enlarged the sphere of the crashing operation, principal items in the armamentarium of litholapaxy are the larger catheters or evacuators which are employed, and the more powerful and perfect aspirator. It has now been satisfactorily proved that and

tation,

The two

catheters of between 25 and 31 French and 15 and 20 standard can be introduced without difficulty

English danger

The observations of into the male urethra. Otis established the fact that the average healthy

or

urethra possessed a capacity larger than the regulation sizes of catheters and bougies recognized. Bigelow's

operation takes practical adTantage of this, and by the evacuation of larger fragments through instruwider bore it is evident that time is saved crushing and evacuating. The narrowest part

ments of

both in

of the urethra, it must be remembered, is its orifice, and it may be necessary to enlarge this with scissors Anaesor knife before introducing a No. 18 or 20. thesia which abolishes spasm and relaxes muscle, is also requisite for the safe use of these large instruLancet of 24th September and 1st a clear and well illustrated account

The

ments.

October contains

most recent patterns of his aspirators. with Cloveu's, the advantages of these compared instruments consist in their larger capacity and special of Bigelow's As

Jntitan 2$ei)tcal (f&a^elte.

CIjc

NOVEMBER l, i88i. LITHOLAPAXY AND SUPRA-PUBIC

LITHOTOMY. distinct modern departures surgical treatment of stone in the bladder,

Thicse terms denote two in the

the safer and more effective recalculi. moval of vesical Litholapaxy rests on the as an

having

prevent return of fragments into the Descriptions and figures are also given

contrivances to

bladder.

object

in the

ing right

paper of more powerful and safe crushWith reference to these it i$ bear in mind Siu Henry Thompson's maxim

same

instruments. to

larger instruments ought to be reserved larger stones, the smaller being best suited for smaller calculi. The subject of litholapaxy was discussed in the Surgical Section of the recent In-

that the for the

principle that the bladder is more tolerant of the prolonged presence of smooth instruments than the more protracted contact of rough fragments or irritating debris. Supra-pubic lithotomy bases its claim on the possibility of its being performed antiseptically and

it may be accepted as a decided advance in dealing with vesical calculus. Untoward results have occurred in some hands and been recorded in the

conferring

nals;

all the benefits of an operation conducted to end in accordance with Listerian

beginning principles and practices. The procedure to which Professor Bigelow of Boston has applied the term litholapaxy is not altogether original. The use of anajsthetics and Clover's aspirator often enabled surgeons to dispose summarily of small stones at one sitting, and many lithotritists from

lists of

operations thus accompatient. Bigelow's plished in the demonstration that large consists originality stones?all stones to which the operation of crushing

are

able

to adduce

with

ease

long

and benefit to the

of removal in

similar manis or rather the invention, in ner and adaptation, of instrulie has also demonstrated to that end. ments

applicable?are capable adapted

the tolerance

bj

the bladder of

a

prolonged

instrumen-

ternational

Congress

Medical

general feeling

was

others,

large stones, is the operation. In this

London.

The

operation,

and

jourThompson, especially in removing

but the success of Bigelow

Harrison and

at

in favour of the

more

best

himself,

of

argument in favour of the of calculi

country the crushing

as yet been practised to any material extent. The native is intolerant of prolonged treatment. His patience and faith soon become exhausted, and he prefers summary removal by cutting to repeated removal by crushing. Litholapaxy obviates this difficulty, and

has not

the

experience of Surgeon-Major

ed in this

journal,

R. C.

Sanders, record-

that the operation is both

proves

feasible and successful. If

litholapaxy

may and established

accepted pubic lithotomy known

that

is

still

be

pronounced to

operation, antiseptic

extravasated

on

be

an

supra-

its trial. It is well urine does not always

THE INDIAN MEDICAL GAZETTE.

312

gangrene ; sometimes not the tissues with which it comes

cause

Harbison in his

"

and that

healthy

urine did not

within the

bladder,

and

irritation of

even

in

contact.

Mr.

surgical disorders of the urinary organs" gives evidence in support of this statement, and Professor Lister ascertained that it was decomposed urine that irritated the tissues, Lectures

was

on

ordinarily decompose practically bland. Found-

on this circumstance* and on the circumstance that the urine and bladder might be rendered and

ing

kept aseptic, even if not so to start with, by means of injections and ablutions, he conceived the idea that by opening the bladder above the pubis the operation might successfully conducted in accordance with strict antiseptic methods, which is impossible in the perineum. He made some experiments to this end in Edinburgh which were not very successful ; in one case the peritoneum was opened, but recovery took place notIn another hernia took place with withstanding. fatal result through a wound which had been made

be

below the umbilicus to ascertain the line of reflection

peritoneum. Subsequent experiments have Kiug's College, London, but the results have not been, as far as we are aware, published. The idea has been taken up by Dr. Carl. Langunbuck. of Berlin, who has advanced an elaborate argument for the superiority of the supra-pubic over the perineal operation. The two great dangers of the former are urinary infiltration and wounding of the peritoneum. Careful stitching of the bladder wound with catgut he contends obviates the former, and distension of bladder and rectum has been shown by Pictisrsun of Kiel to raise the line of reflection of the peritoneum and

of the

been made in

operation. Langenbuck suggested preliminary operation by which

increase the available

area

has further

a

the

peritoneum

may be

of

put

out of harm's way before of the stone.

for extraction

the bladder is

opened

Augisu of Paris

proposed at the International Congress thermo-cantery for supra-pubic opera-

the

use

of the

tions, but the idea was not received kindly. The supra-pubic operation may be said to remain still where it was?a refuge for difficulties or failures in perinseal extractions. While

improved methods of crushing and cutting are exercising surgeons, it is surprising that the important matter of solution or chemical disintegration of calculi does not engage more research and thought than it appears to do. Removal of stone by solution has long been the dream and desire of surgery, but beyond the operation of dilute nitric acid on phosphatic debris, nothing practical has been done. No surer portal to surgical immortality exists than the discovery of an effective lithontriptic, and we commend thus

the

subject

to those of our readers who

of impressing

footprints

on

are

the gauds of time.

desirous

[November ],

1881.

Litholapaxy and Supra-Pubic Lithotomy.

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