Elements of Surgery

by Robert Liston

On one occasion, when practising the operation on the dead body, I found that the instrument had got several stones in its grasp, and was kept so dilated as to be withdrawn with much difficulty—there being no means of disentangling the stones but by farther expansion of the blades, which was impossible. A great many foreign bodies—pieces of pebble—had been introduced; but had the same number of urinary concretions been laid hold of—which is scarcely possible—those farthest from the point and most compressed would have crumbled down, and thus the expansion of the blades would have been diminished. I have not experienced the least difficulty in operating with this instrument, in numerous cases, and at all periods of life. The preferable instrument for the purpose is, however, the small screw scoop. The concretion can by its use be crushed and reduced in volume, so that the urethra does not suffer in the extraction, and the patient is saved much pain. The safety of the proceeding is its greatest recommendation. It is very seldom that any unpleasant symptoms follow; there may, perhaps, be a trifling effusion of blood, and some slight pain in making water may continue for a day or two. Should either irritability of the bladder, or symptoms indicating inflammation of the mucous coat supervene, these must forthwith be combated.

Concretions of such a size as cannot be made to pass through the neck of the bladder, and along the urethra, and yet are not much larger than a filbert, may, if soft and friable, be laid hold of in the bladder by properly contrived instruments, and acted upon so as to be reduced to powder and fragments, which may either pass off along with the urine, or be extracted by means of forceps. This proceeding is not advisable in children, owing to the small size of the parts and their greater irritability, and in consideration also of the concretions in them being in general exceedingly dense; as formerly noticed, they are most frequently composed of the oxalate of lime. In the adult, it cannot be adopted with safety and propriety, when the bladder is irritable and will not bear a certain degree of distention, and when the prostate gland is large. The cases in which the concretion is small, soft, or brittle, and the parts sound and free from irritation, form but a small proportion of those labouring under stone who present themselves to an operating surgeon. However, the bruising, grinding, and rubbing down of stones has been tried in all kinds of cases, but with neither a satisfactory nor an encouraging result; a case will now and then be met with favourable to these proceedings, but they can never become generally applicable, and attempts to make them so will, as experience has shown, be followed by disappointment and disaster.

A stone of a larger size than I have indicated, and of dense structure, may be laid hold of in the bladder, and may by repeated and tedious operations be broken into fragments; but each sitting, as it is called, of the patient, and each attack upon the stone, is attended with more pain, greater risk, and far more exhaustion, than its removal by incision would inflict. The repeated introduction of the instruments, their expansion, and the turning of them about in the bladder, and, if their object is accomplished, the action of the angular and rough surfaces of the fragments on the mucous coat, are certainly followed by an attack of inflammation of the viscus, always tedious and annoying—often excruciating, dangerous, perhaps fatal. Attacks of inflammation of the testicle are also not uncommon, probably from irritation of the prostate, and from the pinching and bruising of the verumontanum, which it is almost impossible to avoid, whatever care and precaution be adopted, when the three-branched instrument is used. In turning to the records of Lithotrity—and under this term we shall include all attempts to break down stones within the bladder, whether by drilling, or filing, or hammering—it will be found that many patients have died from the mere exploration; and altogether, nearly a half of those who have fallen into the hands of the experimenters and adventurers have perished in consequence. Every successful case is well advertised; the dead men rest in peace.

But still the operation of breaking up a stone in the bladder is very advisable in certain cases, and may be resorted to with every prospect of a safe, speedy, and successful conclusion. But it can be recommended and employed only within certain limits; the case must be well chosen, and every circumstance must be perfectly favourable as regards the condition of the urinary passage and of the bladder, and the size and nature of the stone. Every operating surgeon should make himself well acquainted with the instruments and their mode of application, so that he may resort to them as occasion requires.

A great deal of ingenuity has been expended of late years in inventing and improving upon the apparatus. Many useless, inapplicable, and highly dangerous machines have been produced, a few efficient and perfectly safe.

The knowledge of the fact that the curvature of the urethra can be effaced, and a perfectly straight instrument, or one with a short curve can be passed into the bladder with equal ease and freedom from uneasiness as a largely curved one, has facilitated very much the application of means for seizing and acting upon a stone in the bladder.

The three-branched instrument, which it is unnecessary to describe, as it can be readily seen and obtained, can be without difficulty brought in contact with the stone, the bladder being partially distended by urine, or filled to the requisite extent by tepid water injected through the outer canula of the apparatus. The branches are then so far expanded, and the drill withdrawn; and by a little cautious management, turning the instrument, altering the degree of expansion, and sounding with the drill, the stone is seized, and then fixed by pulling back the inner canula. By turning the drill with the fingers, and pulling back forcibly the inner canula so as to close the branches, the concretion may at once be pulverised; or it may be again seized, and attacked by the drill on a different side. The operation may, if necessary, be repeated after the lapse of eight or ten days, or sooner, if the irritation caused by the former have subsided. Diluents are to be given so as to facilitate the washing out of the detritus, and strict rest and abstinence from stimuli must be observed for a few days.

Various forms of drill have been contrived for acting on a large surface of the stone; others for scooping it out, the shell to be afterwards broken into fragments and triturated; they are all unsafe and ineffectual. The instrument is also so constructed that a drill-bow may be used, and the apparatus may be fixed by what mechanics call a bench, or it may be attached, by complicated machinery, to the table on which the patient is laid, and be there secured in a proper position. But all this implies an intention of attacking large and dense stones, and a repetition of the attempts. So far as my experience goes—(and besides having seen Civiale and others operate, I have myself employed the instruments in many cases, and very successfully,)—I should dissuade from all endeavours to rid the patient of stone by such means, unless its size and consistence were such that it would yield to one or two attacks.

A plan of crushing the stone, by forcing one part of an apparatus against another by the stroke of a hammer, has been lately promulgated, and by a person who previously maintained that the grinding and rasping was quite perfect, though now regarding them as nought. This percuteur has a short bend at its farther extremity, one-half separates from and slides on the other, and both are provided with teeth. It is very possible to entangle a portion of the bladder betwixt its blades; and, besides, these may bend or break, as they have done in several very bad and abominable cases, in which incisions were required to disengage the instrument from the patient’s urethra or bladder A stone may also be laid hold of by the apparatus, and being so hard as not to yield to the impulse of the hammer, may become fixed in such a way as it cannot be freed from the grasp, there being no provision for pushing it out as in the lithotriteur.

It will be seen from what has been stated, that I am not so sanguine—and I trust I shall be excused of presumption in giving an opinion upon the subject—as to suppose that the breaking up of the stone in the bladder will ever entirely supersede lithotomy. That it would do so was at one time industriously represented, and perhaps believed, by some of the advocates and promoters of lithotrity. If, by some miraculous interposition of Providence, the deposits from the urine should uniformly be pulverisable, and that bladders be made of less irritable stuff than they are, and if, above all, the affected individuals could only be prevailed upon to apply in due time, then might such pleasant anticipations be entertained, and then might we with some reason hope to see them realised; but as matters now are, urinary concretions must, in a great many instances, be cut out of the bladder. Nor is it a circumstance to be very much deplored, since, in good hands, the patient neither endures so much suffering, nor incurs so much risk, as by the proceedings already detailed. The cure, besides, is far less tedious. The stone-grinders, whilst they conceal their own unfortunate results, endeavour to depreciate lithotomy by blazoning abroad the practice of some unlucky surgeon, who, perhaps, loses four in twelve, or six in twelve, of the patients who come under his knife.