(FIG. 8.)

lithotrite it is important to turn the blades up before crushing, and move them, in order to be sure they are free. 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 unfrequently 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 long 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 débris 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.

(FIG. 8.) e. Male blade, presenting, on alternate sides, triangular notches. The small portion of débris not discharged laterally by these notches is driven through the slot in the female blade. f. Slot in the

female blade.

During the last year I removed by lithotomy two soft stones, weighing 1272 and 1230 grains, from two male adults aged forty and twentyfour years 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 lithotrity.

bladder by examining it This part of the organ,

We get a useful view of the interior of the in position through an opening in its summit. 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 sub

ject 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 that it becomes 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 (see Figures 9 to 13), 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 is 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 (see Figures 9 and 10) 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.

NOTE. The lithotrite and the evacuating apparatus are manufactured by Tiemann & Co., New York.

(FIGS. 9 to 13.) 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 the horizontal subject.

(FIGS. 9 and 9a.) Side and front view of a distended bladder of singular symmetry. The original suggests 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 a trace of the vesical valve.

(FIGS. 10 and 10a.) A less distended bladder containing a straight tube which indents the posterior wall.

(FIGS. 11 and 11a.) A bladder with a curved tube brought forward behind the prostate, slightly indenting the floor.

(FIGS. 12 and 12a.) A bladder containing a large lithotrite, which has so depressed the floor that the posterior wall rises perpendicularly.

(FIGS. 13 and 13a.) A bladder with a very small injection, imprisoning a lithotrite.

CASES.

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, twentyseven. 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 a 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 sixtyseven grains; size of tube, twenty-nine; 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 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.

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 diameter 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 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