THE RECURRENCE OF STONE AFTER OPERATION.
I will now pass on to consider one of the most important points in connection with the history of stone in the bladder; I refer more • particularly to those instances where recurrence takes place after operation. It will be remembered by those who have watched the course events have taken, more especially in connection with the re moval of stone by crushing, that though this operation had made considerable progress in many of its details a few years ago, the views of surgeons were by no means unanimous as to its great superiority over lithotomy, except in the case of comparatively small stones in bladders that were not otherwise disordered. In a discussion `" which took place about the time when the old method of operating by nu merous sittings was giving place to Bigelow's procedure, it was evi dent that lithotrity was not growing in. favor. This was due not to any excessive mortality, or to any special difficulties connected with the operation, but to the fact that, even in the most competent hands, it failed in a considerable proportion of instances to give immunity from recurrence. Nor was there any desire to exaggerate this fact, for, as Sir James Paget observed in the discussion referred to, the proportion of relapses would have been considerably increased if the period of probation subsequent to the operation had been extended from a few weeks to at least a year. Speaking on the same occasion, Mr. Cadge remarked to the effect that it would be necessary to include the results of lithotrity under three headings, namely, those persons who were cured, those who died, and those who did not eventually recover. It was hoped that the new method of operating, which was then coming into vogue, by securing a more rapid and complete evac uation of all fragments from the bladder, would materially mitigate this acknowledged defect. Turning to the address of Mr. Cadge (1886), one of my predecessors in the Hunterian Chair at the Royal College of Surgeons, which was delivered seven years after Bigelow's operation had been introduced, and after a fair trial of the new opera tion in a sphere presenting almost unique opportunities for observa tion, we find he referred to this point in the following words: "Al though the immediate and direct mortality of lithotrity is small, the recurrence of stone is lamentably frequent. In my own list of 133
cases there were 18 in which recurrences one or more times took place, being about one in seven. Sir Henry Thompson, with a much larger number of cases, gives about the same proportion. I am dis posed, however, to infer that recurrence is more frequent than this." I am not aware that the accuracy of this statement has been chal lenged or that anything has since arisen to question its application to what now exists. If my own experience had not furnished me with a text, I should have found it in these weighty testimonies. In pro ceeding to consider the circumstances under which these recurrences take place, I need hardly observe it is not with an intention of dis paraging lithotrity or of upholding lithotomy, but with the object of finding a remedy for defects which cannot fail to be admitted by a candid observer. The due recognition of the considerable mortality that formerly prevailed, and its probable cause, doubtless led Bigelow in the direction of making such improvements as almost entirely to remove at one sweep the chief risk connected with the performance of lithotrity.
From a lay point of view the recurrence of stone after it has once been supposed to be removed is usually regarded as evidence that the operation performed was in some way or other defective. This con clusion is based on an idea that a calculus in the bladder always bears some resemblance to a stone in a box, and that consequently the conditions associated with its removal are of a mechanical and constant nature. A slight acquaintance with the circumstances at tendant upon operations for stone, combined with a knowledge of the pathological changes the bladder often undergoes, is sufficient to show that such a simile is of limited application, and that other con ditions often coexist which are not sufficiently taken into account. The contrast between the ideal (Fig. 65) and the real bladder (Fig. 66) containing a stone may, without exaggeration, in some el derly persons, be approximately shown in the sketches I have drawn. These may also be useful in indicating some of the different circumstances under which washing out of the bladder has to be undertaken.