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LITHOLAPAXY V. THE SUPRAPUBIC OPERATION.

To the Editor of " The Indian Medical Gazette."

Sir,?The long and interesting article which Dr. Keegan contributes to your August number on the work of Assendelft in particular and operative methods of dealing with stone in the bladder in general is very opportune and instructive, so well and so considerably does he put the case that I feel sure every surgeon in India with largo experience in this field will endorse his views. There is no doubt but that Assendelft lias attained great success

and proficiency in the suprapubic operation, and his work is most useful in showing us that we need not despair of attaining to improved results in the cases which we must relegate to this operation for one reason or another. In comparing litholapaxy and suprapubic lithotomy even if it were admitted that the

mortality is the same what a contrast there is between a residence in hospital of about 60 days painfully spent in

_ a constrained

position in the one, and about four days of relative comfort in the other. There is another point which I laid stress^ on in my contribution

to the Stone Number and elsewhere, which is of importance in this discussion, and regarding which Assendelft from his very extensive experience could doubtless enlighten us, viz., the chances of a

functionally impaired bladder resulting from the high operation where an incision is made which surely results in a rigid cicatrix in its most contractile part, and in some cases where healing is slow and unsatisfactory does it never happen that the bladder unites in healing with the surrounding tissues in a common cicatrix, giving the organ a second fixed point which would effectually interfere with its contraction and the expulsion of its contents ?

Assendelft's admirable work is somewhat discounted by the number of cases he sent away unoperated on ; also by his being unable to determine whether two patients had really stone or not inasmuch as they were suffering from cystitis.

I think that it is most probable further that he, like most of us who have had considerable practice in stone districts in this country, has failed to diagnose and extend his admirable skill to the relief of an allied affection, viz., stone in the kidney, and that the 13 patients who had all the symptoms of stone in the bladder but in whom none could bo detected and were discharged suffered from this daDgerous but remediable affection.

354 THE INDIAN MEDICAL GAZETTE. [Sept. 1901.

I attach the greatest importance to Assendelft's method of

placing his patients in the prone position after operation, thus ensuring complete drainage, and am inclined to attribute to it much of his great and unusual success. In my own limited

experience of the suprapubic operation in which I did not a<lopt or think of this plan, my patients suffered greatly from the defective drainage, the urine welled out into the dressings and irritated the surrounding skin, a considerable portion remaining in the bladder, and the wound, causing not only discomfort, but seriously prejudicing recovery. With regard to the vexed question of liability to recurrence,

iJr. Keegan puts the matter very fairly, with an experienced litholapaxist the chances of a particle remaining behind which forms the nucleus for a fresh concretion are practically nil, and when recurrence of this kind does occur, the symptoms will be found never to have been entirely recovered from after the operation, the patient will have cystitis, and the new concretion will be phosphatic, whatever the composition of the original stone. As Keegan rightly points out recurrence is generally the result

of a new nucleus descending from the kidney, an occurrence which should always be expected unless the diathesis bo removed. If any considerable period elapses when the patient is entirely free from symptoms of irritation following a litholapaxy it may be fairly assumed that no particles remained, and if a recurrence took place even three months after it should not be presumed, in the absence of bladder irritation meantime, that any particles wore left behind.

Yours, &c., J. A. CUNNINGHAM, m.d.,

Major, I. M. S. Delhi,

4tli A ugust, 1901. )