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.