LITHOTOMY. 
A TABULATED STATEMENT OF CASES, 
WITU CoNSIDERATIONS IN RELATION TO THE 
Operation, tie Treatment and tlie Preventivas 
MOST PROMISING OF SUOUE3S. 
By DAVID PRINCE. 31. I)., 
JACKSONVILLE, ILL. 
[.Reprinted from the St. Louis Medical and Surgical Journal, April, ISIS.] 
Revised Edition of lssl. 
1 have operated twenty-one times upon twenty persons, the youngest 
being 15 months, and the oldest 81 years. 
My earlier experience was with the lateral method, but 1 became con- 
vinced by reading Allerton’a account of his mode of performing the median 
operation, that the anatomical reasons for it were superior. My later ope- 
rations have been by this method, of cutting in the median line of the per- 
ineum. 
Allerton’s operation, after the introduction of the staff, consists in intro- 
ducing the forefinger of the left hand iuto the rectum. Then a sharp 
pointed bistoury with edge upward is thrust in about half an inch anterior 
to the anus, and pushed forward until the point is lodged in the groove of 
the stall. The finger in the rectum prevents the accidental puncture of the 
wall of the cavity, and by its pressure upon the urethra with its enclosed 
staff, aids in inserting the point of the bistoury into the groove. The third 
movement consists in drawing the bistoury upward toward the operator, 
the point gliding along the groove in the staff for half an inch, and finally 2 
LITHOTOMY. 
cutting the raphe to a sufficient extent as the bistoury is withdrawn. The 
fourth movement is the introduction of a probe along the groove of the 
staff, after which the staff is withdrawn and the Anger is introduced into 
the bladder. 
The Anger, by a rocking movement, works its way along the probe until 
the bladder is entered. A dilator, such as is used for the dilatation of the 
uterus or the fema'e urethra, is then employed to expand the urethra to a 
sufficient extent to permit the entrance of the forceps. Farther dilatation 
Nis effected in the withdrawal of the forceps, after the stone has been 
grasped. * 
This is a speedy and 3howy operation for small stones, and it is free from 
the danger of excessive hemorrhage, A less speedy proceeding is thought 
to be preferable. The anus having been dilated by the introduction of the 
fore-Anger of each baud, pushing in opposite directions, and the staff 
having been introduced, an incision two or three inches in length, is made 
in the median line by an ordinary scalpel, reaching down to a point about 
half an inch anterior to the rectum. This incision is deepened by repeated 
strokes, and when the nail of the fore-Anger of the left hand enters the 
groove of the staff behind the bulb, the intervening membrane is punctured 
by the point of the scalpel, which is then laid aside. A probe-pointed, 
straight bistoury is then inserted into the groove with one A at surface to- 
ward the staff above, and the other toward the rectum below, and pushed 
forward into the prostatic portion, but not into the bladder, The fore- 
Anger of the left hand is then inserted between the staff and the bistoury and 
pushed forward by a rocking motion until the bladder is entered by the 
Anger. If, on attempting to pass the Anger, it is found not to go forward, 
it should be withdrawn and the bistoury carried a little further into the 
prostate, guided by the groove in the staff, The Anger is then returned to 
the prostate, and any necessary cutting is done by the bistoury as it is 
pressed by the Anger upon its Aat surface. The cutting is therefore in the 
side of the urethra. 
It is intended that there shall be no cutting in the posterior part of the 
prostate. 
Allerton’s recommendation of a dilator has not been found necessary. 
The forceps once introduced along the staff, or along a probe by which 
the staff is replaced, affords a wedge for further dilatation, as the stone is 
extracted within the grasp of the forceps. If a moderate pull in a vibratory 
manner fails to bring out the stone which has been grasped in its narrowest 
diameter, aided by the Angers of the left hand in the rectum, the probe- 
pointed bistoury should be passed in on the outside of the forceps, and 
made to divide the most resisting Abers, wThile they are made tense by the 
force of traction applied to the forceps. In this way nothing is divided 
•Allerton’s Operation with remarks by Ward. Half yearly Abstract, Xo. 32, 1861, from 
Lancet, June 9, 1860, Signor Bresclanl de Borsa, and Signor Manzoni reported, (See 
the American Journal of the Medical sciences for July 1846, p. 239, and Medico-Chlrur- 
gtcal Review, for April, 1846,) very gratifying success without cutting the prostate. LITHOTOMY. 
