In reference to the immediate after-treatment of lithotrity there is not much to be said. A successful operation now leaves little more to be done than what is included under the terms warmth, rest, care ful nursing, suitable diet, and a complete discharge of urine at regu lar intervals. If the operation is followed by some degree of local in flammation and there is reason to suspect the presence of fragments, their immediate withdrawal is the proper course to take. The possi bility of such a contingency as incomplete removal must be recognized in connection with lithotrity, since some part of the bladder may be rendered difficult of access. It should not be forgotten that a stone is a foreign body which, to a certain extent, the bladder has learnt to tolerate; but a broken calculus, combined with the circumstances at tending its fracture, is capable of exciting the most urgent signs of its altered shape.
After lithotrity care should be taken to see that the urine has returned to a normal condition, both in appearance and composition, before the case is considered as completed. This is more particu larly necessary in those instances where, in addition to the stone, the case is further complicated by a large prostate, a pouched or saccu lated bladder, or such a state of atony as to render the patient more or less dependent on the catheter. The urine should be clear and free from evidence of shreds or masses of lymph, like feathers, since these are capable of providing not only material for decomposition, but for the aggregation upon them of phosphatic particles. A clean blad der and clear urine present conditions under which it is almost im possible for a recurrence of triple-phosphate stone to take place. Until these conditions are secured, attention to the toilet of the blad der may be required as referred to.
When after lithotrity the urine remains loaded with mucus, bene fit is often derived by injecting into the bladder, with a rubber catheter and glass syringe, a watery solution of nitrate of silver in the pro portion of half a grain to the ounce. Two or three ounces of this may be used and a portion left behind in the bladder, for voluntary expulsion. For a similar purpose acetate of lead, half a grain to the ounce of water, or dilute nitric acid, one or two drops to the ounce, may be employed until the excess of mucus is removed. If after a lithotrity symptoms of vesical irritation continue, such as frequent or painful urination, disordered urine, and the like, the surgeon, in his patient's interest as well as his own, will do well not to permit treat ment to be concluded without a thorough examination of the bladder under an anesthetic. Fragments may escape notice at the time of the operation, or concealed stones may be extruded into the general cavity of the bladder from pouches and depressions where the 'instru ment could not reach, which if allowed to remain would rapidly repro duce the original state of things. This is specially of importance to
remember where the prostate is more or less enlarged. Such a safe guard as this can in no way reflect on the skill of the surgeon, while the patient is protected from the possibility of an oversight. It is a provision for making doubly secure which no prudent operator or re flective patient can take exception to. Lithotrity in elderly men with enlarged prostates and partially atonic bladders is occasionally followed by a complete and permanent dependence on the use of the catheter. Some bladders positively seem better able to discharge the urine they contain when a stone is present, reminding one somewhat of the old fable of the stork and the narrow necked-pitcher.
Since the introduction of Bigelow's method of operating, the mor tality as well as the period of convalescence connected with the oper ation have undergone considerable reduction. It is not unusual to meet with instances in which recovery may be said to be completed within a week, even when stones of a considerable size and hardness have been removed. Without going into statistics, there is no doubt that the mortality connected with lithotrity is not only very small, but has been much reduced since the adoption of the Bigelow method. If stones were dealt with in this way when as yet small, it would be practically nil. Phlebitis after lithotrity is now rarely seen, owing to antiseptic precautions and improved instruments.
I think it will be generally conceded that, for all calculi of a mod erate size occurring in otherwise healthy male adults, lithotrity is the treatment which will give the best results with the least risk to life. Where stones are unusually large, or complicated with disease in the urethra, prostate, bladder, or kidneys, it. cannot be said that there is a consensus of opinion as to the best method of procedure. When calculus is associated, as is often the case in elderly men, with en largement of the prostate, unless this is considerable or unusual, lith otrity is not contra-indicated, though if there is much difficulty in finding or handling the stone with the lithotrite, it may be expedient to substitute lithotomy. Under the same condition, an inability to discharge the urine from the bladder spontaneously may be a reason why it is safer to discard lithotrity. In the after-treatment of lithot rity, when the bladder is atonic or much pouched above the prostate, I make the patient lie on his belly for some time every clay after the bladder has been emptied. This has often proved of service in pro moting both the drainage and contraction of the pouches, and is sometimes combined with the local use of nitrate of silver as pre viously described.