dinaire, par un pas de vis, à un mandrin métallique droit. Celui-ci sert de conducteur à une longue et forte olive métal lique qui, ainsi que la tige en tube qui lui sert FIG. 11. par glissement le long du mandrin conducteur, en dilatant les points rétrécis du canal de l'urèthre. Pour pratiquer la divulsion, on introduit d'abord le mandrin droit central à la suite de la bougie filiforme. Ce mandrin conducteur est immobilisé pendant le cheminement d'avant en arrière de l'olive dilatrice à travers les points rétrécis, au moyen d'une sorte de pavillon en forme d'hémisphère creuse, qui coiffe le gland, en appuyant contre celui-ci, et fournit ainsi un point d'appui. 1 Divulseur Bigelow. L'opérateur, étreignant la verge de la main gauche, pousse l'olive le long du mandrin conducteur central de la main droite, pendant que la propulsion en avant de celui-ci est empêchée par le pavillon évasé qui coiffe le gland et s'y appuie. Il y a en outre certains détails qu'il serait inutile de décrire ici. Il suffit d'inspecter l'instrument pour comprendre de suite sa construction et la manière de s'en servir. Je me contenterai de dire que cet instrument à divulsion a l'avantage sur ceux qui existaient déjà, de n'exiger pour son maniement qu'une seule paire de mains, et qu'il remplit parfaitement le but pour lequel il a éte imaginé. Tels sont l'appareil instrumental nouveau et la méthode opératoire nouvelle pour le traitement des calculs vésicaux que j'ai l'honneur de soumettre, très respectueusement, à l'appréciation du Comité de l'Académie de Médecine pour le prix d'Argenteuil de l'année 1881. MODERN LITHOTRITY.1 My object in the present communication is to show in what the modern operation of lithotrity consists, and to explain the instruments which have made its performance possible; for the removal of a vesical calculus through the urethra is now mainly a question of apparatus, of which certain essential details are new. And as it is by no means necessary that the different parts of the apparatus should be put together exactly in any particular manner, it will be perhaps better to illustrate the principles of its construction than to insist on any special form of it. It will also be unnecessary for me to dwell on those parts of the subject which belong as well to the old lithotrity as to the new. From the days of Civiale to the year 1878 there was little change in the operation. The duration of a sitting was as brief as the skill of the surgeon, stimulated by his fear of producing cystitis, could make it. Three minutes or less was the limit inculcated by standard books and teaching of specialists, and the use of anesthesia was exceptional. At present anæsthetics are the rule. The instruments have been already modified in an important manner, while sittings often last half an hour, and have been successfully extended to three hours and more. Had Clover (whose catheter had a calibre only 21 of the French standard, about 12 English) or Mercier employed larger catheters (between 25 and 31 French,-15 to 20 English), they might have evacuated the bladder completely. They would have found how little affected it was by a long operation if no fragments were left behind, and that polished 1 Transactions of The International Congress of Physicians and Surgeons, Seventh Session; Vol. II., pp. 292–306, London, 1881. instruments were not injurious to it, while sharp fragments were. They would have discovered a tolerance on the part of the bladder wholly at variance with the traditions of half a century. Upon this tolerance modern lithotrity is based. The new and essential instrument of the operation is the large catheter (25 to 31), whether straight or curved (Fig. 1). This is indispensable. It has an orifice at the extreme end, one side of which is prolonged so as to make its introduction easy. FIG. 1.1 It has been adopted with little or no change, so far as I know, everywhere. Although my first apparatus was provided with efficient means of suction and a detached trap, neither of which was used before, its distinctive feature was the large catheter. The small size of the previous evacuating catheter delayed surgical progress for half a century. All the fragments could not pass through it, and it was impossible for surgeons to ascertain how the bladder would behave when once completely emptied of all fragments. Assuming all this to be admitted, let us examine the rest of the apparatus, and see how the operation is modified by it. 1 Large and small evacuating catheters, straight and curved (Nos. 25 and 31 French). As even a single minute fragment left in the bladder may be the nucleus of a future stone, it is important to get rid of it with certainty, and once for all. Now, although a fragment FIG. 2.1 remaining in the catheter after To prevent this I have fixed a simple contrivance to the head of the catheter, which is absolutely effectual in securing every fragment as it comes through it (Fig 2). It consists of a small, light glass cylinder, containing a ball-valve of rubber acting noiselessly, the valve seat of which is perforated so as to strain the return current and to keep back any fragment that 1 Catheter-valve, or strainer. A rubber ball, acting as a valve, has a seat of perforated metal, which strains the water. It prevents the fragments which pass it from returning. |