Lithotomy

Addendum Lithotomies

Lithotomia Celsiana [18]

“A strong, well-trained man sits on a high stool and seizes the boy- who is lying on his back- from behind, after having set the boy’s buttocks on his knees. When the boy’s legs have been drawn up, the man orders him to put his hands behind his knees, and to pull upon them as much as he can, and he too keeps them in this position. But if the body of the patient is stronger, two strong men sit on two stools side by side and the adjacent legs of the stools and the men’s legs are lashed together, so that they cannot be separated. Then the patient is laid in the same way as described above upon the knees of the two men; and according to their position, one takes hold of the patient’s left leg and the other grasps the right while at the same time the patient himself pulls upon his own calves. Whether one or two men hold the patient, they press downwards with their chests upon the patient’s shoulders. Hence it results that the hollow between the iliac region above the pubes is stretched out without any folds, and as the bladder has been crammed into a narrow space, the stone can easily be seized. In addition, moreover, two strong men should be stationed at either side to prevent the one or the two men who are holding the boy from slipping. Then the two fingers, the forefinger and the middle, first one and then the other, into the anus of the patient and places the fingers of his right hand upon the hypogastrium, but lightly, in order to avoid injuring the bladder with the fingers should they apply violent pressure on the calculus from both sides. And, as holds in most cases, the procedure must not be carried out in haste, but in such a way that everything comes off as safely as possible, for an injury to the bladder causes spasm with a consequent danger of death. And the stone is first sought for about the neck of the bladder and when found there it is expelled with less trouble. And this is why I said that the patient must not even be treated except when the stone has been recognized by its special signs. But if it is not at the neck of the bladder, or it has slipped backwards, the fingers are placed at the base of the bladder and the physician must also move his right hand upwards and gradually follow the fingers downwards. When the stone has been found, and it must fall between the hands, it is guided downwards- and the smaller and smoother it is, the greater care that must be taken lest it escape, because we must beware of disturbing the bladder too often. There the physician’s right hand is always kept above the stone, while the fingers of the left press it downwards until it reaches the neck of the bladder, towards which the stone must be pressed so that, if oblong, it will come out end on; if flat, it will lie crossways; if cubical, it will rest on two of its angles; if any part is larger, the smaller part will come out first. In the case of a spherical stone, it is clear that the shape makes no difference, except that if any part is smoother, this should be the first to be extracted. When the stone has reached this position, then the skin over the neck of the bladder next to the anus must be incised to the neck of the bladder by a semilunar cut, the horns of which point towards the hips; then a little lower down in that part where the incision is concave a second cut must be made under the skin, perpendicular to the first, to open up the neck of the bladder until the urinary passage is opened so that the incision is a little larger than the stone. For those who make a small opening for fear of a fistula, which in this place the Greeks call a rhyás, risk the same danger, but to a greater degree, because the stone, when pressed out violently, will make a way out by itself if it is not given one. And this is even more harmful if the shape or the roughness of the stone has led to any further trouble. As a consequence, haemorrhage and spasm may ensue. And even if the patient survives, he is nevertheless doomed to have a much wider fistula- if the neck of the bladder has been torn- than he would have had if it had been incised. Now when the neck of the bladder has been opened, the stone comes into view, and its colour make no difference. If it is small, it can be pushed outwards by the fingers on one side, and extracted by those on the other. If it is large, the hook made for this purpose must be put over the upper part of it. This instrument is thin at the end and beaten out into the semicircular shape, which smooth on the outer side (with which it comes into contact with the body), and rough on the inner side (with which it contacts the stone). And it must be rather long for a short instrument would not be strong enough to extract the stone. When the hook has been inserted, it must be inclined to each side to see whether the stone has been grasped, because if it has been firmly seized it moves together with the hook. This necessary lest- when the physician begins to draw the hook forward- the stone should slip inwards and the hook fall upon the lips of the wound and lacerate them. And I have already noted above how dangerous this is. When it is certain that the stone is firmly held, almost simultaneously a triple movement must be made: first towards each side, then outwards, but in such a way that the movement is gentle and the stone is at first drawn a little outwards; that having been done, one end of the hook must be raised so that it remains further in and the stone can be drawn out with greater ease. But if at any time the stone cannot be easily seized from above, it will have to grasped from one side. This is the simplest operation. But the various contingencies require some further observations. Indeed there are some stones, which are not merely rough, but also spiny, and these may be extracted without any danger if they have reached the neck of the bladder on their own accord. But if they remain inside the bladder, it is not safe either to search for them or draw them out, because if they wound the bladder they will cause a speedy death from spasm. This is all the more true should any spiny stone stick to the bladder, and, on being drawn out, have folded it over. That the stone is at the neck of the bladder may be inferred from the fact that the passing of bloody water in drops. In the presence of these signs we must test the nature of the stone with the fingers too, and the operation should not begin until we are sure of this. And then too, the fingers must be applied to the stone gently, lest they wound by moving the stone forcibly. The incision is made. Many use a scalpel here too, but since this is a rather week instrument, and may meet some prominence of the stone and after having cut the flesh over this prominence fail to cut what is in the hollow beneath, leaving something that necessitates a second incision, Meges devised and made a straight instrument, with a wide border on its upper part, semicucular and sharp below. Grasping this instrument with the two fingers, the forefinger and the middle, and putting the thumb upon the back of it, he pressed it down so that he cut both the flesh and any prominence of the stone at the same time. By this means he succeeded in making a sufficiently large opening with only one incision. But whatever way the neck of the bladder is laid open, any rough stone must be extracted gently and no force is to be used out for haste.”

