LITHOLAPAXY. AN IMPROVED EVACUATOR.1 THE operation for the complete removal of a stone at one sitting has been as successful as its most sanguine advocates could have hoped. Several years may still be needed to determine precisely its relative value; but in the mean time it has been abundantly proved that the bladder tolerates long operations, provided the fragments of the stone, which are the principal cause of inflammation, be removed,and that fragments need no longer be a source of inflammation. Although several cases of litholapaxy have terminated fatally, the cause of death was not the usual one after such operations; it was not an inflammation of obscure origin, connected with previous disease of the bladder or of the kidneys. The few deaths that have occurred were due to mechanical injury, which with greater experience in operations of this kind will doubtless in the future be avoided. It has been remarked by more than one writer that the new lithotrity requires even more care than was necessary in the old method by short sittings. This is true. Each repeated act of crushing or of evacuation is obviously liable to its own casualties; and we must add to this liability any that may arise from the gradual abatement of the operator's vigilance. It was once an object, in persuading surgeons to forego their traditional prejudices, to show that the new operation was safer than they supposed; but this being now generally conceded, it is at present important to insist that it should be attempted only by practised lithotritists, or by a beginner only after familiar practice upon the cadaver. I know no other 1 Boston Medical and Surgical Journal, Jan. 8, 1880. surgical operation in which a little want of skill or of care is so insidiously liable to fatal accident. The skill here is of a particular kind; and though a surgeon may use a knife well, it does not follow that he also uses a lithotrite well. Before considering this instrument, however, let us examine the evacuator, or "rubber bulb." It was an alteration of the evacuator that made litholapaxy possible, and led to the discovery of the tolerance of the bladder. This was the enlargement of its tubes from the size of the common catheter to the largest the urethra will admit without injury. In evacuating a small stone the smaller of the new large tubes (26 or 27 French) works well enough; but in order to evacuate a considerable stone with comfort either to the surgeon or to the patient, we need a tube of from 28 to 31; and for its introduction it is often well to enlarge the meatus, which is the narrowest part of the urethra. I cannot but think that the preference of some operators for the curved tube I at first employed is connected with their previous familiarity with curved catheters; and yet when a curved evacuating tube is in position its entire curve is in the bladder, and in the manipulation of the instrument there exists the disadvantage of not knowing, as readily as with a straight tube, where its point lies. The orifice in either case is on the side of the extremity, and there is a quarter of an inch, more or less, of tapering solid metal beyond it, necessary to make its introduction easy and to keep the bladder from obstructing it. The large evacuating-tube being the essential instrument in the new operation, a vacuum produced by almost any apparatus will draw fragments through it. Certain principles, however, observed in their construction will make them more convenient and efficient. An apparatus I early employed consisted of a stiff bulb and Clover's trap, attached to the large catheter by a short elastic tube. The combination was a good one; for the elastic tube allowed the bulb, when in use, to be bent down to the level of the bladder. The bulb could thus be laid on its side, and by further depression reversed; which brought the catheter tube to the top. It then remained only to construct a glass trap at its lowest point, so that the fragments should be left where they fell. This arrangement, placed in a stand, is practically the evacuator I still use. A strong rubber bulb is an indispensable substitute for the former slender one. In the glass trap at the bottom of the instrument the fragments are kept out of the current at a point distant from the catheter. After entering at the top of the bulb, they settle at once to the bottom and remain there undisturbed. If fragments are drawn through the tube with the force and rapidity that are given to the current by a strong rubber bulb, a few inches added to the length of the route are of no consequence. A short and curved elastic tube five inches long, but which I have varied from two inches to two feet,between the bulb and the evacuating tube, makes it possible to move one without the other. It relieves the surgeon and protects the patient. The surgeon can explore the bladder in search of fragments without having to move the bulb, which weighs a pound or two; while the jar of pumping does not reach the bladder. The discomfort to the unetherized patient resulting from this jar is a serious objection to the rigid attachment of the bulb of water to the tube. The bulb should have a support of its own, placed upon the table or bed between the patient's legs, which may be separated a little as in the case of the introduction of a catheter or a lithotrite. The surgeon's hand, instead of supporting the evacuator, is then supported by it. The bulb, when thus near the level of the bladder, acts as a siphon. This is desirable. By experiment it will be found FIG. 1. A, Glass trap, forming with the screw-catch B, which supports it, a ball-and-socket joint. c, Elastic bulb. D, Elastic tube, five FIG. 2. Diagram of a bulb used for experiment. that the difficulty of suction increases as the bulb is held higher than the evacuating-tube; it is very marked in Clover's instrument. There is great advantage in keeping the bulb low, near the level of the bladder. The evacuator thus described works very well. I have used it in most of the operations I have performed. Its imperfections are that if by accident a little air gets inside, the bulb has to be uncoupled to get rid of it, and a few drops of water may escape and wet the bed. By a simple expedient I have remedied these inconveniences. In the instrument I here show (Fig. 1) the air can be removed, or water withdrawn from the bulb, or added to it, without a drop being spilled. Indeed, the operation would be absolutely dry did not a sensitive bladder occasionally contract and squeeze out a little water by the side of the lithotrite or catheter, in spite of the elastic band I usually tie around the penis to prevent it. When this happens, it is perhaps best not to try to stop it. In this instrument the large evacuating tube at the top of the bulb extends an inch or more downward into its cavity. A space is thus formed where any accidental air collects, but cannot pass to the bladder. This space is emptied at will through an elastic tube or hose, a little more than a quarter of an inch in diameter, placed by the side of the first. The arrangement is a very simple one. Through this small hose, which can be attached and detached in a moment, the turbid contents of the bulb may be replaced by clear water without unfastening it from the catheter; or the contents of a tumblerful of water can be transferred to the bladder and back again, absolutely without loss, and with the elimination of all the air. With one end of the apparatus in the bladder and the other in a tumbler of water, the operator, even while he is evacuating the fragments, can vary the volume of water at will and put it where he pleases. The catheter and the elastic tubes, large and small, are each provided with a stop-cock. |