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. 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 very much shorter time. In a majority of cases the bladder can be completely and at once evacuated.

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." " 1

"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 irritating as lithotrity itself."2

"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." 8

"All these evacuating catheters are little employed. They require frequent and long manoeuvres, 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."4

M. Voillemier here states the precise difficulty. 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

1 Article Lithotritie, by Demarquay et Cousin, in the Nouveau Dictionnaire de Médecine et de Chirurgie Pratique, pp. 693, 694. Paris, 1875. 2 S. D. GROSS: Diseases, etc., of the Urinary Organs, p. 232. Philadelphia, 1876.

8 Sir H. THOMPSON: Practical Lithotrity and Lithotomy, p. 215. 1871.

4 Article Lithotritie, by M. Voillemier, Dictionnaire Encyclopédique des Sciences Médicales, p. 733. 1869.

small fragment or two. This attempt at evacuation was aided by suction. With this object, and before the year 1846, Sir Philip Crampton employed an exhausted glass globe.1 For the same purpose a rubber enema-syringe has been used, or a hydrocele bottle, with which fluid could also be 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.

Before describing my own instruments, it may be well to say a word in regard to the introduction of large instruments

1 The apparatus here alluded to was intended more particularly “for clearing the bladder of detritus, in cases in which the expulsive power of that organ has been, as so frequently happens in old persons, impaired or destroyed." In Sir Philip's own words : "The apparatus consists of a strong glass vessel of an oval form and six or eight inches in length by three in diameter, and capable of holding about a pint and a half of water; to this vessel is attached a tube of about half an inch bore, furnished with a stop-cock. The air being exhausted by means of an exhausting syringe, and one of Heurteloup's wide-eyed steel evacuating catheters being introduced into the bladder, it is next attached to the exhausted vessel; the stop-cock is then turned, and a communication being thus established between the bladder and the glass, the pressure of the atmosphere is by this means brought to bear on the bladder, and supplies an expulsive power, which may be increased to any required amount." The Dublin Quarterly Journal of Medical Science, vol. i. p. 22. 1846.

into the bladder. The successful introduction of the large straight tube is so important that it deserves especial mention. It throws light upon the successful passage of the lithotrite, and also of the large-sized curved tubes.

Urethra to be measured.—In order to ascertain the maximum calibre of the urethra before introducing a tube, it should be measured by an instrument which will enter more readily than the tube. Such instruments we have in Van Buren's Sounds, which are slightly curved at the end and a little conical. Being made of solid metal and nickel-plated, they traverse the urethra with singular facility. Both Otis's Sounds and the conical probe-pointed elastic bougie also answer admirably for this purpose.

How to pass a straight instrument into the bladder. — 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.

How to pass the triangular 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 until it is almost horizontal, 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 cork

screw. 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.

Presence of an enlarged prostate. Even the enlarged prostate can often be traversed with facility 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.

Obstruction by fissure in the prostate. - An occasional difficulty in passing the enlarged prostate deserves mention here; namely, that resulting from a series of cracks or fissures, having their apex at the verumontanum, and radiating toward the bladder. I have a specimen of large prostate where these fissures readily engage a medium-sized catheter.

In such a case a large instrument may pass more readily than a small one. The finger in the rectum is here also of especial service. The handle of the tube may be also lowered to tilt up the tip in passing the inner meatus.

Obstruction at the inner meatus. 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 fairly within; and I have known its further entrance, after sliding over this obstacle, to be erroneously explained by assuming the existence of a second or hour-glass cavity in the bladder itself.

How to overcome it. To obviate this difficulty, and so soon as the triangular ligament is passed, a catheter, if