An Account of the New Method of Cutting for the Stone, By J. Douglas, Surgeon, F. R. S.

IX. An Account of the new Method of Cutting for the Stone. By J. Douglas, Surgeon, F. R. S. Ever since I was Anatomist and Surgeon enough, to reason upon the Causes of the Tediousness and bad Success of the common Methods of Cutting for the Stone, I concluded that they were principally owing to the natural Structure and Situation of the Parts concern'd. Therefore I began to consider, why that Operation might not be perform'd the high way, so frequently mention'd by Authors, but never approv'd of by any, except the most sagacious of all Surgeons, Fr. Rossetus, who has certainly been very little read, or else very ill understood, else this Operation had not been so long a Secret. After making some Experiments on dead Bodies, I was convinced, that the Stone might be extracted that way with a great deal of less trouble than commonly, and I was perswaded that the Wound would heal again, by the great number of authentick Instances we have of accidental Wounds in the same place being speedily and firmly cured; and therefore I resolv'd to make the Experiment on the first Patient I could meet with, which I could not procure till December 1719. and then I proceeded as follows. The Patient was plac'd flat on his Back, on a Table, with a Pillow under his Head; then his Wrists and Ancles were fasten'd together, with Straps. Then I ordered one Assistant to his Head, another to each of his Shoulders, two to the Penis, one of which was to manage the Ligature, and the other the Prepuce, and one to each Knee, to hold them as fast and firm as possible. The Patient and Assistants being thus plac'd, the Operation consists of three Parts. 1st, In filling the Bladder, which is done thus: First, Pass the Catheter, Fig. i. then draw out the Stillet, Fig. ii. then order the Ligature Assistant to cast the Ligature, with is a skein of Silk, round the Penis, above the Glans. Then fix the Key, Fig. iii. to the head of the Catheter, Fig. iv. to keep it steady, while you screw on the Syringe, Fig. v. then screw the second part of the Sucking-Pipe, Fig. vi. to the first, Fig. vii. Then order the Penis Ligature to be straiten'd, and the Prepuce Assistant to gather the Prepuce up about the Catheter, and to hold it as close as possible. Then order the Water, being a little warmer than Milk, to be clapp'd under the Sucking-Pipe; then draw up the Water into the Syringe, and thrust it into the Bladder at leisure, and repeat it till the Bladder is so full, that you can perceive its Tumour through the Abdomen, (at which time you will also observe the Penis above, and the Prepuce below the Ligature, very much swell'd, and the Patient in a great deal of Pain) which is a certain Sign that there is enough injected; then withdraw your Syringe and Catheter together, taking particular care that your Penis Assistants straiten their gripe, least the Water should follow the Catheter, which would undo all. 2dly, In making the Incision, which is done thus: Order the Penis Assistants to turn the Penis towards the Anus, that so their Hands may be the more out of the way, then take the first Knife, Fig. viii. and cut at leisure, and with a steady Hand, from near near the upper part of the Tumour of the Bladder, or lower, according to the computed bigness of the Stone, down to the Os Pubis, and exactly in the middle; when you are got a little more than half way through the abdominal Muscles, take the second Knife, Fig. ix. clap its back on the middle of the Os Pubis, then run its point down towards the Sphincter, until you get into the Cavity of the Bladder, which is discover'd by the issuing out of the Water, then run your Knife along very quickly towards the Fund of the Bladder, as far as is necessary. 