Lectures

ON

LITHOTOMY AND LITHOTRITY.

Delivered at St. Mary's Hospital.

BY WILLIAM COULSON, Esq.,

SURGEON TO THE HOSPITAL.

LECTURE III.

GENTLEMEN,-As I have already informed you, I propose levoting a few lectures to the important subject of the exfaction of calculus from the bladder. It is so vast a question, nd embraces such a variety of details, that you must permit de to enter on its examination at once without any preface. et us commence with lithotrity, or that part of the subject ith which you are probably less familiar. Here a few histoical remarks may be interesting, for nothing is more curious instructive than to follow the history of the mechanical Jestruction of stone through its successive epochs. Lithotrity, in one sense of the term, is not a modern invenion. It has been known, and occasionally practised, from ime almost immemorial; but these isolated operations, as I hall presently show, detract nothing from the merit of the llustrious surgeon of modern days, to whom the honour of aving erected it into a system incontestably belongs, and who may therefore be regarded, as he now universally is, the real

inventor.

The germ of lithotrity may be found in the old idea of extracting calculi from the urethra without a cutting operation. From the urethra to the bladder there is but a single step, yet it required more than a thousand years to make this step, short and simple as it may now appear to you.

Urethral calculi were sometimes extracted whole, sometimes broken up, to facilitate their extraction. Hippocrates mentions a certain Ammon, of Alexandria, who thus broke up a calculus in his own person with a statuary's scissors, from which circumstance he was named the "Lithotomos." Colonel Martin, as you see, was not the first who operated in this way on himself.

Albucasis, a Moorish surgeon, who lived in Spain at the

FIGS. 1 and 2.-The ball-extractor of Alphonso Ferri (1553): fig. 1, the blades; fig. 2, the instrument enclosed in its sheath. FIG. 3.-The quadrupulus vesica of Franco (1561), for extraction of calculi from the urethra.

Fies. 4 and 5.-The forceps of Fabricius Hildanus, for the same purpose (1593): fig. 4 shows the instrument shut, and grasping the stone; fig. 5, the three-bladed canula. No. 1505.

latter end of the eleventh century, (1090,) describes the operation of perforating and breaking up urethral calculi. In the year 1561, Franco described a four-branched instrument, which he named quadrupulus vesicæ, for the same purpose; and analogous instruments, with four, three, or two branches, sometimes intended to perforate or crush, sometimes merely to extract, were invented by Fabricius Hildanus, Sanctorius, Paré, &c., and in modern times by Hunter, and Sir Astley Cooper. The greater part of the instruments prepared since the 16th century were probably borrowed from those invented by De la Croix and Alphonso Ferri for the extraction of bullets.

In this drawing of Ferri's instrument, which I show you, you will at once discover many of the elements of modern lithotriptic instruments the external canula, the threebladed forceps received into it, and the screw for working. The instrument of Hildanus also shows the fly screw, which has been claimed as a modern invention.

But the older surgeons did not confine their practice to the simple extraction of calculi from the urethra. It is certain that they not only sought to extract stones from the bladder itself, but perforated or crushed such calculi as were too large to find an exit through the natural passages.

The extraction of calculi from the bladder without breaking them up, was practised in Egypt from time immemorial: the French surgeons who accompanied Buonaparte in his Egyptian expedition saw the operation performed there, and it is probably practised in that country at the present day. But this would evidently apply to small calculi only. Was the operation of perforating and crushing larger calculi known to the older surgeons? Undoubtedly it was.

Albucasis, who died in the year 1105, must have been acquainted with the operation of lithotrity when he wrote the following passage:-" Accipiatur instrumentum subtile quod nominat Mashabra Rebilia, et suaviter intromittatur in virgam, et volve lapidem in medio vesicæ, et si fuerit mollis, frangitur et exibit."

From the context of Albucasis, however, it would appear that the operation of which he speaks referred to the relief of retention of urine produced by the impaction of a small calculus either in the neck of the bladder or in the urethra. In such cases, he says, "the calculus is to be pushed back into the bladder, and if it is friable it breaks up and is expelled. But if it be not expelled, the patient must be cut." It is impossible to ascertain the nature of the instrument to which Albucasis alludes, his Latin translator having preserved the original Arabic name, apparently from not understanding what it meant.

In the year 1506, Antonio Benevieni performed the operation of percussion, for the introduction of which, in modern times, we are indebted to Baron Heurteloup. The patient, however, was a female, and the stone appears to have been impacted in the neck of the bladder. Benevieni passed a hook behind the calculus, so as to fix it, and then struck the calculus with an iron rod, until by the repeated blows it was broken into pieces.

In 1533, Alexander Benedetti thus alludes to perforation"Cum vero his præsidiis (dissoluentibus) lapis non comminuitur, nec ullo modo eximitur, curatio chirurgica adhibeatur, et per fistulam, priusquam humor profusus dolores levet, aliqui intus, sine plaga, lapidem conterunt ferreis instrumentis, quod equidem tutum non invenimus."

Sanctorius, who lived in the early part of the 17th century, appears to have invented several instruments, drawings of which are before you, for perforating calculi.

Haller thus alludes to them in his " Bibliotheca Chirurgica”— "Catheterem delineat trifidum, per eum in grandiorem calculum specillum sagittatum immittit: eo, ut putat, calculum dividit, ut fragmenta inter specilli crura cadant et possint extrahi." But Haller adds, "meram speculationem puto."

This is an extremely curious passage. Haller evidently quoted Sanctorius from memory, for on referring to the original work of this latter author, you will find that the instrument of which I have shown you a drawing was solely intended for the extraction of small calculi from the bladder, and that the arrow-headed stilet merely served to expand the branches of the three-bladed forceps. The idea of perforating the calculus, and extracting its fragments, was a creation of Haller's own genius, which he attributes to Sanctorius, and calls "a pure speculation." Yet, one hundred years afterwards, this speculation was converted into a reality. It would hence appear, that the original idea of lithotrity, as a system, belonged to Haller, but that Haller attributed his own idea to another, and discarded it as a fancy,

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