Paul of Aegina [18]

“I have already explained not only the cause of the formation of calculi, but also why they form chiefly in the bladder of boys, and in the kidneys in adults. Now I will speak about the method by which they can be extracted, after having described the signs of bladder stones. The urine is watery and has sandy deposits; the penis is tormented by a continuous pruritis, relaxes and grows erect again without any reason; the patients are irritated and rub it frequently, most of all the boys, and the flow of urine is suddenly blocked when a calculus sticks in the neck of the bladder. Boys up to fourteen years can safely be operated on, because they recover more easily owing to their tender bodies; old people are unlikely to recover, because wounds in their tough bodies heal only with great difficulty, but middle-aged people are a middle way have an average chance of recovery. Moreover, those who suffer from big stones recover more easily, because they are accustomed to suffering from inflammations, while those who suffer from small calculi recover with difficulty for the opposite reason. This being the case, when we have decided to perform the operation, first of all we must shake the patient, who will either be shaken from our assistant, or he himself shall jump down from a higher place, in order to push the stone to the neck of the bladder. Then the patient must be placed on a bench, on which he must sit erect with his hands under his thighs, to compress the bladder into a space as narrow as possible. That having been done, we must palpate the stone. Should palpation reveal that the stone, moved by shaking, lies in the middle region between the anus and the scrotum, we shall perform the incision. If, instead, this is not the case, we must grease the forefinger of our left hand with oil, if the patient is a boy, and also the middle finger, if the patient is an older man, and insert them into the anus, and then, searching for the stone with the finger tips and inching it along little by little once it has been found, we must block it in the neck of the bladder, push it outside, hold it firmly, and order one of the assistants to press the bladder with his hands and the other to pull the testicles upwards with his right hand while using his left hand to stretch the middle region between the scrotum and the anus towards the part opposite to the place where we shall make the incision. That having been done, we must take the lithotome and perform an oblique incision between the anus and the testicles, not in the exact midline between the scrotum and the anus, but laterally, near the left buttock, using the stone as a chopping-board. The incision must be wide enough at the surface, but small enough inside, as to let the stone come out easily. Sometimes the stone comes out immediately through the incision, if gently pushed by the finger or the fingers we have inserted into the anus, without the aid of any instrument. If it does not, we must extract it with the special hook known as the ‘lithoulkós.’ The stone having been extracted, we must stanch the flow of blood with styptic medicaments like manna, incense, aloe, comfrey, or also yew and the like and put wool or flax compresses soaked in wine and oil on the wound. Then we will bandage it with the six-tailed binding that is peculiar to lithotomy.”

