STONE IN THE BLADDER.
Once a calculus has been detected in thelbladder by the sound the question arises: Should medical treatment have a trial ? Notwithstand ing the views put forth by Roberts regarding the possibility of dissolving small uric acid stones by the administration of Bicarbonate of Potassium, all surgeons recommend immediate resort to operation. This advice is justified by the great advances made in the surgery of the bladder during recent years, though undoubtedly small uric acid stones, if they have not been dissolved, have been so reduced in size as to permit of their passage down the urethra, and the same result has been maintained in the case of oxalate of lime calculi by the free administration of the Acid Phosphate of Sodium.
The old operation of lateral lithotomy has been entirely superseded, whilst that of median lithotomy is only used for stones impacted in the posterior urethra. In all other cases the suprapuhic operation, which alone allows of free investigation of the interior of the bladder cavity, is chosen if cutting is to be done at all.
The choice of operation, therefore, in the vast majority of all cases of vesical calculi lies between Lithotrity (litholapaxy or Bigelow's crushing operation) and suprapuhic Lithotomy. The crushing operation should be regarded as the routine method of dealing with vesical calculi, the exceptions to its exhibition being found in (t) very large and very hard stones; (2) where, owing to the stone being encysted or located in a saccule, it cannot be grasped in the lithotrite; (3) where there is marked enlarge ment of the prostate; (4) where a stricture of the urethra prevents that wide dilatation of the passage necessary for the large-sized instruments employed in lithotrity; and (5) where the bladder is so small and firmly contracted that the blades of the crushing instrument cannot be safely trusted to grasp the stone without injuring the coats of the bladder.
Lithotrity as now practised after Bigelow's method aims at the entire disintegration of the calculus by mechanical pressure, and the complete removal of the debris at a single prolonged seance. The amesthetised
patient being placed on his back with the pelvis slightly raised and the thighs separated, about 5 oz. Boric solution being injected into the bladder, the sterilised and lubricated lithotrite with its blades screwed home is introduced into the urethra and allowed to glide by its own weight into the bladder. On opening the blades the stone usually falls between their jaws if the lithotrite rests on the lowest part of the bladder; the male blade is then pushed home to grasp the calculus, and the handle of the instrument is to be slightly depressed so as to elevate the blades from contact with the bladder wall. The screw movement is now substituted for the sliding one, and firm, steady pressure applied to break it into large fragments. These are next individually seized by a repetition of the original manoeuvre or by rotating the open blades to an angle of 45 degrees to the right and left before screwing home. After each fragment has been crushed small, the instrument is withdrawn with the blades screwed firmly in contact with each other, and the largest sized evacuating catheter is passed to which the lithotrity aspirator or evacuator is attached after being filled with warm boric solution. By alternately squeezing the rubber bulb of the instrument and allowing it to relax, the debris is gradually pumped out of the bladder and falls into the trap provided for it. When fragments cease to return the catheter should be withdrawn and a small lithotrite passed in order to sound for any remaining pieces of stone too large to pass through the evacuating catheter; if such are found they should be seized by the blade of the small instrument and crushed till the bladder is thoroughly cleared of all debris. Where any doubt of a residuum exists the cystoscope may be employed, hut the use of this is handicapped by the presence of blood in the bladder cavity.