3 
which is easily stretched or easily torn. The conversion of the median in- 
cision, into the medio-bilateral, is done with the greatest economy of tissue 
and without danger of subsequent pelvic abscess from the infiltration ef urine 
into the loose cellular tissue. 
If the stone is small it is not necessary to employ the forceps ; the stone 
being pushed forward by the fingers placed within the rectum. Generally, 
however, the smooth surface of the forceps obviates the abrasion of the 
parts by the rough surface of the stone, and thus more than compensates 
for the room the instrument occupies. 
With the modifications here described, the median method is applicable 
to the cases presenting the largest calculi which can be extracted under the 
pubis. In the case of a large stone the operator takes sufficient time and 
feels his way with the forceps engaged in the wound. He carefully intro- 
duces the probe pointed bistoury, and divides little by little, whatever af- 
fords most resistance, first on one side, and then on the other, until the 
stone is delivered. 
The element of time is important to enable the tissues to dilate as they 
do in slow parturition. Haste to remove a large stone must show a loss of 
presence of mind or an unmindfulness of the correct theory of the proceeding. 
The bladder having been found clear of stones, fragments or blood clots, 
a syringe with warm water having generally been employed : a cotton pro- 
bang, saturated with undiluted carbolic acid, is mopped over the incised 
and the mucous surfaces. 
The interior of the bladder is found to bear this application well, and 
■ very little pain is felt on awaking from the anesthesia. The local anes- 
thesia caused by the contact of the carbolic acid may account for this. Af- 
ter the thorough mopping wit h carbolic acid, the incised and lacerated sur- 
faces are mopped with a tincture of chloride of iron, with a view to the 
formation of an incrustation unfavorable to the absorption of fluids. 
The patient is directed to be bathed in a full length or in a sitz-bath sev- 
eral times each day. The theory of this is, that the water of the bath enters 
by its gravity the urethra and the bladder, and that any material in pro- 
cess of decomposition is likely to be washed away. Unless resisted by the 
tonic muscular contraction of the bladder, the water must enter to the ex- 
tent of the natural capacity, carrying away any ammonical urine oi* other 
causes of irritation or septic influence. The feeling of comfort from bath- 
ing is always great, and the time is anticipated with pleasure and often with 
impatience. Cutaneous excoriations are avoided and all fear of septic ab- 
sorption is banished. No catheter is left in the wound. The iron and car- 
bolic acid applications are certain to prevent union by the first intention 
so that the urine is sure to flow without obstruction and the wound is pro- 
tected from the irritation of flowing urine by these applica-tions, until 
protection is afforded by the suppuration, which throws off the 
artificial crust. 
A hypodermic injection of morphia is generally given before the patient 
has become fully aroused from the sleep of ether. The state of insensibil- 4 
LITHOTOMY. 
ity is thus prolonged. Since the adoption of this expedient, it is a rare event 
for a patient to complain of pain. The restlessness which prevents sleep is 
generally more effectually removed by a bath than by a Dover’s powder. 
A liberal use of quinine helps the reparative processes, and the diet should 
be that which agrees and furnishes the best relish. To avoid the tedious- 
ness of detail of cases, they have been incorporated in the following table: 
Kind of operat’n. 
X 
3 
t> 
6 
s 
l 
0 
8 
a 
1 
21 
Id 
. 1 V 
X fc- 
3 •- 
-3 -C 
| 
4 1 
l1 
3 ft 
2 1 
2 
1 
X 
ft 
1 
9 
2 
1 Females, 
No. of stones In 
each operation. 
4-14-8-1 
1 
l-l-l-I-l l-l-l-l 
14-1 
1 
1 
- X 
X o> 
1- V 
o a 
~ 2 
o 
i 
i 
1 
r* 
23 
1 
» 
6 
2 
1 
42 
Of the two cases of other sub- 
stances, one was that of the 
bone of the male organ of the 
coon. In the male bladder, 
carried six weeks—the soft 
investment being infiltrated 
with calculous material. 
The other was that of a pen 
knife carried a year and a 
half in the female bladder, 
incrusted In calculous mate- 
rial. 
Lateral convert- 
ed into bilateral 
Median 
Medio-hilateral 
Vagino Vesical. 
