Birmingham Medical Review

DR. Bigelow has taught the profession that litholopaxy is the procedure for the removal of stones from the bladder, and that none other should be thought of in any case until the surgeon is confronted by some contra-indicating circumstance. Unfortunately the obstacles to litholopaxy are many; a large number of vesical calculi therefore will still have to be dealt with by other means. My remarks will be confined to stone as it occurs in the male, and it will be well at the outset to enumerate the circumstances under which Bigelow's operation is inapplicable. Firstly, those negativing conditions of the stone itself, as large size, excessive hardness, multiple number (when they amount in the aggregate to a considerable mass), and, lastly, encysted stones. Secondly, anatomical conditions, such as stricture and enlarged prostate. Thirdly, advanced kidney disease, where the prolonged administration of ether is likely to be dangerous; and, lastly--the largest class of all ---calculi in boys. With regard to the latter, the recently published results of the work of Surgeon-Majors Keegan and Fryer in India, make

* Paper read before the Midland Medical Society, Feb. 29. 1888.

it probable that many stones in boys will, in the future, have to be dealt with by litholopaxy; setting aside these, however, there still remain a large number for the cure of which the profession is not yet unanimous in its opinion as to the best procedure. There are three claimants in the field at least : lateral, median, and suprapubic lithotomy. My own experience suggests that to each might legitimately be allotted a share of the residuum. To the lateral operation I would assign stones of moderate size, which are very hard or multiple ; and those cases complicated by advanced kidney disorder, or by stricture. To median lithotomy, small stones in small children only, and the remainder, large stones, encysted stones, and stones associated with enlarged prostates to suprapubic lithotomy.

The six cases detailed at the end of this paper have occurred during the past 18 months : they do not include all my lithotomies for this period, and although I might not now elect to deal with the whole of them by the suprapubic incision, there were circumstances in each, at the time of operation, which led me to adopt it in preference to perineal lithotomy.

Suprapubic lithotomy was probably the first operation practised for the removal of a stone from the bladder. It has been revived, and has fallen into disuse again and again, and not until quite recent times has it ever taken a tight hold of the operating surgeon's fancy; probably because its frequentlyoccurring wound of the peritoneum and injury to the pelvic connective tissue gave the operation a higher death-rate than attended incisions through the perineum. It was not until Peterssen, of Kiel, systematised a plan by which danger could be reduced to a minimum, if not altogether avoided, that the operaion came seriously into competition with Cheselden's laterallithotomy. Our countryman, Garson, demonstrated by experiment, several years ago, how the peritoneal reflection was lifted up from the pubes during combined rectal and vesical distension; but no particular notice seems to have been taken of his observations. Whether Peterssen worked out the matter for himself or took advantage of Garson's publications there is no need to discuss,

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Birmingham Medical Review, Bind 24