The two chief methods may be described as the English and the French, the latter, Civiale's, being now used by Sir Henry Thompson, and other English operators. Briefly, the two are:—
(1.) Heurteloup's and Sir B. C. Brodie's.—In this, after the instrument is fairly entered, its handle is elevated, thus depressing the curved extremity, the forceps are then opened, and, by being kept as low as possible in the bladder, it is hoped that the calculus will fall into the opened blades by its own weight. In this method the fundus is the scene of crushing, and there is a risk of injuring the sensitive neck of the bladder, especially at the moment of opening the blades.
(2.) Civiale's—Thompson's.—In this the pelvis is to be so elevated that the centre of the bladder and space beneath it give plenty of room for seizing the stone, and all contact with the wall of the bladder is (as far as possible) avoided.
The instrument is introduced closed, and carried fairly away in to the posterior part of the bladder before it is opened at all. It probably grazes the stone in passing, and, if so, is directed to the side of the bladder in which the stone is not lying. Then when nearly touching the posterior wall, the movable blade is withdrawn, the instrument inclined towards the stone lying unmoved in the most dependent part, and there seizes it generally with ease.
If not felt, the blades are again to be opened, turned a little to the other side of the bladder, and then closed. Sir H. Thompson lays the greatest stress on the importance of always having the blades fairly opened before shifting their position, for if moved when closed, the very opening of the movable blade is certain to drive the stone out of the way and prevent its seizure.
Certain rules are useful:—Move the axis of the instrument as little as possible; it should be kept in the centre of the bladder, so far in, that the movements of the male blade are quite free from the neck of the bladder and prostate, and the blades only should be moved in the bladder on the centre of the shaft as an axis. There should be no jerking once the stone is caught, and the crushing should be done as far as possible in the very centre of the bladder, the blades not touching any of the walls.
After the stone is seized, do not crush till, by a turn of the blades from side to side, you discover that none of the mucous membrane of the bladder is caught in the instrument.
The lithotrite is not meant to extract stones, but to crush them, hence never attempt to withdraw it unless the blades are in absolute apposition.
Never attempt too much at one time. Sir H. Thompson holds that five minutes is the longest time that should be given, perhaps in most cases three minutes being long enough.
While many surgeons will still agree with the above advice, Dr. Bigelow of Boston has lately been highly commending a method which he has called Litholapaxy, in which, at one sitting under chloroform, the stone is crushed and aspirated, or sucked out of the bladder at once.[152]