WITH EVACUATION. BY HENRY J. BIGELOW, M. D., PROFESSOR OF SURGERY IN HARVARD UNIVERSITY; SURGEON OF THE From the American Journal of the Medical Sciences, Philadelphia, January, 1878. Ad- LITHOTRITY WITH EVACUATION. WHEN Sydney Smith asked, "What human plan, device, or invention two hundred and seventy years old does not require reconsideration?" he would no doubt have regarded with favor an occasional reconsideration of the theory and practice of medicine and surgery, especially in view of the current belief that their traditions had been kept alive and their rules prescribed in part by authority. The surgical literature of Lithotomy, both French and English, so long showed the influence of the early specialists, that we have hardly now escaped from its exaggerated circumstance and detail. And yet, with attention to a few precise rules, the operation of lithotomy is quite a simple one, much less difficult, for example, than the dissection of tumors. It is not impossible that convictions in some degree traditionary may prevail in regard to certain points connected with the practice of the more recent art of Lithotrity. Civiale was among the first to inculcate the excessive susceptibility of the bladder under instruments. Later surgeons, perhaps influenced in part by his teaching, have continued to invest the operation of lithotrity with precautions which, though by no means groundless, because under certain conditions both the bladder and urethra are actively resentful of even slight interference, are nevertheless greater than this operation generally requires. As a rule, there is little difficulty in it. The stone is readily caught and broken into fragments, of which a few are pulverized; a large-eyed catheter is then sometimes introduced; a little sand and a few bits of stone are washed out; after which the patient is kept quiet, to discharge the remainder and await another "sitting." Under favorable circumstances, such an operation, lasting a few minutes, is not only simple, but, if skillfully performed, safe. On the other hand, it is not always safe. This is the fact that seems to have arrested so strongly the attention of surgeons. It may happen that during the succeeding night the patient has a chill,—not the chill of so-called "urethral fever," which sometimes follows the mere passage of a bougie, and which is of little consequence, but one followed by other symptoms, such as tenderness in the region of the bladder, a quickened pulse, an increasing temperature, and the frequent and painful passage of urine. These symptoms may insidiously persist rather than abate. Others may supervene. The surgeon vainly waits for a favorable moment to repeat his operation; it becomes too evident that the patient is seriously ill, and it is quite within the range of possibilities that in the course of days or weeks he may quietly succumb. An autopsy discloses a variety of lesions, some of them remote or obscure, others of more obvious origin, and among them, not the least common, an inflamed bladder, upon the floor of which angular fragments and chips of stone are resting. It is then evident that during a certain interval before death the bladder was not in a condition for further instrumental interference; and although, in view of the fatal result of delay, lithotomy or active lithotrity, to both of which I have resorted, might have been deemed on the whole the less dangerous, still it is plain that either operation would have furnished in itself an additional cause of serious inflammation. Such cases have been supposed to point to the necessity of extreme precaution, as well as of extreme remedies. It is evident that the purpose of such interference at an unfavorable moment is the removal of the offending fragments as a last resource. But if at the first operation the bladder could have been completely disembarrassed of every particle of stone, even with the risk of irritating its lining membrane, we can hardly doubt that the relief would then have been followed by comparatively ready repair. In short, it is difficult to avoid the conviction that in an average case damage to the mucous membrane is as likely to result from irritation by angular fragments, added to the injury inflicted by an opera tion, as from the use of instruments protracted beyond the usual time, for the entire removal of a stone, if this result can be accomplished. It is probable that injury from the use of instruments has been confounded with that resulting from the presence of fragments in the bladder. That the average bladder and urethra have no extreme susceptibility is attested by the generally favorable results of lithotrity, and even of catheterism, which are practised with very varying skill everywhere; also by the singularly innocuous results of laceration of the contracted urethra, by an instrument like that of Voillemier, for example; so, too, by the recovery of these organs from the considerable injury inflicted during the extraction of a large and rough stone in lithotomy. The bladder is often also to an extraordinary degree tolerant of the presence even of a mulberry calculus. If we remember that in this case it clasps the stone at every micturition, often with a persistent gripe, the comparative immunity of its tender mucous membrane is quite remarkable. But when after an operation, sharp fragments are thus embraced, presenting acute angles, which do not soon become blunted, and to which the bladder is unaccustomed, it is still more remarkable that serious consequences are the exception and not the rule in lithotrity. Polished metallic surfaces carefully manipulated can hardly do such damage as the other agencies here mentioned. Gentleness, dexterity, and experience are especially to be valued in lithotrity. If the bladder is pinched, the patient may die. A false passage or a lacerated inner meatus is a serious complication. It has been well said that no novice should undertake this operation. But the habit of confounding the symptoms resulting from the presence of fragments with those following the use of instruments originally led to precautions in the introduction and manipulation of the latter which are sometimes excessive. Civiale, with an almost unparalleled experience, introduced a small lithotrite with much less pressure than its own weight, and with uniform and great slowness. And yet, in a healthy urethra, it is only at the triangular ligament and beyond it that such extreme care is called for. The same author, who had no means of evacuating fragments in the bladder, restricted the length of his operation |