(5.) The only other source of obstruction, and not an uncommon one, is by the wall of the bladder, when drawn against the tube with a dull thud, or a rapid succession of jerks, not unlike the bite of a fish. The tube orifice may be moved to another part of the bladder, where aspiration is more free. Perhaps the orifice has been accidentally turned sideways; it then readily engages the floor. Or the walls of the bladder are a little slack, and more water may be advantageously introduced to distend them.1

After a dozen or more aspirations it may be found that all the fragments which can pass the tube have done so, and that many of them have its full diameter. By the usual method of crushing, the lithotrite would now again be introduced, and again be followed by the tube.

LITHOTRITE. (Fig. 8.) — It would be plainly desirable, if it were easy, to crush the whole stone before attempting to evacuate it; but this has hitherto been rarely possible. The lithotrite becomes so choked with impacted debris that the convex surface of the mass less readily receives other fragments. A clean lithotrite always works to best advantage; and the operator frequently withdraws the loaded instrument to evacuate it, sometimes with injury to the neck of the bladder. It would be obviously better, if the instrument could be emptied at will in the bladder, especially if we distinctly recognize that what can be withdrawn in a lithotrite would come through a tube, and that the province of the lithotrite should be to pulverize, or indeed merely to comminute, and not to evacuate.

Although all lithotrites are made a little loose for the purpose of working out the debris, and although I have had one constructed with an especial device for this motion, I do not find it easy to clear the female blade by a lateral movement of the male blade, chiefly because the impaction is so firm that the dense mass, instead of yielding, twists the female blade from side to side. Nor does an instrument like that of Reliquet fulfill the indications. It discharges itself, indeed, as does the

1 The process of evacuation has been improved by repeated experiment since this paper was first published; that here described shortens materially the time occupied in drawing off the debris.

old fenestrated "brise-pierre"; but, as in the brise-pierre, its high sides are an obstacle to the approach of fragments. The male blade also of Reliquet's instrument is that of the lithoclast, and we need only close the blades between the thumb and finger to be satisfied of their scissor-like action upon the bladder.

The instrument about to be described keeps its blades clear, and secures certain other desirable ends pertaining to the injection of water, the lock, handle, etc.

(FIG. 6.)

(FIG. 7.)

(FIGS. 6 and 7.) Position of the hands in holding and locking this lithotrite. Fig. 6. Lithotrite unlocked. Fig. 7. Lithotrite locked by a quarter rotation of the right wrist.

Lock. The general acceptance of the cylindrical handle of

FIG. 8.

Thompson's instrument testifies to its convenience as a hold for the left hand. But it is always a little awkward to disengage the thumb of this hand, or indeed of either hand, in order to close the lock of a lithotrite at the critical moment of grasping the stone. This objection I have obviated in closing the lock by rotation of the right wrist, without displacement of the fingers of either hand. (Figures 6 and 7.)

Wheel. In a protracted sitting the wheel is an inconvenient handle, its chief merit being that it affords so insecure a grasp that the operator is supposed to be unable, with its prescribed radius, to break the blades. But in a larger instrument these blades are stronger, and a ball may be substituted for the wheel. (Figure 8 a.)

Injecting tube. If the sitting be protracted, as proposed, the water dribbles away, and the collapsing bladder, especially if trabeculated, is liable to a serious damage from the lithotrite. To meet this difficulty, my lithotrite contains a tube or groove between the blades for the injection of water without removal. (Figure 8 d.) I formerly injected water by means of a short flat tube introduced into the urethra from time to time by the side of the lithotrite a valuable resource in a long operation.

Blades. The blades of this lithotrite consist of a shoe or female blade, the sides of which are so low that a fragment readily falls or slides upon it; while the male blade, or stamp, offers a series of alternate triangular notches by whose inclined planes the detritus escapes laterally, after being crushed against the floor and rim of the shoe. At the heel of the shoe, where most of the stone is usually comminuted, and where the impact is there

a

(FIG. 8.) Lithotrite by Collin & Cie., from a working model. a. Ball which turns the screw. b. Revolving cylinder-handle attached to the screw-guard, which also revolves. This guard consists of two square or T-shaped rods, which slide through notches in the cap of the lock. By their revolution the cylinder-handle turns the cap and operates upon the lock. c. Cap of the lock, which by its revolution wedges up the screws. d. Injecting pipe communicating with the blades. (This pipe is now omitted as too small for effectual use.)

