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favorable circumstances, such an operation, lasting a few minutes, is not only simple, but, if skillfully performed, safe.

On the other hand, it is not always safe. This is the fact that seems to have arrested so strongly the attention of surgeons. It may happen that during the succeeding night the patient has a chill, not the chill of so-called "urethral fever," which sometimes follows the mere passage of a bougie, and which is of little consequence, but one followed by other symptoms, such as tenderness in the region of the bladder, a quickened pulse, an increasing temperature, and the frequent and painful passage of urine. These symptoms may insidiously persist rather than abate. Others may supervene. The surgeon vainly waits for a favorable moment to repeat his operation; it becomes too evident that the patient is seriously ill, and it is quite within the range of possibilities that in the course of days or weeks he may quietly succumb. An autopsy discloses a variety of lesions, some of them remote or obscure, others of more obvious origin, and among them, not the least common, an inflamed bladder, upon the floor of which angular fragments and chips of stone are resting. It is then evident that during a certain interval before death the bladder was not in a condition for further instrumental interference; and although, in view of the fatal result of delay, lithotomy or active lithotrity, to both of which I have resorted, might have been deemed on the whole the less dangerous, still it is plain that either operation would have furnished in itself an additional cause of serious inflammation.

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Such cases have been supposed to point to the necessity of extreme precaution, as well as of extreme remedies. It is evident that the purpose of such interference at an unfavorable moment is the removal of the offending fragments as a last resource. But if at the first operation the bladder could have been completely disembarrassed of every particle of stone, even with the risk of irritating its lining membrane, we can hardly doubt that the relief would then have been followed by comparatively ready repair. In short, it is difficult to avoid the conviction that in an average case damage to the mucous membrane is as likely to result from irritation by angular fragments, added to the injury inflicted by an opera

tion, as from the use of instruments protracted beyond the usual time, for the entire removal of a stone, if this result can be accomplished.

It is probable that injury from the use of instruments has been confounded with that resulting from the presence of fragments in the bladder. That the average bladder and urethra have no extreme susceptibility is attested by the generally favorable results of lithotrity, and even of catheterism, which are practised with very varying skill everywhere; also by the singularly innocuous results of laceration of the contracted urethra, by an instrument like that of Voillemier, for example; so, too, by the recovery of these organs from the considerable injury inflicted during the extraction of a large and rough stone in lithotomy. The bladder is often also to an extraordinary degree tolerant of the presence even of a mulberry calculus. If we remember that in this case it clasps the stone at every micturition, often with a persistent gripe, the comparative immunity of its tender mucous membrane is quite remarkable. But when after an operation, sharp fragments are thus embraced, presenting acute angles, which do not soon become blunted, and to which the bladder is unaccustomed, it is still more remarkable that serious consequences are the exception and not the rule in lithotrity. Polished metallic surfaces carefully manipulated can hardly do such damage as the other agencies here mentioned.

Gentleness, dexterity, and experience are especially to be valued in lithotrity. If the bladder is pinched, the patient may die. A false passage or a lacerated inner meatus is a serious complication. It has been well said that no novice should undertake this operation. But the habit of confounding the symptoms resulting from the presence of fragments with those following the use of instruments originally led to precautions in the introduction and manipulation of the latter which are sometimes excessive. Civiale, with an almost unparalleled experience, introduced a small lithotrite with much less pressure than its own weight, and with uniform and great slowness. And yet, in a healthy urethra, it is only at the triangular ligament and beyond it that such extreme care is called for. The same author, who had no means of evacuating fragments in the bladder, restricted the length of his operation

to two or three or perhaps five minutes. The like solicitude seems to have led Sir Henry Thompson, in his admirable and standard work upon this subject, to assign two minutes as the proper average duration of a sitting, a period which his exceptional skill has often in his own practice enabled him materially to reduce. I have been gratified to find, however, that since he has availed himself of the advantage of etherization he recognizes the benefit to be derived from somewhat more prolonged manipulation. My own conviction is that it is better to protract the operation indefinitely in point of time, if thus the whole stone can be removed without serious injury to the bladder. I believe that in any case as favorable to lithotrity as the average, in these days when stones are detected early, this can be effected, and that if the bladder be completely emptied of detritus, we have as little to apprehend from the fatigue of the organ consequent upon such manipulation as from the alternative of residual fragments and further operations. The duration of the longest sitting among the cases reported at the end of this paper was three hours and three quarters. The same result can be now accomplished in a shorter time. In a majority of cases the bladder can be completely and at once evacuated. The stone, after crushing, can be removed through the urethra by a tube contrived for the purpose.

