy, although it is probable that he merely explained the method of operating in Alexandria, the surgeons of which city had acquired great celebrity in performing this operation. He forbids the operation, except after every other remedy had failed; and in children between the ages of nine and fourteen, and in the season of spring. The patient is to be kept upon a spare diet beforehand; and when the operation is about to be performed, he is to be directed to walk, so as to bring down the stone to the neck of the bladder, which is to be ascertained by introducing a finger into the anus. Then a strong and experienced person, sitting on a high seat, is to take the patient and hold him secure, his buttocks being placed upon the assistant’s knee, and his legs being drawn in and his hands placed on them and held there. But if the patient be strong he is to be held by two assistants, one on each side, upon two seats placed beside one another, and they are to be directed to press upon his shoulders with their breasts, so as to force down the bladder. Two other assistants are to be at hand, to prevent any risk of the former two losing their hold. The surgeon having pared his nails, is to introduce gently first the index and then the middle finger into the anus, whilst with the right he makes pressure upon the abdomen, and in this way the stone is to be secured at the neck of the bladder. The shape of the stone is to be considered, and it is to be pressed down so as to favour its exit. These matters being properly arranged, a lunated incision is to be made over the neck of the bladder near the anus down to the neck of the bladder, the horns of the incision inclining a little towards the (left?) buttock; then at that part where the incision is bent round (at the curvature of the incision?) even under the skin, another transverse incision is to be made, by which the neck is to be opened, and the urinary passage dilated, the opening being somewhat larger than the stone. When the stone is small it may be propelled and drawn out by the fingers; but if large, it is to be extracted by a hook or crotchet made for that purpose. This hook is of a semi-circular form, smooth externally, and rough on the inside. By the help of it the stone is to be taken out dexterously, attention being paid to the shape of it. He mentions that Ammonius the lithotomist was in the practice of breaking down the stone into pieces when it was so large that it could not be extracted without tearing the neck of the bladder. He states that the operation is seldom required in the case of females, but that if the stone be large it may sometimes be necessary. The fingers are to be introduced into the vagina, as they are into the rectum of males, and then, if the patient be a girl, an incision is to be made under the left edge (of the labia pudendi?); but if in an adult female, a transverse incision is to be made on both sides between the urethra and os pubis.
The above is but an abridgment of the Celsian description, which, it must be admitted, is attended with considerable difficulties. We shall give the passage in which he describes the form and place of the incisions. “Incidi super vesicæ cervicem juxta anum cutis plaga lunata usque ad cervicem vesicæ debet, cornibus ad coxas spectantibus paulum: deinde eâ parte, qua resima plaga est, etiamnum sub cute altera transversa plaga facienda est, qua cervix aperiatur; donec urinæ iter pateat, sic, ut plaga paulo major, quam calculus sit.” Sprengel renders the words “cornibus ad coxas spectantibus paulum” by “dont les angles regardant les aines;” but coxæ signifies properly not the groins, but the nates, viz., the buttocks, or perhaps the hips. (Celsus viii, 1.) In the English translation of M. Foubert’s paper on Lithotomy, in the ‘Memoirs of the French Academy of Surgery,’ these words are more correctly rendered, “the extremities of which incision must be in some measure directed towards the thighs.” Dr. Milligan, however, in his edition of Celsus, proposes to read coxam, by which he supposes that Celsus understood the coxa sinistra. He adds: “hinc liquet, cornua plagæ Celsianæ, ut hodiernæ, coxam sinistram respexisse.” We are inclined to adopt this conjecture, as it makes the Celsian description agree with that of our author and his Arabian copyists, all of whom direct the first incision to be made towards the left nates. The words “qua resima plaga est,” must signify, we suppose, the curvature in the middle of the incision where the two horns unite. M. Foubert reads “qua strictior ima plaga est,” but we suspect without any proper authority from MSS.
We may be permitted to remark that the advantages of the semi-lunar incision are pointed out by Bromfield, and the Celsian operation was generally practised by the late Baron Dupuytren of Paris.