(FIG. 9.)

fore greatest, the floor is high and discharges itself laterally, while its customary slot (Figure 9 f) is made to work effectively. It may be unnecessary to say that the female blade of the common lithotrite, when drawn from a thin flat plate, as in the French instrument, has a disadvantageous cavity at the heel, where the greatest impaction occurs by gravitation. One of the dangers of lithotrity, which has been already emphasized, is the liability of the bladder to be nipped in the instrument. In view of the character of many of the instruments sold, we might expect to hear more of this accident, although indeed it is a quiet one. It cannot be too carefully provided against, not only by skill in the operator, but also

(FIG. 9.) e. Male blade, presenting on al

ternate sides triangular notches. The small portion of debris not discharged laterally by these notches is driven through the slot in the

female blade. f. Slot in the female blade.

in the construction of the instrument itself, and especially during a protracted operation, while water is escaping and the bladder collapsing. With this object, the shoe is here wider and longer than is usual, to repel the vesical walls. (Fig. 9 f.)

It can hardly be doubted that in practice dexterous operators secure most stones and fragments as they gravitate into the female blade while it depresses the floor of the bladder, perhaps a little to one side or the other, where the stone is felt. A simple and efficient manoeuvre, especially for a small fragment, is that of opening the blades of the lithotrite widely in the vertical position, then slowly turning them to one side and closing them along the floor of the bladder. If, in attempting this, the instrument be opened after it is turned, the male blade displaces the fragment without securing it; and it is of course understood, that, in opening the lithotrite, the blade in contact with the bladder, commonly the female blade, is stationary. The inverted lithotrite works efficiently in a depression, if the bladder be kept out of harm's way by a special device; but with the common lithotrite it is essential to turn the blades up before crushing, and move them, in order to be sure

they are free. Indeed, whatever be the position of the lithotrite, it is important always to give it a little rotation before screwing down, to see if it is free from the mucous membrane. This habit also keeps the operator informed whether he has room, or needs more water in the bladder. In the exceptional case of a stone behind the prostate, it may be necessary to invert the lithotrite and seek it. Fragments, however, are readily washed from this region within reach of the evacuating tube by occasionally turning the orifice and directing the stream from the tube upon them.

While many years ago I had not infrequently prolonged lithotrity to ten or fifteen minutes, and longer, it is only within two years that I have aimed at the evacuation of a considerable stone during a single sitting; and although experience will perhaps be necessary to determine precisely what cases are unfavorable to such an operation, there can now be no question that it is practicable to remove at once a far greater quantity of debris than has hitherto been considered possible. The conditions most favorable to lithotrity are obviously most favorable to this modification of it, a stone neither very large nor hard, and especially a large urethra, promising its best results. But if the preceding views are correct, the future of lithotrity lies in the direction of a fast-working lithotrite, which, while it effectually protects the bladder, is more powerful than the usual instrument, and better proportioned to the work it is to do, a rapid comminution of the stone,its immediate and complete evacuation by means of a large tube with an efficient orifice, while the fragments are at will scattered or gathered, for aspiration, and the ready recognition and removal of any obstruction which delays the process. It will be no longer essential to pulverize the stone, but only to comminute it; and if, in so doing, the lithotrite can be kept free from impaction, the process will be more rapid and efficient.

During the last year I removed by lithotomy two soft stones, weighing 1272 and 1230 grains, from two male adults, aged forty and twenty-four respectively, who recovered after various risks. I now cannot but think that with a tolerably sound bladder, a urethra of good size, a large lithotrite, and a large tube, the operation could have been performed with less risk by the method of lithotrity now described.