But has not this result been already attained by evacuating instruments variously devised and modified? The following quotations from the latest authorities sufficiently answer this question in the negative.

"We may here say, without fear of being accused of exaggeration, that evacuating injections practised after sittings of lithotrity have no apology for their use. The whole surgical arsenal invented for their performance is absolutely useless. It should be well understood that the best of evacuating catheters is worthless." (Article Lithotritie, by Demarquay et Cousin, in the Nouveau Dictionnaire de Médecine et de Chirurgie Pratique. Paris, 1875. Pages 693, 694.)

"The practice of injecting the bladder to wash out detritus is obsolete. This apparatus of Mr. Clover should not be employed, if it is possible to dispense with it, as its use is quite as

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irritating as lithotrity itself." (S. D. Gross, Diseases, etc., the Urinary Organs. Philadelphia, 1876. Page 232.)


Having used it [Clover's apparatus], very frequently, I would add that it is necessary to use all such apparatus with extreme gentleness, and I prefer to do without it, if possible." (Sir H. Thompson, Practical Lithotrity and Lithotomy. 1871. Page 215.)

"All these evacuating catheters are little employed. They require frequent and long manœuvres, which are not exempt from dangers; besides, they give passage, as a rule, only to dust, or to little fragments of stone, which would have escaped of themselves without inconvenience to the urethra." (Article Lithotritie, by M. Voillemier, Dictionnaire Encyclopédique des Sciences Médicales. 1869. Page 733.)

In short, the "evacuating apparatus" and the evacuating method hitherto employed do not evacuate. This fact is beyond question.

Such apparatus is not of recent contrivance. From the earlier days of lithotrity, the operation of breaking the stone has been followed by the obvious expedient of introducing a large and special catheter, through which water was injected and allowed to escape, bringing away a little sand, with a small fragment or two. This attempt at evacuation was aided by suction. With this objet, and before the year 1846, Sir Philip Crampton employed an exhausted glass globe. For the same purpose a syringe has been used, or a rubber enema or hydrocele bottle, with which fluid could be also injected and the bladder washed. By entering the catheter well within the bottle or syringe, fragments were dropped inside the neck, where, lying below the current, they remained when the bottle was again compressed. When this neck was made of glass, by Clover, the fragments became visible, as in Crampton's globe, and to this neat arrangement the accomplished lithotritist, Sir Henry Thompson, refers as Clover's bottle. But neither the previous practice nor the efficiency of evacuation by suction through a tube had been materially advanced. In the mean time the syringe was modified in France by a rack and pinion attached to the piston, so that water could be injected and withdrawn with great force, a procedure not only useless, but detrimental to the bladder, if inflamed and thickened.

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Before describing my own instruments, it may be well to say a word in regard to the introduction of large instruments into the bladder. The successful introduction of the large straight tube is so important that it deserves especial mention.

A syringe facilitates the copious use of oil both in the urethra and within the tube. Into the normal urethra a straight instrument can be introduced with more accuracy than a curved one. Either may be passed rapidly as far as the triangular ligament, unless the instrument is very large, in which case great care is required not to rupture the mucous membrane. Having reached this point, which implies that there should be no premature endeavor to turn the instrument, but that it should be passed as far as it will go in the general direction of the anus before its direction is changed, the extremity of the instrument depresses the floor of the urethra in front of the ligament. Traction upon the penis next effaces this depression, and adds firmness to the urethral walls; so that if the instrument be withdrawn a little, and again advanced after lowering the handle, it can be coaxed without difficulty through the ligament in question, a natural obstruction which physicians often mistake for a stricture. The straight tube may be advantageously rotated through the aperture like a corkscrew. This obstruction passed, the rest of the canal is short, and corresponds to the axis of the body, to the line of which the instrument is now depressed. Even the enlarged prostate can often be traversed advantageously by a straight instrument. In fact, the metallic prostatic catheter, before it was superseded by the modern rubber one, consisted essentially of an inch or two of straighter tube added to the extremity of a common catheter, to reach through the unyielding prostate before the hand was depressed and the beak turned up. In passing either a sound, catheter, or lithotrite, the extremity of a straight instrument, and, curiously enough, the convexity of a curved one, is sometimes arrested just at the entrance of the bladder by the firm lower edge of the inner meatus. The fact that water now dribbles through the inner meatus thus dilated, or that a stone is felt with the tip of the curved instrument, which has really entered the bladder, may lead the operator into the mistake of supposing that the instrument is

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