-

lithotrity, an operation which, indeed, depends more than any other for its success upon a careful and economical adaptation of its instruments to their employment, a few observations may be here added respecting the lithotrite.1

It is very desirable, during a long operation, to prevent the impaction of the lithotrite, which interferes with crushing, and sometimes injures the neck of the bladder. This may be effected by raising the floor of the female blade, and by adding lateral notches to the male blade, which should be also provided with a central septum at the heel. The lateral grooves for the male blade should also extend through the heel of the female blade. I am persuaded that the simplest movement for locking a lithotrite is a quarter rotation of the right wrist, without displacing the fingers of either hand. Further, it seems not to be always remembered by surgeons that the "rapidity" of a lithotrite depends upon the inclination of its screw thread; and that while the slowest screw gives most power and requires the strongest blades, " rapidity" sacrifices power. In the longer and more rapid operation now contemplated, larger and stronger blades than have been commonly employed, and which also better protect the bladder than do the latter, seem to me desirable.

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I have elsewhere said that the blades of a lithotrite should be as nearly at right angles with the shaft, and their floor as straight, as is compatible with their convenient introduction into the bladder. Many instruments are made with oblique blades, which are also so rounded at the heel as to curve their floor. This is a mistake. A cubical stone, for instance, would exactly fit a right-angled lithotrite. But when the same blades are made oblique, at an angle for example of forty-five degrees with the shaft, then in order to grasp the same stone they must not only be opened wider, but they will

1 The aspirating siphon and the lithotrite have been made by Weiss and Son, with great mechanical perfection.

not reach so far out upon the stone. In other words, the size of their grasp rapidly diminishes with their obliquity. They must be opened wider, and they seize less of the stone. Their power also diminishes, because if they are made longer with the view of preserving their grasp, their increasing leverage increases friction in the slide. This is readily seen by increasing the obliquity until they reach the line of the stem of the instrument. The shaft and blades are then in a continuous straight line, and they merely roll the fragment between them. The latter acts only as a wedge to separate them, while the friction of the slide is at its maximum. In other words, right-angled blades crush best and wedge least. Oblique blades, on the contrary, wedge more and crush less, and the depth of their grasp is also less. And what is here true of the whole blade is true of any part of it, the heel, for example, which should not be oblique nor much rounded, but as nearly at right angles with the shaft and with as straight a floor as is compatible with its convenient introduction. It is only the difficulty of introducing right-angled blades that compels us to make them a little oblique and curved. But the slanting and hooked blades, sometimes still made, act at great disadvantage. It may be added that the tip of the female blade should be bevelled, so that (if we compare it to a bent finger) it may impinge against the upper wall of the prostate, while passing it, rather with its pulp than with its nail.

In conclusion, it may be said that a small stone does not usually entail a serious operation of any kind. On the other hand, a large stone does. It may be better to resort to lithotomy in the case of a large stone, with a diseased bladder or kidney, however fatal the former operation may be in such cases. But there has hardly been any material change of late years in the operation of lithotomy, unless it be in a greater attention to cleanliness and in the general treatment

of the patient. It is certain that no bona fide Lister dressing can be applied to the wound. The danger also of hæmorrhage remains the same as heretofore. So that I think any very great increase in the percentage of recoveries from lithotomy would, perhaps, result chiefly from a resort to the operation in more favorable cases than formerly, — by which I mean in certain cases of stone which have been of late relegated to lithotrity, and which might as well be subjects for experiment with the operation now proposed, as for lithotomy.

The question then presents itself thus:—

1. Whether, when any stone, large or small, has been crushed, it is not better to distend the urethra to its natural limits, and remove the detritus at once by a few strokes of the siphon, than to leave it to be expelled through the contracted urethra by the unaided and comparatively ineffectual efforts of the bladder.

2. Whether, by thus assisting the bladder, we may not so increase the amount evacuated, and so diminish the time of the operation, that it may be possible by the method now proposed to treat with success larger stones than heretofore by lithotrity.

16

LITHOLAPAXY.1

TO THE EDITOR:

THE LANCET of February 1 contains a paper by Sir Henry Thompson, entitled "A Lecture on Lithotrity at one or more Sittings." In another communication, February 15, he promises to give his views more completely "in the fifth edition" of his Clinical Lectures" now going through the press." The publication of this volume will be looked for with the more interest because the Lecture on Lithotrity fails to give a clear exposition of the author's existing views. It mixes new and old ideas, its tendency being to obliterate rather than define the line between what has been done by lithotrity hitherto and what can be accomplished now, leaving the reader uncertain how far Sir Henry discriminates between the new and old method.

The new operation enlarges the range of lithotrity, and encroaches upon that which has hitherto been regarded as belonging exclusively to lithotomy. This is all I claim for it. Cases can be relieved by litholapaxy which would not have been treated by the old lithotrity; as, for instance, one case where eighteen hundred and two grains of soft stone were removed at three sittings, one of nearly four hours' duration, the patient travelling home four days afterward. Such a result, till now wholly unprecedented, would have been before regarded as bordering on the impossible. Experience alone can decide the limits of the new operation. I am surprised

1 The Lancet, May 17, 1879.

2 So early as 1846 Sir Philip Crampton said: "It appears, then, that cystotomy and lithotrity are not to be considered as rivals, and that the question as to which of these operations should be the rule and which the exception should never be brought into discussion; each operation

that Sir Henry should attribute to me a disposition "to make the rule absolute to remove at one sitting an entire stone, no matter how large it may be, or what may be the condition of the patient." He adds: "Invariable conformity to such a rule, I do not hesitate at the outset to say, will lead to results. which though often successful will not seldom be disastrous." This is obvious.

1

In attempting to identify the old operation with the new, Sir Henry relies mainly upon his having used Clover's form of Crampton's instrument, with which Sir Philip, before 1846, drew "upwards of two drachms of pulverized calculus at once from the bladder." He dwells much on what he calls "that useful instrument, the aspirator of Clover." It is figured in his former works with half-a-dozen differently curved catheters attached to it. He now figures it (see Lancet) with “ a slight modification," as he says, based upon what he calls a "hint" from my "aspirator." It is quite extraordinary that Sir Henry should claim such efficiency for Clover's apparatus. Except in cases where the prostate is so enlarged that the bladder retains even sand, his is the only voice, so far as I know, that has spoken in its favor.2

has its special province, the boundaries of which (if, indeed, they admit of being fixed at all) can be determined only by a comparison of a vast collection of facts carefully noted, and above all faithfully reported and properly authenticated." (Dublin Quarterly Journal of Medical Science, 1846, vol. i. p. 25.)

1 Dublin Quarterly Journal of Medical Science, 1846, vol. i. p. 22.

2 For the information of those who have not seen my paper, I here cite the latest authorities on this point:

We may here say, without fear of being accused of exaggeration, that evacuating injections practised after sittings of lithotrity have no apology for their use. The whole surgical arsenal invented for their performance is absolutely useless. . . . It should be well understood that the best of evacuating catheters is worthless. DEMARQUAY ET COUSIN: Nouveau Dictionnaire de Médecine et de Chirurgie Pratique, pp. 693, 694. (Paris, 1875). Having used it [Clover's apparatus] very frequently, I would add that it is necessary to use all such apparatus with extreme gentleness, and I