Aëtius and other of the Greek authorities allude frequently to the operation, but none of them describe it minutely except Paulus. Our author’s statement, that there is less danger from the extraction of large than of small stones, is at variance, we believe, with modern experience. Aretæus states that small stones are most easily extracted. He was, however, no advocate for the operation at all, except in extreme cases. He speaks of cutting “the neck of the bladder.” (Morb. Acut. Curat, ii, 9.) Does he not allude to attempts at lithotrity in the following passage?—ὄυτε γὰρ (λίθος μέγας) θρύπτεται, ἢ πόσι, ἤ φαρμάκῳ, ἢ αμφιθρυπτοιτο, ὂυτε ἀσινέως τέμνεται. (Morb. Chron. ii, 4.) Which passage may be thus translated: “when the stone is large neither lithotrity, or lithotripsy, nor lithotomy, can be practised safely.” Theophilus, in his ‘Commentary on the Aphorisms of Hippocrates,’ states that in lithotomy it is not the bladder, properly speaking, but the neck of the bladder, which is muscular, that is cut.
We now proceed to the Arabians. Albucasis, after detailing the symptoms in much the same terms as our author, goes on to describe the operation as follows. Having cleared out the bowels with a clyster, the patient is to be shaken so as to make the stone descend, and he is then to be secured in the arms of an assistant, with his hands under his nates. The surgeon is then to press upon the perineum, and, if the stone be felt, the operation is to be proceeded with; but otherwise, the index finger of the left hand, if the patient be a child, and the middle if an adult, is to be introduced into the anus, and the stone is thereby to be gradually brought down to the neck of the bladder. Having pushed it outwards to the place where you mean to make your incision, an assistant is to be directed to press down the bladder from above the pubes, while another draws up the testicles with the one hand, and with the other stretches the skin under them. Then with a proper scalpel the operator is to make an incision between the anus and the testicles, not in the middle, but towards the left nates, straight upon the stone which is to be pressed out by the finger. Let the incision be transverse (oblique?), large externally, but internally of the size of the stone. If the stone does not then start out, the operator must seize upon it with a forceps, or a hook having a lunated extremity. If there be more than one stone, the largest is to be extracted first, and then the others may be easily removed. When the stone is large he directs us to break it down with a forceps. His directions respecting the treatment afterwards are similar to those of Paulus. When the stone sticks in the urethra he recommends us to cut down upon it. His description of the operation on women is likewise similar to our author’s, but more circumstantial. Having got a dexterous midwife, or some proper person to introduce her finger into the rectum or vagina, and press the stone down to the left hip, the operator is to make first a small incision over it, and afterwards, by the help of a sound or specillum, it is to be enlarged so as to allow a passage for the stone. (Chirurg. ii, 60, 61.)
Avicenna’s description is nearly the same as that of Albucasis, but not so minute. He directs the surgeon to introduce a finger into the anus, if the patient be a male, but into the vagina if a woman who is not a virgin, and to push the stone outwards, so as to make it protrude. He is then to cut down upon it, making an incision proportionate to the size of the stone; but if the stone be very large, the incision must not be made of the same size, but it is to be grasped in a forceps and broken into pieces. If inflammation come on after the operation, he recommends him to have recourse to clysters, the warm bath, and venesection, and a piece of cloth dipped in oil of roses and some vinegar is to be applied to the part. The bad symptoms after the operation are said to be violent pain in the part and under the navel, coldness of the extremities, prostration of strength, loss of appetite, and, at last, singultus and involuntary discharges from the bowels. (iii, xix, 1, 7.)
The description given by Haly Abbas being nearly the same as that of Albucasis, need not be noticed here but very briefly. He prefers performing the operation in infancy, but permits it to be done at all ages. For the reason assigned by our author he states that recovery is most likely to take place when the stone is large. Like the others, he directs the surgeon to introduce either the fore-finger alone, or it and the middle finger into the anus, behind the stone, and to push it outwards, and then the operator is to cut down upon it, making the incision between the testes and the anus, yet not in the middle, but towards the left side. When the incision is carried down to the stone it will sometimes start out from the pressure of the fingers in the anus; but otherwise, it is to be seized upon with a forceps and extracted. If inflammation come on he recommends us to apply a cataplasm, and to throw into the bladder an injection consisting of oil of roses and of camomile, or of melted butter. (Practic. ix, 46.)