TTrethral 
Totals 
13 7 
17 
3 
40 
2 
Twenty-one operations have been made upon twenty persons, nineteen 
recovered, and one (that of a woman with a small calculus) died at the end 
of five days, probably from the lose of blood. The infant was operated on 
at fifteen months and again at twenty-one months; died three months after- 
ward. Two adult cases died at the end of a year. The other cases sur- 
vived several years or are now living. 
In one of the lateral operations in a gentleman fi3 years of age. fourteen 
stones were obtained very similar to each other, weighing in the aggregate 
four ounces avoirdupois, or 113 grams. The patient was able to walk a 
mile in five weeks from the time of the operation. 
The lateral converted into the bilateral operation furnished a stone weigh- 
ing four ounces avoirdupois. Five days after the operation a fistulous open- 
ing was developed which never healed. This probably resulted from a 
slough, very much as a fistula is developed after parturition. The conver- 
sion of the lateral incision into the bilateral was done with the probe-point- 
ed bistoury, with its flat surface to the outer surface of the blade of the 
forceps, the edge being turned out sufficiently to divide the most resisting 
tissues. 
operations were subsequently made to close the fistula, but 
were unsuccessful. 
Thi6 patient came very near being lost by a peritoneal inflammation 
which supervened five weeks after the time of the operation, as the result 
of drafts of air from the cracks of a window. 
An illustration is also afforded of the relief of irritation which follows 
the removal of a stone. Great prostration from vesical inflammation was 
attended before the operation by a pulse of over 100. Spare diet aggravated 
the condition. Liberal feeding and quinine improved the condition of the 
patient, but the pulse would not come below 80. 
The operation afforded relief from this great irritation. It follows from 
the consideration, of which this is an illustration, that it is not advisable to LITHOTOMY. 
5 
■wait for the complete removal of morbid general conditions. The removal 
of the stone is essential to this end. 
This case is also illustrative of the influence of diuretic spring water. 
The patient consulted me six years before he submitted to an operation, and 
on being told that cutting would afford the only relief, he went away sor- 
rowing . He afterwards spent two years at a saline spring in Greene county, 
111., and was so much benefitted as to think he was completely recovered. 
He married and engaged in farming, and for three years believed himself 
free from the presence of a stone. Overwork brought on a vesical inflam- 
mation, from which he found no complete relief except in lithotomy. 
The rationale of the diuretic cure,probably,is that the large amount of fluid 
holds in solution the material which would otherwise be deposited, while 
the surface of the stone becomes polished by Its friction against the mucous 
membrane. 
The penis bone, (of a coon) mentioned in the table, was removed from a 
man aged about fifty, whose story was that “a doctor had attempted to re 
move the gravel and had broken his instrument, leaving a part of it within 
the bladder, where it had remained about six weeks. 
The pen-knife, mentioned in the table, had been carried in the bladder a, 
year and a half, and assumed a transverse position, so that the patient, a 
girl of fifteen, could not completely empty her bladder, and yet there was 
a constant and imperative desire to urinate. 
An incision through the vagina was closed successfully by sutures, six 
weeks after the removal of the knife. The amount of inflammation, inci- 
dent to the presence of the knife, did not permit an earlier attempt at clo- 
sure. The restoration of health was complete. 
The other case of vagino-vesical incision for the removal of a small cal- 
culus, resulted in death in five days. 
The patient was extremely emaciated and anemic before the operation, 
and it is supposed, that a loss of blood sufficient to stain the discharges 
for three days, exhausted the already impoverished blood below the grade 
of repair. The death was by asthenia. 
It is regretted that the operation had not been by an incision by the pla- 
tinum -wire, heated by the galvanic current, or by extraction thiough the 
urethra. 
The readiness with which the patient was thrown into a condition of 
terror, led to the making of the incision at the close of an examination, 
rather than subject the mind of the patient to the anticipation of an opera- 
tion at a subsequent time. 
The removal of a fusible calculus, weighing 121 grains, (18.67 grams,) 
through the urethra sufflcieutly dilated, resulted in permanent incontinence 
of urine, though the patient, aged 60, regained good health in other re- 
spects. 
It is regretted that the stone was not thoroughly crushed before its ex- 
traction. 
The yougest case was that of a child, fifteen months old, from whom a LITHOTOMY. 
soft, phosphatic calculus, weighing forty-four grains, was removed by the 
median operation. In six months another similar formation was removed 
in the same wyay. The child became»eickly and died about three months 
after the second operation. 
