"LITHOTRITY WITHOUT INJECTIONS."
IN THE LANCET of February 20th, Mr. Thompson, surgeon to University College Hospital, drew attention to the subject of "Lithotrity without Injections." He writes: "For some time past I have practised lithotrity, first without preliminary injection of the bladder, and secondly almost without any injections subsequent to the sitting;" and further, that as, in his opinion, this is a " considerable improvement on the usual practice," he ventures to ask the attention of the profession to it. It has
... een recorded in a great Book, by a much more distinguished writer than either of us can ever aspire to be, that There is no new thing under the sun." The supposed considerable improvement on the usual practice of surgeons of the present day, like many other supposed novelties, falls under the meaning of the wise old preacher's words. In the wards of St. George's Hospital, and in private, I have for some time past discontinued the use of injections prior to the operation of lithotrity. In a case of stone in the bladder of an adult, and on whom it is decided to perform the operation of lithotrity, to inject the bladder previous to the introduction of the lithotrite has long appeared to me, not only a superfluous interference, but an unnecessary prolongation of operative manipulation. In a sensitive individual, or in the case of an irritable bladder, an injection appears rather to increase than diminish annoyance, and mechanically affords no aid; for atone, readily detected on the introduction of a catheter for the purpose of injecting the bladder, often less readily falls into the gripe of the lithotrite than if no injection be employed. It has never been satisfactorily proved to me that preliminary injection in cases of lithotrity is either requisite or beneficial in any degree. My experience has entirely gone to prove that, as a rule. there is no occasion for it. Why should it be otherwise ? Whatever quantity of urine the bladder is capable of retaining is all-sufficient for the purposes of the operator and for the successful accomplishment of the operation. If a bladder will not hold more than three ounces of urine, that quantity will suffice to enable the surgeon to crush the stone, without difficulty and without danger. If the bladder will not hold more than three ounces of urine, rarely will that viscus hold a greater quantity of tepid water; and, other things being equal, there is no benefit in tepid water over urine as a medium in which to crush a o-Jculus; so that it does not appear that there is any advantage in the use of preliminary injection, even in the case of an irritable bladder. If the bladder will not hold more than a small quantity of urine, it will not probably hold more tepid water; and so, to the operator, the evil is equally balanced between the capacity of holding the one or the other. Therefore, if the urine is not drawn off prior to the introduction of the lithotrite, there is pro tanto the less irritation to be endured by the patient. During the past few years several successful cases of lithotrity in the female have occurred in St. George's Hospital; and many equally successful cases have been recorded in the journals, from other hospitals. But the testimony which my experience enables me to furnish in such operations bears, I think, strongly in the balance against the use of injections prior to lithotrity. In the female, on the introduction of the lithotrite into the bladder, the greater portion of the urine immediately escapes. 1 doubt whether three ounces of urine, or water, were ever retained in any snch instance during the act of crushing a stone ; it is more probable that in most, if not in all cases, the bladder was almost empty. But in a.11, calculi have invariably been readily and successfully crushed, without local irritation or injury. If we may draw any analogy based on justifiable reasoning, it is but fair to infer that if a stone be successfully crushed ie a female bladder under such conditions as have been stated. there is not much reason to apprehend danger under ciroum stances somewhat similar, but usually more favourable, in the male ; for in the latter the bladder can rarely be so entirely emptied on the mere introduction of the lithotrite. There is another remark in the observations of Mr. Thompsor which 1 am sure he will thank me for drawing his attention to and correcting. He states that " hitherto all operators* have agreed in recommending that the urine should first be withdrawn ;" and subsequently that from four to six ounces of water should be injected into the bladder, before the introduction of the lithotrite for the purpose of crushing a stone. It is to be regretted that care was not taken to aecertain the practice of the many experienced surgeons of he metropolitan hospitals in this respect, before this statement was made; for while my own practice disproves its accuracy, I cannot but think tbat men of more matured experience than either of us, and with equal if not superior powers of discrimination, may have arrived at results similar to our own. My own experience of lithotrity-first gained in the wards of St. George's Hospital, under the earlier instruction of our great teacher Brodie, and later under the practice of those who worthily followed him, and now matured by not a few years of personal observation-has taught me, as others most also have learned, that there are numerous cases in which patients MfSicted with stone in the bladder cannot retain six or even four ounces of urine at a time ; much less can the introduction of that specific quantity of tepid water be borne, at any rate not until the stone has been once crushed. Such are the results of my personal experience, and such are the principles that have been inculcated on those who have associated with me in our daily work in the wards of St. George's. I see no reason to anticipate that the experience of others, with equal if not larger fields for observation, will materially differ from mine or contravene the statements herein made. The treatment usually pursued by myself in cases of lithotrity is the very simplest that can be adopted so as to obtain the object in view. The patient is requested to retain his urine for a few hours, if possible, prior to the introduction of the lithotrite. At the time of the operation he lies flat on his back, sufficiently low in his bed to ensure the entire trunk being on one plane, that the shoulders be not on a higher level than the pelvis. The pelvis is not raised in any degree above the rest of the body. It is rare that this rule need be departed from. The lithotrite is introduced without any preliminary use of a catheter; and as soon as the stone is crushed as much as may be considered advisable, the instrument is withdrawn, and the bladder left without further molestation for that day. A small dose of laudanum is usually given in warm brandyand-water immediately after the operation, with a view to relieve discomfort and ward off a rigor. Mr. Thompson states that "little or nothing appears to be gained" by the employment of injections afer the crushing of a calculus. If, however, injections are to be recommended or employed, it is certainly after the operation that they appear occasionally and not unfrequently to ensure comfort, and to be attended by advantage. -There are cases in which a catheter must be employed to draw off the urine after a stone has been crushed. A patient is occasionally unable to pass his urine without the aid of an instrument. A patient at present under my care has passed the entire débris of a considerable mass of stone through a catheter, for no urine can be passed otherwise. In such cases the urine is generally alkaline, loaded with ropy mucus, often offensive, and the bladder extremely irritable. Under such circumstances, the comfort and relief from tepid water injections, occasionally used, are so marked that patients have requested me to have recourse to them, when once their efficacy has been experienced, to relieve discomfort and to get rid of fragmens. I only speak of what has occurred to me, but there is no reason why my experience should be exceptional in its results. The catheter through which the blander should be injected subsequent to crushing a stone had better be of the largest size the urethra will admit with comfort, and should be furnished ' with a proportionately capacious and longitudinal eye on the anterior face of the curve. With a large catheter, and through a correspondingly large eye, fragments of stone will more i rapidly pass away than if left to the mere chances of natural escape. As far as my observations extend, the maximum size of cal. , culi which readily pass through the urethra, without mechanical l aid (either of catheter or other instrument), is usually restricted , by the weight of four grains, although occasionally we observe larger ones passed. With the aid of a large-sized catheter (No. 11 or 12), fragments of a heavier weight may be removed r without much difficulty or pain ; but in this respect much more depends on the shape than on thf size nf a cal culus It must, t * The italucs are my own.