Susruta’s Lithotomy [24]

A person of strong physique and unagitated in mind should then be made to sit on a table as high as the knee-joint. The patient should be made to lie on his back on the table, placing the upper part of his body on the attendant’s lap with his waist resting on an elevated cushion. His elbows and knees should be flexed and bound up with fastening of linen (sataka). After that, the umbilical region of the patient should be well rubbed with oil or clarified butter and the left side of the umbilical region should be pressed down with a closed fist so that the stone comes within reach of the operator. The surgeon should then introduce into the rectum the second and third fingers of his left hand duly anointed and with the nails well pared. The fingers should be carried upwards toward the raphe of the perineum so as to bring the stone between the rectum and penis where it should be so firmly pressed as to look like an elvated tumor.

An incision should then be made on the left side of the raphe of the perineum and of sufficient width to allow the free egress of the stone. Speical care should be taken in extracting the stone so that it will not break into pieces or leave any broken particle behind, however small, as they would in such case be sure to grow large again. Hence, the entire stone should be extracted with the help of an Agrabakra yantra (an instrument with a long handle and flattened end bent in the form of a wide scoop.

William Cheseldon (via John Douglas)

“Every thing necessary being in this manner got ready, the Patient, in a loose Night-Gown, his Head and legs covered, but nothing tight about his Neck or Belly, is brought from the Cutting-Ward in the Hospital to the Theatre, for here I suppose the scene of Action, and laid on the Table, his Head resting on the Pillow, and his Hips on its lower Edge. In this situation he is tyed, as in the greater Apparatus. that is, his Wrists are gently brought down to the Out-sides of his Ancles, and secured there by proper Bandages, his Knees having first been bent, and his Heels brought back near his Buttocks: then, his Thighs being raised and separated from one another, he is kept in this Posture by two Assistants (commonly Apprentices to some of the Hospital Surgeons) during the whole Time of the Operation, they holding his Ancles with one hand, and his knees with the other: there is one more standing at his Shoulders, in order to prevent his rising up or retiring from the Operator while he makes the incision.

Then, Mr. Cheselden, standing before the Patient at the End of the Table, takes the Catheter, first dipt in Oil, and introduces it in the usual Manner through the Urehtra into the Bladder, where having searched for and discovered the Stone, he delivers it to one of his fellow Surgeons standing on his Right-hand, whom he desires first of all to satisfy himself whether there be a Stone or not; and then his Assistant, holding the Handle between the Fingers convex Side close up to the Os Pubis, near the Commissure of Joining of the Bones, to remove or bear up the Urethra as far as may be from the intestinum Rectum, being frequently desired by Mr. Cheselden, not to push it down, nor make the convex or grooved Side thrust the Parts forwards or outwards towards the Perinaeum; for tho’ by so doing the Place of the external Wound would in some measure be ascertained, and the Groove of the Catheter be more easily found in making the internal one; yet the Danger of bringing the Urethra nearer the Rectum, which, in that case, is more liable to be cut, does more than counter-ballance these seeming Advantages. Besides, in his Method of operating, there can be little Occasion for any such Contrivance, were it attempted with no Inconveniency, the external Wound being very large and deep.

The Staff being fixed in this Situation, and its grooved Part being turned outward and laterally, Mr. Cheselden sits down in a low Chair, and drawing the Patient nearer him, till his Buttocks reach a little over the End of the Table, his Feet being quite off from it, takes his Knife, which he sometimes arms with a little Tow rolled about it, to prevent his Fingers from slipping when it becomes wetted with the Blood, and holding it firm in his Right-hand, his Thumb on the Inside of the Blade, his Fore-finger on the Outside opposite to it, his Middle-finger on the Outside of the Handle, and the Extremities of the rest on its upper Edge. Then distending and keeping steady the Skin of the Perinaeum with the Thumb and Fore-finger of the Left-hand, he makes the first or outward Incision, through the Integuments from above downwards, beginning on the Left-side of the Raphe or Seam between the Scrotum and the Verge of the Anus, almost as high up as where the Skin of the Perinaeum begins to dilate and form the Bag that contains the Testicles; and from thence he continues the Wound obliquely outwards, as low down as the Middle of the Margin of the Anus, at about half an Inch distance from it near the Skin, and consequently beyond the great Protuberance of the Ischium. The first or upper Part of this Incision is but superficial; after that he plunges his Knife much deeper by the Side of the Rectum, and finishes it by drawing his Knife obliquely towards himself; these three Motions may always be observed in his external Incision, but the last is performed pretty much at Random, there being her no Danger of doing any Mischief; and indeed I have, however, often observed that he is very little sollicitious about the precise Place and Limits of the external Wound, for I have seen him sometimes cut the Skin much nearer the Anus; sometimes at a greater Distance from it; sometimes he begins the Incision very high up, at other times lower down (and all this Variety in Patients of the same Bigness or Size); but his Intention and principal Design is to make the Wound as large as he can with Safety, always avoiding to wound the vesicular Membrane of the Scrotum.