Rhases gives from preceding authors several descriptions of lithotomy, but as they closely resemble our author’s, we shall treat of them only in a cursory manner. In his first description he directs the surgeon to place the patient with his hands fastened to his ankles so as to press down the bladder. When the stone does not descend properly, so as to be felt externally, he recommends him to introduce one or more fingers into the rectum and push it outwards; and then while an assistant draws up the testicles the operator is to make a transverse (oblique?) incision, larger externally, but internally only of such a size as to allow the stone to pass out. If the stone does not come out readily it is to be extracted with an instrument, and the hemorrhage checked with a composition of aloes, frankincense, and vitriol. When the patient is a child he recommends the operator to place him upon the knees of an assistant, and to make pressure on the abdomen so as to force down the bladder. He forbids the operation when the stone cannot be brought down to the neck of the bladder. When the stone is large he directs it to be broken into pieces before extraction. His next description is taken from the celebrated Antyllus, but as it scarcely differs at all from the preceding one, we shall merely select a few remarks. When the stone is smooth, round, and small, he directs the surgeon to push it down to the neck of the bladder by means of a finger introduced into the rectum, and to make an incision down upon it; after which the stone is to be forced out. When pain supervenes after the operation, he recommends him to place the patient in a bath medicated with camomile, linseed, mallows, &c.; or if it be summer, and there be any disposition to hemorrhage, to place him in a vessel filled with strong vinegar. When it is ascertained that there are clots of blood in the bladder obstructing the urine, he directs the surgeon to introduce a finger by the incision, and extract them gradually. His next description is from an author named Sarad, whom he frequently quotes in other parts of his works. He directs the operator to introduce a finger into the rectum and push the stone outwards to the left side of the perineum, removed about the size of a grain of barley from the raphe (daram), and then to make an incision into the neck of the bladder. He afterwards gives a very circumstantial account of the operation from another author called Athuriscus. He particularly directs the operator to make an incision in the left side of the perineum and to open the neck of the bladder, as a wound of the body of the bladder seldom unites. When the stone is large he recommends him to seize it with strong pincers and break it into pieces. When a stone sticks in the urethra he directs him to tie one ligature behind it and to secure the prepuce before the glans with another, and then to cut down upon the stone. He gives very minute directions about the after treatment, recommending especially the removal of any clots which obstruct the passage. (Cont. xxiii.)
The practice of lithotomy appears to have been reckoned a disreputable occupation among the Arabians, for Avenzoar mentions it as an operation which an upright and respectable man would not witness, far less perform. (ii, 2, 7.)
As there are some doubts regarding the form of the incisions in the ancient methods of performing lithotomy, we will now give the words of some of the Arabian translators. Stephanus Antiochensis, the translator of Haly Abbas, has the following words: “Inter testes anumque finde et non in mediâ viâ sed in sinistri lateris parte ab intestinis, sitque perallela fissura, et ab exterioribus larga, ab interioribus non.” The translator of Albucasis expresses himself thus: “Finde in eo quod est inter anum et testiculos et non in medio, ad latus natis sinistræ: fiat sectio transversa.” The following are the words of Avicenna’s translator: “Cave ne scindas super commissuram quum sit malum, commissura enim secundum veritatem est locus mortalis. Amplius fac super ipsum (lapidem?) scissuram tendentem ad transversum, studendo ut cadat scissura in collo vesicæ.” The translator of Rhases expresses himself in the following terms: “Scinde super lapidem cum instrumento camadan; et scissura debet fieri transversa, et sit exterior caro larga et in interiori vesicæ stricta.”
Yet notwithstanding all this we are inclined to think that the incision was oblique and not transverse; for our author, whom they all follow, directs us to make the incision oblique (λοξὸς), and it is further clear that a transverse one would not answer the purpose so well. No dependence can be put in the accuracy of these barbarous translations. The language of Stephanus Antiochensis is particularly obscure. Casiri justly characterizes the translations of the Arabian authors as being “perversiones potius quam versiones.” (Bibl. Hisp. Arab, i, 266.)
The ancient operation, with scarcely any alterations, is described by the earlier modern writers on surgery. See Brunus (Chirurg. Magna. ii, 17); and Guido de Cauliaco (Chir. vi, 2.) They direct us to introduce a finger into the rectum and push the stone outwards; then to make an incision down upon it on the left side of the raphe. Brunus recommends a longitudinal incision.
It appears that the ancient operation of lithotomy is still practised with great success by the native doctors of Hindostan. See ‘Transactions of the Medical and Physical Society of Calcutta,’ vol. iv. An interesting case in point, related in the ‘Medical Gazette’ for Feb. 7, 1845, forms a valuable commentary on the Celsian description of lithotomy. In the year 1827 Mr. Madden the traveller saw it performed in Tyre by an old pilot on a boy of thirteen years of age. The case did well.