RAPID LITHOTRITY, WITH EVACUATION.1

TO THE EDITOR:

AN article by Dr. Keyes in your last issue (May 18) gives me occasion to refer to one or two misapprehensions which pervade his allusions to "Modern Lithotrity," as he terms the new operation for stone.

In this article, which is devoted mainly to a description of the jaws of a lithotrite, the writer states that my lithotrite "must sometimes clog," because "it is made on the principle of Reliquet's." He is mistaken. In the first place, Reliquet's instrument is fenestrated; mine is solid. In the second place, as an ascertained fact, my lithotrite does not impact. The male blade is furnished with lateral notches forming inclined planes by which the detritus is extruded right and left, except where a small portion at the heel is driven through a slot by an effective spur. Reliquet's non-impacting lithotrite is identical with the obsolete fenestrated brisepierre, with teeth in the opening below to insure pulverization. Dr. Keyes proposes to remove these added teeth, and return to the brisepierre à mors fenêtré (porte à faux) of Charrière.2 In fact, he goes back to the flattened jaws of the "slightly indented and fenestrated or open female blade" figured by Costello,3 with a male blade as small as in the common lithotrite, to avoid pinching the mucous membrane, in short, to a common lithotrite with the floor removed.

1 New York Medical Record, June 8, 1878.

2 Nouveau Dictionnaire de Médecine et de Chirurgie, tom. xx. p. 667. Paris, 1875.

Cyclopædia of Practical Surgery, vol. iii. pp. 21, 50.

London, 1861.

4 The mucous membrane would be more secure if care were taken always to blunt, or round a little, the edge of the sole of the male blade.

I am gratified to find that the writer of the article indorses my statement (which is an important corollary of the new system) that "in future it will be no longer essential to pulverize the fragments, but only to comminute them." This may be accomplished by either a fenestrated or a solid instrument. Any fenestrated lithotrite that sufficiently reduces the size of fragments driven through it, enables them to pass the evacuating tubes, the use of which characterizes the new method. But although instruments of this class will doubtless do well enough with small stones, as does indeed a common lithotrite, my objections to a fenestrated instrument, of which I considered and rejected several (including that proposed in your journal), are these:

1. Sharp fragments, while firmly engaged in the opening, or driven through it, are likely to injure the floor of the bladder. During a long operation, such as I propose, it is hardly possible to prevent the frequent contact of the floor of the bladder with the extremity of the instrument; in which case the latter does not present to the mucous membrane a rounded and polished surface, but irritates it with protruding splinters of calculus, continually coming in contact with the same limited region of the floor.

2. The sides separately are not as strong as when united by a floor of metal, and if they are made low enough to be readily accessible to fragments (which is important) are consequently liable to break, especially should the strain come on one alone. The strength of a fenestrated blade lies in the height of its sides, and is but partially compensated by their breadth, unless the latter is extreme. Moreover, the male blade must be disadvantageously narrow. When it is wide, the corresponding opening not only impairs the strength, but delivers large fragments.

3. Now, although fragments, if small enough, pass the tube readily, dust and small débris pass more readily, and first.

Therefore when a fragment has been fortunately seized, the operator loses an opportunity if he fails to crush it, — as happens when he drives it through a fenestrated blade to be again seized. Although by the new method pulverization is no longer essential as before, our aim is still to accomplish a maximum disintegration at each closure of the jaws; and this is better done with a solid upper and lower jaw than when either of them is fenestrated. A non-impacting instrument is very desirable, but not at the sacrifice of efficient and rapid crushing, or with danger to the mucous membrane.

I may add that, to prevent impaction, when the blades are closed it is quite unnecessary that the male blade should project below the female blade, - an arrangement Dr. Keyes has devised and emphasized for this purpose, and a description of which, indeed, occupies a considerable portion of his paper. It is sufficient that the blades of a fenestrated instrument occupy the same level at the outlet.

Again, the heel of the instrument figured in your journal has the form of the segment of a circle. Such curved blades admit fragments, and crush them at great disadvantage.

Blades should be as straight, set at as nearly a right angle with the shaft, and as little rounded at the heel as is compatible with their introduction.

In my non-fenestrated lithotrite the blades are nearly straight, and the triangular notches deliver on alternate sides. This lateral action not only clears the jaws, but makes their hold very tenacious. It also secures to the blades the incidental advantage of grinding while they crush.

Your contributor finds my instrument too large (or, as he says, "clumsy "). It is made large with a distinct object; namely, to break larger and harder stones than have been hitherto considered within the province of the lithotrite. It comminutes, with safety to the bladder and without impac

tion, as no lithotrite hitherto devised has done. The new method of treatment is grounded in the fact that the normal urethra admits larger instruments, and is an easier road to the bladder, than the lithotritist has hitherto recognized. The operator soon becomes not only accustomed to the use of a large lithotrite, but reluctantly foregoes the power it gives him, even when the stone is small. Collin has, however, made a second size.

While the power possessed by this lithotrite and the fact that it does not impact are its more important features, and especially adapt it to the requirements of the method now proposed, almost as useful is the change in its lock. I believe that this will ultimately be adopted by those not already educated to the old system, because it is based upon the readiest movements of the hand and wrist.

But a modification of the jaws and lock of the lithotrite is an inconsiderable feature of the proposed new method. Rapid work is indeed thereby facilitated; and an empty instrument can safely be withdrawn as often as the operator pleases, to relieve the bladder of what will come through the tubes, and so clear the way for more rapid crushing.

A far more important point to the lithotritist is the comparative harmlessness of long sittings, which I think was unsuspected until the publication of my paper. In the first trials, what was wanted was not so much an improvement of the existing crushing apparatus, as an efficient means of evacuation, capable of removing all the débris at one sitting. For this purpose, the large tubes criticised in your journal are absolutely indispensable. Their use is precisely what makes the new operation practicable, and together with their manipulation is perhaps its chief innovation. The set of tubes described in my paper ranges from 27 to 31 Charrière; but they can be procured of any smaller size, and should of course be adapted to the previously ascertained calibre of the urethra.

It will, however, be found that the efficiency of the tubes diminishes very rapidly with their size, and that a canal narrowed by stricture, or by a small meatus, will require to be enlarged so that the introduction of a large tube may be made possible. In such a case as that reported, where the urethra admitted only a No. 20 instrument (French), and in which the operator of course found my largest tubes too large, I should prefer to increase the size of the passage rather than attempt to extract the fragments of a calculus through the small calibres formerly in use, even though the tube were otherwise modified as I have recommended. With a normal urethra I do not believe that the tubes supplied by Tiemann will be found any too large.

The change proposed in the new procedure, and the consequent advantages, will appear in a clearer light if we consider the limitations of the usual dilatory method explicitly acknowledged, quite recently, by both Sir Henry Thompson and Sir James Paget. These distinguished authorities gave their opinion that lithotrity should be restricted to stones requiring only two or three or at most four sittings of two or three minutes each. For larger stones, in their judgment, lithotomy does better, though resulting, in adults, in a mortality of one in three. It should be added that when lithotrity was thus pronounced unsuccessful in such cases, all attempts at the immediate evacuation of débris had resulted in practical failure.

The new method not only crushes calculi exceeding in size the limits hitherto affixed to crushing alone, but at the same sitting evacuates by the urethra the fragments and débris. This is done under ether, in a sitting of one or two hours' duration, or even longer. So far, its results have been better. than could have been anticipated, - being sixteen or seventeen cases of complete evacuation with but one death, against one in thirteen by the usual method. Several of these pa