3dly, In extracting the Stone, which is done thus: Before you withdraw your Knife, introduce the fore and middle Fingers of your left hand, between the Knife and the Os Pubis, into the Bladder, then withdraw your Knife, and thrust the fore and middle Fingers of your right hand into the Anus, and raise the Stone up towards the Wound, and so you will easily catch hold of it, (though never so small) with your Fingers which are in the Bladder, then draw it out with the smallest end foremost. Then introduce your Fingers again, to see if there are any more Stones, which are to be drawn out as before. Then take a Needle and Thread, and make one Stitch through the Skin, in the middle of the Wound, and tie it pretty close, then undo the Straps and carry the Patient to Bed. The Patient being put to Bed, I laid a Pledget arm'd with Balsam over the Wound, and a bit of sticking Plaister over that. Then I embrocated all the Abdomen, Scrotum and Penis, with warm Ol. Charmel.; then I applied over the dressing and all the Abdomen an Emollient Pultice, spread almost an Inch thick on soft Flannel; then I turn'd a swath a little broader than the Patient's Hand once round him, and and pinn'd it on the Pultice Cloath, just tight enough to keep it on. As soon as he was dress'd, I gave him an Opiate (for nothing is so proper as rest) such as this & Ag. Cinnam. Hord. 3ii. Laud. Liq. Gutt. xv. Syr. de Mecon. 3ii. which may be encreased or diminished as the Case requires. Next Evening I took off the Pultice and dressing, and cut the Stitch; then fomented the Wound and all the Abdomen with Stupes wrung out of Ag. Calc. and fresh Urine, as warm as he could bear it; then dress'd the Wound as before. Then I rubb'd all the Scrotum, Penis, and Groins with Unguentum Album, to prevent their being scalded by the Urine, which flows from the Wound. The Wound must be dress'd twice a Day at least, till you have a plentiful Digestion. After every dressing, the Ointment and Oil was used, as before directed. There is little Variation in the dressing of the Wound, except what is common in others. The Urine flows always through the Wound, until the Wound of the Bladder is cured, which is sooner or later according to the Constitution of the Patient. When the Urine begins to come the right way, it pains and scalds them much after the same manner, as when they had the Stone, (which is caused by the Contraction of the Urethra, that has been so long useless,) but it never lasts above a Day or two, and then they make Water with the same Ease and Freedom, as any other Person. They ought not to be forced to go to Stool under six or seven Days, unless there is some particular reason for it, because straining to go to Stool injures the Wound. They ought never to be taken up, except to get their Beds made, until the Urine comes all the right way, because it makes them sick and faint; and consequently hinders the Cure of the Wound. Cold is to be avoided as the Pest, because it puts them to a great deal of pain either to stifle it, or to Cough out. N. B. If a flexible Catheter could be pass'd, and kept in the Passage without pain, it would very much hasten the Cure of the Wound. I made this Operation the first time on the 23d of December 1719. upon a Boy between 16 and 17 Years of age, and in five Weeks time he was perfectly cured. The Stone was of the Figure and Bigness of Fig. x. I made the second Operation on the 12th of May 1720. on a Boy of Eight Years of age, and in six Weeks time he was perfectly cur'd. The Stone was of the Figure and Bigness of Fig. xi. The third Patient was but three Years of age, and was Cut in August 1720. but died of Convulsions about 15 Hours after the Operation. Fig. xii. Shews the Form and Bigness of this Stone. The fourth Operation was made on the 23d of March 1720-21. upon a Boy about 14 Years of age, and in four Weeks afterwards he was perfectly cured. This Stone is represented in Fig. xiii. In this Patient I made a small Wound in the Peritoneum, through which I saw the Guts present, but I push'd them back with my Finger, and then stitch'd the Skin, and we had no farther Inconveniency by it. These three Patients have been already shew'd before this Society. This Operation may be perform'd with equal Success on Females, when the Stone is large, but if it is but small, the common way of extracting them is very good. From all which I think I may safely conclude in the Words of the inimitable Rossetus. Post hac nemini dubium esse debet, novam hanc nostram Cystotomiam, vetere illâ tot d. etissimorum Chirurgorum Cystotomiâ (tam periculosâ, ut eam aggredi vel ipse Hippocrates Chirurgôn Chirurgotatos metuerit) & leniorem & tutiorem habet. FINIS. LONDON: Printed for W. and J. Innys, Printers to the Royal Society; at the Sign of the Prince's-Arms, the West-End of St. Paul's-Church-Yard.