tients would have been, by accepted rules, subjected to lithotomy, and consequently to a risk equal to one death in three cases. I cannot but think that with due care in its application the method now proposed will be found to yield results at least as favorable as those before obtained.

HENRY J. BIGELOW.

BOSTON, May 25, 1878.

LITHOLAPAXY.1

THE object of this operation is to remove at once, by the urethra, the débris created by the lithotrite. It is based on the belief of a tolerance by the bladder of protracted manipulation, which has not been hitherto recognized. It is also based on a theory that a brief manipulation, in the bladder, of polished and blunted instruments is less irritating to that organ than is the protracted presence of fragments, especially in view of the fact that the bladder hugs the latter more or less sharply at each micturition. When lithotrity is properly done, the process of crushing is easy and safe. The real question relates to the subsequent disposal of the fragments. If the purpose of the surgeon is to get rid of them, and if their evacuation has hitherto been, for the want of proper appliances, slow and injurious to the bladder, it is fair to consider whether this object cannot be attained with the aid of an instrument devised to evacuate the bladder more quickly through the urethra, while its walls are held apart at their full normal dimensions, such, for example, as this canal attains when the meatus is compressed during the passage

of urine.

It is quite safe to leave this question to be settled by such further experiments as shall be deemed wholly satisfactory. In the mean time, in order that the operation of evacuation may be accomplished in the readiest and safest way, it may be well to offer a few explanatory suggestions in respect to it.

One difficulty at the outset may be illustrated by a simple experiment. If a small catheter, surmounted by a funnel, be

1 The Lancet, Nov. 2, 1878.

tied in an ox's bladder and held vertically, water introduced by the funnel will distend the bladder very forcibly. Similarly, the hydrostatic pressure of a column of water but a few inches higher than the pubes will distend the human bladder beyond its safe capacity. So that it may be assumed that any catheter surmounted by a bulb is more liable to injure the bladder by over-distending it than when the bulb is lowered to the level of the bladder or below it. The weight of a full bulb in the former position also prevents accurate manipulation of the catheter. It is more easily handled in a stand.

The instrument now employed is a siphon, at one of whose extremities is a large metal tube that takes advantage of the full normal capacity of the urethra, while the other terminates in an elastic bulb and glass receptacle. The tube extremity is shaped to facilitate its introduction, and also so that its orifice may be placed, if necessary, at the lowest point in the bladder, at the apex of an inverted funnel, among the fragments, without being occluded by the usual valve-like action of the bladder-wall. A straight tube has advantages over a curved one: the surgeon can more readily direct it and regulate its pressure; it is less liable to obstruction, and better cleared by a rod. Again, a straight instrument, when of the size 29, 30, or 31 of Charrière, is more easy to introduce than a curved one. In order to carry it into the bladder with least resistance, it should be passed as far as possible in a nearly vertical direction toward the anus, before the handle is depressed; its extremity then lies not only in front of the aperture in the triangular ligament, but, what is of more importance, below it, and is afterward tilted up to this orifice by depressing the handle of the instrument to the axis of the body. The tube should next be rotated through this aperture like a corkscrew; and during this process its point, which is made a little eccentric for this purpose, revolves in a

small circle until it discovers the orifice. A common difficulty in introducing a catheter or lithotrite results from depressing the handle prematurely, by which the beak is arrested above the aperture in the ligament instead of below it. This error should be carefully avoided in introducing the large straight tube, which so fills the urethra that it needs every advantage in traversing its less yielding parts. Indeed, it is not superfluous to say that even a free use of oil injected with a syringe both into the urethra and into the tube may sometimes determine the question of the passage of the larger sizes. And yet, with these precautions, the whole manœuvre is a very easy one. Before introducing the tube, the calibre of the urethra is ascertained by a common olive-pointed elastic bougie, or a sound. I have not found much advantage in trying to dilate it, unless at the moment of the operation, by incising the meatus, which is the narrowest part, or by "divulsing" a stricture when it exists. Such preliminary enlargement of the contracted canal, unless especially contraindicated, suggests itself.

But there is another important measure that does not suggest itself, and yet deserves careful attention. In order to protect the bladder from over-distention, the first movement of the aspirator should be to withdraw water from it, and not to inject water into it. This cannot be too strongly emphasized. As a preliminary to this precaution, the surgeon ascertains exactly the capacity of the bladder. For this purpose it should be emptied by a catheter, and tepid water slowly injected, until the fluid is forcibly expelled between the catheter and the loosely grasped urethral walls. This reaction of the organ, which anæsthesia does not prevent, may be relied on to furnish a sufficiently accurate indication of the size of its cavity. If the fluid be now drawn off and measured, the same amount may be safely reinjected through the large tube, which is next to be introduced, the injected fluid being

retained in the bladder by a tape tied round the penis, with the thumb or a cork at the extremity of the tube. Here is, I think, a critical moment of the operation; because if the contents of the bulb are added to those of the already distended bladder, the organ may be over-stretched. It should not be forgotten, therefore, that the elastic bulb, before it is attached to the tube, should be compressed until the sides meet, in order that its first action may be to withdraw from the bladder, by its expansion, such an amount of fluid as can be reinjected with safety. The present instrument holds ten ounces; by compression it loses five ounces. This amount would then be aspirated from the bladder by its first expansion, after which the usual pumping action displaces only about two ounces of fluid at each stroke, and can hardly injure the bladder. In order to direct attention to the importance of compressing the elastic bulb, a clamp is provided with the instrument to compress the bulb before it is attached to the tube. Other details, relating especially to the signs and avoidance of obstruction, may be found elsewhere. Briefly, when fragments are still felt, and yet cease to fall into the trap, there is either obstruction, which usually occurs in the tube, and should be removed by compressing the bulb or introducing the rod, or the fragments are too large to pass the tube, and need further crushing. In respect to the time occupied by the whole operation, I would suggest that if the surgeon will crush the stone as usual and then remove the fragments, he will probably find his patient to be still in so good a condition that he will be tempted again to introduce the lithotrite, followed by the tube. At the end of half an hour or more he will have repeated this several times, and will then find that the stone, if of average dimensions, has been evacuated. He will also find, in a common case, that the patient is no worse for the operation.

As these remarks apply chiefly to the mechanical part of