The greatest age is that of eighty-one years, in a gentleman who had lived 
an active and healthy life until old age. For many years he had been 'obliged 
to employ a catheter, which passed easily and without pain. Ijolypous 
growths around the urethra were suggested as the cause of the retention, 
and they were found in the progress of the lithotomy. 
In July, 1877, the patient detected a calculus in introducing the catheter. 
Since then a burning sensation had been one of the most annoying symp- 
toms. He had been for a considerable time bed-ridden, and was willing to 
have an operation performed as a means of terminating his life or his suf- 
fering. C. 
Oct. 29, 1877, after a cathartic taken the night before and 10 grains of 
quinine each morning for three mornings and the usual preparations in a 
warm room, the median incision was made as already described. The 
sphincter of the anus having been dilated previous to the incision, the Au- 
gers of the left hand were readily passed behind the bladder,and the forceps 
were thus aided in grasping a calculus. The extraction w.as found to re- 
quire considerable force, and the probe-pointed bistoury wraspassed in along 
the blade of the forceps on one side and the resisting libers were divided, 
and then the same thing was done on the other sick). The stone was extract- 
ed, piloted by a polypus which had been torn off by being caught in front 
of the stone. Tnree other stones were seized and extracted in succession, 
each one driving a polypus before it. Four polypi, each about an inch in 
length, were thus removed, and one of smaller dimensions, making five in 
all. 
The calculi were irregularly triangular, one a little larger than the others 
and weighed in the aggregate four and a half ouuces avoirdupois, (122 
grams.) 
The wound and the bladder were freely mopped wnth carbolic acid and 
the wound afterwards mopped with chloride of iron. 
The pulse, before going into operation, was 120. On coming out from 
the effects of ether, so as to talk rationally, or about four hours after the 
operation, the rate was 90, soft and full. 
Bathing several times a day was enjoined. The recovery wTas without a 
bad symptom. Writing several months after the operation; he holds his 
wratcr completely, w7hen in the horizontal position, but in the erect posture 
there is some loss. He uses no catheter. 
I early got a hint that the great success of Dr. Benjamin Dudley w7as at- 
tributed by himself in part, to cutting as little as possible. The more con- 
sideration I have given to this subject, the more value I have placed upon the 
maxim. The other extreme, of excessive violence in tearing the tissues in 
the extraction, must be avoided. 
After an incision of moderate extent, the remainder of the cutting can bo LITHOTOMY. 
7 
executed much more safely under the tension of the expanded forceps, than 
as a part of the primary cutting made preparatory to the extraction. 
In the proceeding as here described, the vessels and other easily yielding 
parts escape before the knife, (which should have a thick edge,) while the 
fascia and the trabeculse are divided. The elasticity of the undivided tis- 
sues helps to lessen the size of the wound remaining after the conclusion of 
the operation, thus lessening the work to be accomplished by gran ulation 
and cicatrization. 
One of the cases of median,operation in a child and one in a lad of thir- 
teen, had the stone pushed out by the fingers of the left hand in the rectum, 
and those of the right hand above the pubis. There is, however, nothing 
in this procedure to recommend it as a general practice, because the rough 
surface of the stone produces an unnecessary abrasion of the mucous and 
the incised surfaces. My cases have all been in the white race. 
I have not selected my cases, and have never rejected a case. I have not 
operated in a case of such congestion or degeneration of the kidneys as to 
produce albuminous urine There is therefore something of the element of 
luck in not having lost a case in a male; but I cannot avoid feeling that the 
methods which I have described are in part to be credited with the success 
in the later cases. 
The recent improvements in the methods of crushing stones within the 
bladder, especially the improved apparatus devised by Dr. Bigelow of Bos- 
ton, have enlarged the field of fitness for this proceeding, but the process 
of cutting must remain the preferable method for a considerable portion of 
the cases, and the indispensable method for the cases in which the stones 
are hard or in which the nueleis are some substances incapable of being 
crushed by ordinary pressure. 
The great safety of lithotomy, (wThere the methods and precautions here 
insisted upon are employed,) makes it probable that this operation will 
always hold nearly its present comparative value. 
Such is the sense of relief expressed by the patient recovering from perineal section, 
on being placed in a bath, that it seems proper to add a few paragraphs in explanation. 
The open air management is unavoidable; because the flow of urine must saturate 
any application, rendering it necessary that it should be changed. It is then both au 
open air and at the same time a wet treatment. 
