When stone and tumor of the bladder coexist, supra-pubic lithot omy would, as a rule, be indicated in preference to lithotrity, as the former permits of the tumor being explored and removed, if this be found practicable on inspection. In a case of this kind, reported by Dr. Alexander," where he performed supra-pubic lithotomy, and removed a stone from a cancerous bladder, we have an illustration of what, perhaps, is best to be done under these circumstances.
Suppression of urine after lithotrity is a serious complication, and for the most part happens in patients with unsound kidneys when the operation has been of a prolonged character. For the management of this symptom reference may be made to the subject of urethral or urinary fever. As in other disorders, where operative treatment has to be considered, advanced structural kidney disease is unfavorable both for lithotomy and for lithotrity. It is, however, a question of degree, which often requires fine balancing, and where some previous knowledge of the patient and his constitution is of assistance. Whether under such circumstances to remove the stone by lithotrity or by lithotomy, or not to attempt either, are questions involving grave responsibility, which cannot be answered by rules having gen eral rather than individual application. More than one case has come under notice in which I have advised, with regard primarily to the serious state of the kidneys or other vital organs, that the removal of stone should not be attempted, and have had the satisfaction of believ ing that the course adopted has been the means of permitting a per son to live out his days with not more discomfort than surgery could entirely alleviate.
Stricture of the urethra sometimes complicates stone in the blad der. In one instance which I saw, with Dr. E. Adam of Liverpool, of a middle-aged man, where lithotrity was performed, the result was not satisfactory.
Case.—Seven days after the operation, and when the patient had left the Infirmary, rupture of the urethra, behind the stricture, and extravasation of urine suddenly took place and caused death, in spite of incisions wherever the vitality of the tissues was threatened. Though the operation was simple, and the water in the aspirator hardly tinged with blood, it is possible that the manipulations may have further weakened a urethra which had been long diseased, and so contributed to the fatal result. Before performing lithotrity I had dilated the urethra, so that the lithotrite passed readily.
In a similar case, in which the stricture is at all tight or chronic, I should prefer perineal lithotrity, as it is not always possible to avoid the contingency to which all persons suffering from stricture are liable—namely, peri-urethral abscess and extravasation of urine, which in this instance caused the death of the patient, though it might have been entirely unconnected with the removal of the stone.
The presence of saccules or recesses in the bladder offers an obstacle in the way of lithotrity, and where they are known to exist lithotomy, as a rule, is indicated. An extensively sacculated bladder is unfavorable for lithotrity, as though by means of the latter opera tion the stone may be completely removed, the physical condition of the bladder is rarely thereby improved. Saccules may conceal other
stones as well as lodge fragments. I saw an instructive case in the practice of my colleague, Mr. Swinford Edwards, at St. Peter's Hos pital. He had crushed a stone of some size under difficulties arising from a contracted bladder and a large prostate, where considerable time was occupied. Two months afterward, all the symptoms of stone having returned, Mr. Edwards performed median cystotomy and took out of sacs communicating by small mouths with the general cavity of the bladder three large urate stones coated with phosphates. If stones are difficult to find under such circumstances with the fin ger and the forceps, when the bladder is laid open, how can we be surprised if they occasionally escape the reach of the sound or the grip of the lithotrite? I have previously alluded to a somewhat simi lar case where I abandoned lithotrity and by a median lithotomy took out of a sac above the prostate thirty-four stones weighing altogether about an ounce and a half.
On the completion of a crushing operation, the aanount of frag ments removed should be approximately proportioned to the size of the stone, as determined by the lithotrite. This may be estimated by putting the debris in a handkerchief or piece of thin linen, and then screwing it up within the folds so as to form a globular mass. Dr. Alexander '° reports a case of stone with sacculation of the female bladder where vaginal lithotomy was performed, and subsequently ligature and amputation of the sac, with a good effect.
A few remarks may be made in reference to the employment of lithotrity in male children. Having regard to the good results ob tained from lithotomy, it seems almost unnecessary to suggest any other operation. Such was my opinion until some years ago, when I happened:to be examining a number of calculi removed from chil dren which were so small as to be capable of being pulverized by one or two grips of the lithotrite. Working in this direction, and making some experiments with calculi of various size and composition, I came to the conclusion that small stones might, in male children, be readily disposed of with the lithotrite without damage to either the urethra or bladder.
Surgeon-Major Keegan " has added important testimony in favor of litholapaxy in male children, having practised this operation largely in India with results which have been most satisfactory. The experience of lithotomy in children has been so generally favorable that I should not feel disposed to materially extend the limit I have illustrated. Many practitioners, who are expert lithotomists, would fail to find the same success in their application of the crushing oper ation to male children. Some instances have been recorded where the bladder was ruptured in performing lithotrity, and it is probable that we should have further examples of this if the practice were much extended.