(FIGS. 10 to 14.) Plaster casts of bladders variously distended, and holding instruments to show the effect of a slight pressure in indenting the floor of the bladder in order to facilitate the approach of fragments. The dotted line near the summit of each represents the level of an air cavity, which makes it possible to place the cast in the exact position it occupied in a horizontal subject.

(FIGS. 10 and 10a.) Side and front views of a distended bladder of singular symmetry. The original suggests in profile the torso of a Silenus, the pectoral pouches overhanging the pubes, the abdomen beneath the symphysis, while the hollow loins were cushioned on the sigmoid flexure which indented them. The extremity of a curved tube is seen below, at the apex of an inverted tunnel, and just above it is a trace of the vesical valve. These figures are one fifth larger than the rest.

(FIGS. 11 and 11a.) A less distended bladder, containing a straight tube which indents the posterior wall.

(FIGS. 12 and 12a.) A bladder with a curved tube brought forward behind the prostate, slightly indenting the floor.

(FIGS. 13 and 13a.) A bladder containing a large lithotrite, which has so depressed the floor that the posterior wall rises perpendicularly.

(FIG. 14.)

(FIG. 14a.)

(FIGS. 14 and 14a.) A bladder with a very small injection, imprisoning a lithotrite.

We get a useful view of the interior of the bladder by examining it in position through an opening in its summit. This part of the organ, with the free and thin posterior wall, is mainly concerned in distention. The floor of the bladder is comparatively firm and flat, and, if the subject be in good condition, adheres to a thick mass of cellular tissue in and near the ischio-rectal fossæ, upon which it rests. This mass is traversed by the rectum variously distended; and this canal, in a thin subject, may be advantageously filled with air during an operation, to facilitate its indentation by an instrument,―reversing, for the operation of lithotrity, one of the precepts of lithotomy.

The sigmoid flexure is largely concerned in compressing the bladder behind. The posterior wall of this viscus may be so crowded by the intestines as to become flat, or even concave. A horizontal section of the bladder is then transversely oval, flattened between the intestines behind and the pubes in front, each of these indenting it. A well-filled or tense abdomen tends so to shorten the antero-posterior diameter of the bladder, that, while a large stone may gravitate backward into that part of the bladder which is compressed by the intestines, carrying the thin wall with it, it is not so with a small fragment, which, unless the floor be artificially depressed, may lie on one side or the other of the vesical orifice more readily than at a considerable distance behind it. So, in sounding with a curved sound, it may sometimes be a little difficult to move the instrument back and forth in the urethra, when its extremity may be readily turned down upon the floor of the bladder on either side. It is seen also, (Figures 11, 13, 14,) as a result of this conformation, that a lithotrite or straight tube, standing at an angle of forty-five degrees with the recumbent body, abruptly buries its extremity in the floor of the bladder near the foot of the posterior wall, which then becomes more upright, and does not lie upon the centre of an extended concave surface, as sometimes represented. The deep pit at the extremity of the straight tube, and the similar depression made further forward by the curved and inverted tube, (Figures 10 and 12,) show how readily fragments can be made to gravitate to the lithotrite, or to the tube orifice,

provided the latter be not plugged by the mucous membrane. The curved tube, when inverted, rests on the adherent floor; but the straight tube, bearing upon the free and thin posterior wall (Figure 10,) should not be urged too forcibly against it. In either case, the nearer the instrument approaches a vertical position, the deeper will be the indentation. A pit of this sort, formed in the elastic floor by an almost insensible pressure of the instrument, explains the observation of Thompson, that, when a fragment is caught by the lithotrite, many more are likely to be caught, like fish, in the same place. A central indentation of the floor also explains how, in certain cases of large stone, a lithotrite or sound may be passed back and forth beneath it without touching it, unless the beak is tilted up. The stone may then seem to adhere to the upper wall of the bladder, and to be suspended from it.

CASE I. December 14, 1875. Age, sixty-four. Date of symptoms, six years. Two or three stones, measuring from half an inch to more than three-quarters. Three sittings. First sitting: no fragments were removed through a tube. Second sitting: interval, seven days; duration, forty-five minutes, under ether; quantity removed, " a large mass of fragments"; size of tube, twenty-seven. Third sitting: interval, twelve days; quantity removed, "a few fragments." Result: the patient was discharged, well, one week after.

CASE II. May 15, 1876. Age, sixty. Date of symptoms, twenty years. Two stones, of one and one-quarter inches and three-quarters of an inch diameter, respectively. One sitting: duration, one hour and a half, under ether; lithotrite introduced three times; quantity removed, one hundred and sixty-seven grains; size of tube, twentynine; there was afterwards a slight cystitis; no fragments were passed; in two weeks the patient was again sounded, and no fragments were found. Result: discharged, well.

CASE III. August 6, 1876. Age, sixty-two. Date of symptoms, eighteen months. Several stones, none larger than three quarters of an inch. The patient was confined to the house, in great pain, drawing his water every half-hour or less. The prostate was unusually large. One sitting: duration, about one hour and three-quarters, under ether; size of tube, twenty-nine. He afterwards passed a few grains of sand only. Result: no unfavorable symptoms; almost entire relief from pain; later, no difficulty in retaining water, but

continues to pass a catheter; gained flesh and former health, and resumed avocation.

CASE IV. December 14, 1876. Age, sixty-six. Date of symptoms, two years. Single stone. One sitting: duration, about an hour, under ether; quantity removed, one hundred and eleven grains; size of tube, twenty-eight. Result: the patient did well for two days; then there was a chill, with higher temperature; pain in the back, and pain referred to the left hip; a gradually failing pulse; moderate meteorism, with but little tenderness; death on the sixth day. An autopsy was not permitted.

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CASE V. January 8, 1877. Age, fifty-five. Date of symptoms, one year. Single stone. 'A severe chill followed the primary examination." Seven days after, the meatus was incised and enlarged from 28 to 31 Charrière. One sitting: diameters of stone, ten to twenty millimetres; duration, one hour, under ether; size of tube, thirty-one. Result: no sand nor fragments were afterwards passed; nor were there any subsequent symptoms.

CASE VI. April 21, 1877. Age, forty-three. Single stone, with nucleus of dead bone. Five years ago the pelvis of this patient was crushed. Sinuses, discharging dead bone, opened on both hips. Six months after the injury, symptoms of stone existed. One sitting: duration, one hour and a half, under ether; meatus incised; size of tube, thirty; quantity removed, sixty-six grains, and also three small pieces of bone, doubtless nuclei, one of which was incrusted; an indurated spot was detected by the tube, where the bladder seemed to adhere to the pelvis. Four days after, under ether, the lithotrite brought away, with difficulty, through the urethra, a square scale of bone, too elastic to be broken, measuring five-eighths of an inch by seven-sixteenths, but neither sand nor fragments. Result: there were no unpleasant symptoms at any time; and after another careful examination for bone, the patient was discharged, well.

CASE VII. (Dr. T. B. Curtis's case.) March 6, 1877. Age, fiftyfour. Date of symptoms, two years. Single stone. One sitting: diameter of stone, one inch and a quarter; duration, one hour and twenty-five minutes, under ether; lithotrite introduced three times; size of tube, thirty-one; quantity removed, when dry, two hundred and fifty-seven grains; the six largest fragments weighed together twentyfour grains; the strained urine yielded, during the next week, two and one-half grains. Result: rapid recovery, with no subsequent symptoms.