The Litter method of a spray of carbolic acid to prevent the introduction of organisms 
during au operation, and of a nitration of air through carbolized dressings afterwards, 
to prevent their entrance, is altogether inapplicable. The -antiseptic application must 
be wet, because a fountain of liquid is ready to saturate any dry application w hich can 
be made. 
The wound is necessarily onecf suppuration, where the mingled pus and'urine quickly 
pass into putrefaction in the warmth of animal heat. The application of sponges must 
be limited to the cutaneous surfaces, while the introduction of the point of a syringe 
must occasion pain unless effected with more care and skill than is to be expected. The 
use of sponges or syringes for the application of water,either simple or medicated, must 
therefore be very imperfect, though better than no application at ail. 
THE ZB A/THEE. 8 
Lithotomy 
The position of the pelvis in water meets the necessity for cleanliness without any 
harsh contact; the.water passing to the fundus of the suppurating surfaces, and in those 
in which the urine is dripping away without any the water of the bath 
passes into the bladder itself. 
if the bathing is employed as often as the irritating character of the discharge creates 
uneasiness, the pus is almost certain to be washed away before it passes into the putre- 
factiove condition. 
A child, whose case has been referred to in the preceding pages, who was nursed by 
his father, usually became restless in the night. His father would then place him in the 
bath with a speedy subsidence of all irritation. A refreshing sleep Invariably followed 
the bathing. 
This is an example of the uniform experience of those who have been subjected to 
bathing to the extent of desire, after perineal section. 
If the measure were not one believed to add greatly to the safety of the patient, it 
would be worth the trouble it requires, in order to secure the comfort which must 
otherwise be obtained by opiates The latter blunts the sensibility to a source of irri- 
tation, which is itself the occasion of danger as well as of discomfort. This suppression 
of irritation often deceives the surgeon, with regard to the presence of dangerous pu- 
trefaction, which only needs a shallow pocket as the beginning of a deep burrow, while 
the bath removes at the same time the source of uneasiness and the cause of mischief, 
From the great relief obtained by the frequently repeated and the prolonged bath after 
lithotomy,'the suggestion occurs that perhaps the expedient has been underestimated 
in other suppurating wounds. In a paper on the management of wounds, I have pub- 
lished in some detail the history of cases In which exceedingly great relief has been de- 
rived from this management.’1' 
In suppurating wounds of ihe extremities it is practicable to employ prolonged irri- 
gation, but in wounds of the pelvis this is difficult. It is however practicable to alter- 
nate the drip with the bath, so that the wound may be kept constantly wet, either with 
simple water, or with water medicated with carbolic acid, salicylic acid or other disin- 
fectants. 
In the operation for extroversion of the bladder, where the perpetual dow of urine is 
liable to inflame the flaps and destroy their adhesion, this combination of irrigation and 
immersion is of exceedingly great advantage. 
Observations have proved that union by the first intention, as well as union by the 
second intention, goes on under irrigation and immersion quite as well as under a dry 
dressing, whether the dry dressing be a scab or a blood clot dried in the open air, or, be 
an artilicial dry dressing. 
Operations upon the vigina, as for vesico-vaginal fistula, aud upon the perineum (o 
close lacei'ations from child-birth, present cases which, according to analogy, should be 
treated subsequent to surgical operation, by the employment of the bath to the extent 
of comfort. Any other method of securing cleanliness Involves danger of destroying 
the adhesions while they are delicate, and without cleanliness, the adhesions are liable 
to fail, through the destructive presence of pus in the condition of putrefaction. 
It is probable that this method of after treatment has not received the attention which 
it deserves, on account of the trouble its execution occasions where there is not proper 
preparation for it. If water must be brought and carried away in buckets, the bath is 
nearly certain not to be employed as often as it ought to be. 
In a case of such importance as the cure of stone in the bladder and one involving the 
danger attendant upon the ordinary management, It is worth while to make the neces- 
sary preparation. 
In all public institutions it is entirely practicable to have a room In which there shall 
be a bed with a bathtub alongside of it—with hot and cold water supply, easy of man- 
agement. If the patient is very helpless the assistants can lift him into the water and 
when sufficiently soaked they can lift him out again. This will be less trouble to the 
attendants than giving an opiate, aud will therefore be willingly executed. 
•The management of weunds by David Prince, Jl. D.--Lindsay Jt KlaUaton, Pblia