LITHORITY OR LOTHOLAPAXY.
I will proceed to consider the treatment of stone in the bladder, and as lithotrity, litholapaxy, or the crushing operation, as now prac tised, is the one more generally adopted and the safest, it will be given first place. If stones were detected when small, there is no doubt that this method of disposing of them would not only supplant all other mechanical ones, but be practised with as little risk as at tends any minor though delicate operation. It is because a calculus is permitted to attain considerable dimensions that an element of dan ger is imported into the question of its removal—an element which may be approximately stated as proportionate to the size of the stone. Hence the importance surgeons attach to the early detection of these concretions.
It is not necessary at the present day, in a practical treatise, to oc cupy time by recording the steps by which lithotrity has reached its present position, or the fluctuations it has undergone within this cen tury. It would, however, be impossible to proceed without noticing the impulse given to Civiale's proposals by the demonstrations of Otis and Bigelow, in America, at a time when the prospects of litho trity were beginning to wane. It is to the former we are indebted for supplying us with a proper estimate of the capabilities of the male urethra as to size and its power of adaptation to larger instruments than were formerly used; while to the latter it was reserved to show that the bladder is more tolerant of prolonged manipulations than was supposed, provided that, in the case of lithotrity, all fragments of stone are removed from it without unnecessary delay.
In 1878, shortly after an article by the late Professor Bigelow, of Boston, "On Lithotrity by a Single Operation," " appeared, I was present at the Massachusetts General Hospital, and saw him remove a large lithic acid stone from the bladder of a man by a proceeding which was different from anything I had previously seen or read of. The chief points of distinction seemed to be the recognition, as a prin ciple, of the possibility and propriety of removing the entire stone from the bladder at one operation, and the employment of an evacu ating apparatus adequate to the purpose. In one hour and nineteen minutes, under ether, a large lithic acid calculus was reduced to frag ments and entirely removed from the bladder, and on the fourth day the patient was convalescent. At that date I understood this opera tion had been practised fourteen times—including a case each by Dr.
J. C. Warren and the late Dr. Curtis, of Boston—with but one death. I was much indebted to Dr. Bigelow, not only for the explanation he gave of his method of operating, but also for permitting me to take part in the various manipulations. In the same year I reported to the British Medical Association, at Bath," what I had seen, and ex hibited, I believe for the first time in England, Dr. Bigelow's appa ratus. Shortly afterward I performed the new operation, and have continued to do so. In the removal of some large stones the time taken up has been considerable. In a successful case reported by Professor Cheever," of Boston, the operation lasted three hours under ether, the stone being composed of oxalate of lime. In a patient from whom I removed with safety a stone weighing upward of two ounces the operation lasted over two hours. Reference is made to such ex ceptional cases as these merely to show that there need hardly be any time limit, so long as the manipulations are carefully conducted.
It will be convenient to discuss the question relating to the selec tion of an operation in a given case after the various details have been described, and I will therefore offer some remarks on the instruments employed and their use.
Lithotrites are required of different sizes and strength, ate not only to individuals of almost all ages, but to stones of various dimensions and composition. These instruments are of two kinds, smooth-bladed (Fig. 50) and fenestrated (Fig. 51), the former being adapted to the lighter kinds of work, and the latter to the largest and hardest specimens of stone which come within the range of rity. The modern instrument is constructed to permit of the male blade sliding within the female, so as to enable the surgeon to seize the stone or fragment, as the case may be. This is accomplished by means of a button on the handle, and without moving the position of his hands the operator can fix the stone within the grasp of the instrument, and at the same time bring into play the mechanism necessary for the screw or breaking movement. There are other contrivances for accomplishing the latter object. In many of the French instruments the change from the slide to the screw is effected by a catch which can be elevated or depressed as required by the alternate movement of the thumbs. I think the former method is generally preferable.