Accidents occurring in the course of a lithotrity are fortunately rare, but some have been recorded which may be briefly reviewed.
They may be classified under three headings in connection with (1) the instruments employed; (2) the stone ; (3) the soft parts.
(1) A good lithotrite may break under a strain beyond its power, but I am not acquainted with an instance of serious bending. The lat ter mischance would probably be more awkward than the former. The breaking of a portion of the crushing blades would most likely neces sitate the immediate resort to a perineal or supra-pubic cystotomy. Dr. Vander Veer," of Albany, U. S. A., records an instance in a•male adult operated on by Dr. N. L. Snow, in which the stone was large and hard, and the lithotrite broke " about half an inch from the end, leaving the portions of both blades in the bladder." Lateral lithotomy was performed, and the fragments of stone and portions of instrument were removed. The patient died on the fifth day after the operation, which is stated to have occupied an hour and a half. I have no in formation connected with any important bending of a lithotrite. The impaction of a lithotrite with stone, so as to render the instrument immovable, has been previously illustrated by a case of Mr. Cadge, where the difficulty was safely overcome by a supra-pubic cystotomy. To have attempted to withdraw the lithotrite along the urethra under such circumstances would certainly have been fatal. The eyes of as pirator catheters may be so firmly filled with stone fragments as to impede their withdrawal. When this is the case the instrument should be cleared by means of a stylet. Hence the importance of al ways having the latter at hand.
(2) It has happened in the course of a lithotrity that, by the spas modic action of a powerful bladder, a piece of the broken stone has been so firmly jammed into the deep urethra as to render the further stages of the crushing operation either impossible or hazardous. When this is the case it is better to perform a median cystotomy, either upon the fragment thus impacted, or upon a small staff which may be pasSed alongside of it into the bladder, rather than to perse vere with efforts to force the fragment back.
Small fragments impacted in the urethra may sometimes be re moved by a pair of forceps with crocodile jaws or by gently pushing them back into the bladder, where they can be crushed. Incidentally
I may mention a case recently seen in which a renal calculus was im pacted behind a deep urethral stricture. The stricture was dilated under ether, by the successive introduction of Lister's bulbous metal bougies, up to a No. 12 English size. When the patient recovered from the effects of the ether, he spontaneously passed the boracic solution with which I had filled his bladder with such force as to readily expel the stone. I assume that it must have been lodged there for some little time previously, and so made a depression for itself in the canal, otherwise it would have been pushed back by the intro duction of the boogies. Large or irregular fragments, however, can not with safety be treated in this way.
(3) In connection with the preliminary stages of lithotrity atten tion has been drawn to the importance of endeavoring to avoid making a simple operation a difficult one by occasioning any damage to the parts, sometimes abnormal and obstructive, through which the instra ments, have to pass on their way to the bladder, or in the course of their withdrawal. Any serious damage of this kind would probably necessitate a recourse to some form of lithotomy, as, if the operation of crushing could be brought to a successful issue under such condi tions of difficulty and embarrassment, the prospect of eventual recov ery would be considerably reduced by the complication necessarily attendant upon structural lacerations of this kind. Such complica tions would be likely to be more serious in their results than those usually attending the direct wound—for instance, of a median cystot omy provided with suitable drainage. Instances have been recorded when—from an unnatural thinness of its walls, from spasm, or from an undue amount of force, as, for instance, in the case of a child—the bladder has been ruptured. If the lesion is known to have occurred on the peritoneal aspect of the viscus, a laparotomy with the object of closing the rent would be indicated; whereas if it were, as in a specimen I once saw at a medical society, in the floor, a lateral lith otomy, by providing a means for immediately producing urinary in continence, would give a chance of recovery. A lesion occurring under such circumstances is, however, seldom recognized until after death.