Having cut the Fat pretty deep, especially near the Intestinum Rectum, covered by the Sphincter and Levator Ani, he puts the Forefinger of his Left-hand into the Wound, and keeps it there till the internal Incision is quite finished; first to direct the Point of his Knife into the Groove of his Staff, which he now feels with the End of his Finger, and likewise to hold down the Intestinum Rectum, by the Side of which his Knife is to pass, and to prevent its being wounded. This inward Incision is made with more Caution and more Leisure than the former.

His Knife first enters the Groove of the rostrated or strait Part of his Catheter, thro’ the sides of the Bladder, immediately above the Prostate, and afterwards the Point of it continuing to run in the same Groove in a Direction downwards and forwards, or towards himself, he divides that Part of the Sphincter of the Bladder that lies upon that Gland, and then he cuts the Outside of one half of it obliquely, according to the Direction and whole Length of the Urethra that runs within it, and finishes his internal Incision, by dividing the muscular portion of the Urethra on the convex Part of his Staff.

When he first began to practice this Method, he cut the very same Parts the contrary way; this is, his Knife enter’d first the muscular Part of the Urethra, which he divided laterally from the pendulous Part of its Bulb to the Apex, or first Point of the prostate Gland, and from thence directed his Knife upward and backward all the way into the Bladder; as we may read in the Appendix he lately published to the Fourth Edition of his Book of Anatomy. But some time after he observed, that in that Manner of Cutting, the Bulb of the Urethra lay too much in the way; the Groove of the Staff was not so easily found, and the Intestinum Rectum was in more Danger of being wounded.

A sufficient Opening being made, Mr. Cheselden rises from his Chair, his Finger still remaining in the Wound, and calling for the Gorgeret, he puts its Beek into the Groove of the Catheter, and so thrusts it into the Cavity of the Bladder, where he is often at once sensible of the Stone, which thus becomes a Direction to him when he uses his Forceps.

This done, he draws out the Staff, and holding the Gorgeret in his Left-hand, he introduced the Forceps, the flat Side uppermost, sliding them with great Caution along its concave Part, nicely observing when they pass the Wound into the wide Part of the Bladder and then he withdraws the Gorgeret, and taking hold of the two Branches of the Forecpes with both his Hands, he searches gently for the Stone they being still shut, and having felt it, he opens them, and endeavours to get the uppermost Blade under the Stone, that it may fall more conveniently into their Chops, and so be laid hold of; which being done, he extracts it with both Hands, one upon the Ends of the Forceps, the other about the Middle, but with a very slow Motion to give the Parts time to stretch and dilate, which he promotes by turning the Forceps gently in all Directions, taking all possible Care that it may not slip; of which if he perceives any Danger, he endeavors to recover it again without pulling his Forceps.

If the Stone is pretty large and smooth, and lies in that Sinus of the Bladder on the same side with the Wound, he draws it out with the greatest Facility imaginable, in Subjects of all Ages. But when he observes that the Stone is either very small, or does not lie right to the Forceps, he immediately pull them out, and introducing his Finger into the Bladder, he tries to turn it, and to disengage it from the Folds of the inner Membrane, in which it is sometimes entangled. Then he thrusts in his Gorgeret upon the upper side of his Finger; which being drawn out, he turns the Gorgeret, and introduces his forceps, and so extracts the Stone; but without any manner of Hurry or Precipitation…

He performs this Operation with so much Dexterity and Quickness that he seldom exceeds half a Minute, unless when he is obliged to take up and tie the Vessels before the Stone is extracted, or when there happens to be something uncommon in the Stone itself.”