LITHOLAPAXY.1

TO THE EDITOR:

AN editorial paragraph in the "Record" of May 31 mentions that the letter from Sir Henry Thompson to Professor Van Buren, which appeared in the previous issue, was written for publication.

Sir Henry's reiterated criticisms of lithotrites should not be allowed to obscure the main facts, be their value more or less, of rapid lithotrity, which means long sittings for the immediate and complete evacuation of the fragments by large tubes, and depends upon the newly discovered tolerance of the bladder to the smooth surfaces of instruments; while the old lithotrity meant repeated short sittings and sharp fragments left in the bladder.

The size of a lithotrite has little to do with litholapaxy. Stones are so frequently soft and small that a small lithotrite of any kind may be large enough. Of course the operator will be careful not to break such a lithotrite upon a large or hard stone. Like other lithotrites, mine is made in various sizes. It is not, however, the large lithotrite that I have desired to bring to the attention of surgeons, but the new lock, and the protective and non-impacting blades, designed to promote safe and rapid work at a moment when the hand or the attention of the operator is fatigued by a long operation. I prefer a large lithotrite if it possesses these qualities, even in dealing with common calculi. Sir Henry prefers a smaller one, whether it clogs or not, and frequently withdraws it to clean it. His prejudice against a large instrument is connected with a life-long and erroneous theory that the dangers of lithotrity result mainly from the instruments used in the

1 The Boston Medical and Surgical Journal, June 19, 1879.

operation. This was the general mistake of the day. It was not known that the irritation was really occasioned by the fragments which it was the custom to leave in the bladder. When these fragments were drawn out by my apparatus, and that source of danger to the bladder was removed, it was found that the instruments themselves did but little harm. Sir Henry, perhaps, might long ago have discovered this fact of the tolerance of the bladder to instrumentation if he had possessed any means of evacuating it thoroughly. But he had only Clover's instrument, the tube of which was so small (21 French) that it drew out only sand and left the fragments. Hence his error and failure to discover the new facts of what is now known as rapid lithotrity.

Sir Henry devotes the last half of his letter to the expression of creditable sentiments in relation to his attitude toward surgical progress. A little explanation may be here desirable.

A year after the publication of my paper, he published a lecture in the "Lancet" (Feb. 1, 1879), in which he says: "My own system has for a long time past been gradually inclining to the practice of crushing more calculus at a sitting, and removing more débris by the aspirator than I formerly did," which might very well be true, his former sittings having been limited to two minutes or less; but the hindrance to his "removing more débris" was the small size of Clover's tube. The editor of the "Lancet" replied (February 15): "We cannot close our eyes to the fact that the views advanced in his lecture of the 1st inst. do involve an abandonment of his old position. Lithotrity as hitherto practised by him and lithotrity as recommended and performed by Professor Bigelow are different operations, and based on opposite and contradictory principles." This "editorial observation" in the "Lancet" Sir Henry, curiously enough, chooses to regard, in his letter published in the "Record,"

as "adverse criticism of himself personally, not of his mode of operating."

Sir Henry's position will now be understood. It is in this connection that he expresses the opinion that the terms "abandonment of position" and the like, "adapted as they are to military men," do not accord with the aims of men who "live and learn.' . . . It is an error," he says, "to look for a life-long consistency in matters of opinion from men who think for themselves." The world will not question the right of Sir Henry to "live and learn," nor to " think for himself," but only the propriety of his claiming to have originated by "thinking for himself" ideas he has learned from others.

A friend has to-day sent me the fifth edition, just published, of Sir Henry's "Diseases of the Urinary Organs." I find that in this edition Sir Henry both honors rapid lithotrity with his indorsement and appropriates as his own its essential details. He adopts large tubes, increasing the ineffectual catheter of Clover from 21 to 29, which latter calibre I often employ, my smallest tube being 27, my usual size 30, and the largest 31. "You are first to introduce," he says (page 173), "an evacuating silver catheter fitted with a flexible stylet, - in size, say, from No. 14 to No. 16, English scale," calibres equivalent to 24 and 29 French. Here being the essential feature of the operation, Sir Henry at this point definitively abandons

1 Handerson's comparative scale, from which these equivalent numbers are taken, is made by Reynders & Co., New York. It is accurate, and very convenient in having instead of holes a long triangular slit like a wire gauge. "In England," says Sir Henry Thompson, "we cannot be said to have a uniform scale; all our measurements are very arbitrary. One maker has one scale, and another another." (Diseases of the Urinary Organs, 1879, p. 47.) On page 48, however, he gives a scale, of which the largest size 14 is the equivalent of 24; and this corresponds to Handerson's scale (New York Medical Record, 1877, p. 638). The French numbers increase more rapidly than the English. Larger calibres have hitherto been but little known either in France or England. The main point is the necessity of enlarging Clover's tube.

"consistency" and the 21 tube of his previous editions in favor of "large evacuating catheters and a good aspirator" (page 177). Neither of these he used before I described them. This gives him the whole key to rapid lithotrity, and he is able to accomplish thorough evacuation at once by prolonging the sitting till evacuation is complete, demonstrating at the same time that the bladder tolerates instrumentation if the fragments are removed, — which is the new principle that underlies litholapaxy. The large tube once appropriated, what remains is easy. The aspiration of his new edition means effectual aspiration with large tubes, and his lithotrity becomes rapid lithotrity.

A comparison of this, Sir Henry's present practice, with his recent opposite teaching of frequent repeated crushings - each confined to a few minutes, lest the polished instrument injure the bladder, but leaving the bladder nevertheless to struggle in the intervals with sharp, broken pieces of stone, which he had no means of extracting-will show the significance of the criticism by the editor of the "Lancet." 1

In conclusion, I may venture to hope that the valuable example set by Sir Henry in accepting large tubes will aid in doing away with whatever apprehension still exists of danger from their use.

HENRY J. BIGELOW.

1 The Lancet of May 17 contains a letter on this subject.

17

LITHOLAPAXY.1

TO THE EDITOR:

DEAR SIR, Will you allow me to correct an erroneous statement contained in one of your recent editorial articles upon the new lithotrity (vol. xvi., Nos. 7 and 8)? It relates to the lithotrite devised by me. This particular instrument is not indispensable for the performance of litholapaxy, since almost any lithotrite can be made to crush the stone, the novel and essential characteristic of the new method being the complete evacuation of the calculus by a long sitting and a large catheter. But although the error referred to is unimportant, it should, I think, be corrected in deference to surgeons who use my non-impacting instrument.

The writer says, referring to the lock of this lithotrite, "The liability to break is a serious objection. Thompson's catch cannot be broken in this manner." Now, this is a mistake. My instrument, although employed by myself and others upon stones both large and hard, has never been, as your writer states, "broken." Nor do the parts he alludes to (the old screw-blocks of Charrière and their boxes) differ in strength from those of all other lithotrites, inasmuch as they are identical in all of them. If one breaks, others must be liable to the same accident.

This writer has misapprehended a trivial occurrence, incidentally mentioned many months ago, in connection with the then novel method. This was what happened. Tiemann and Co. borrowed from me, for examination, a lithotrite just arrived, one of the first of my instruments made in Paris, and lent it for use. The French workman, to whom the lock

1 The New York Medical Record, Sept. 27, 1879.