was new, had miscalculated the width in this combination of the Charrière screw-blocks, so that when the instrument was locked and screwed up these blocks had little or no bearing. They were at once lifted out of their boxes, just as they are purposely lifted out by thumb and finger when they need cleaning. That was the whole of it. The skilful French maker, annoyed at the carelessness of his workman, made the lithotrite perfect in a few hours; and the surgeon, in whose hands the defective adjustment revealed itself, ordered one of my lithotrites from Weiss.

The error here corrected does not impair the general excellence of the other criticism, it being quite possible that the writer should be a skilful surgeon without being perfectly familiar with the locks of lithotrites, - just as a skilful navigator may not have investigated the construction of the chronometer he uses.

Several of the critical remarks of your able editorial writer are well founded. He rightly says that the evacuating process, though not more efficient, is drier and neater if all the water is kept inside the aspirator and all the air outside of it; which implies that there should be good joints and no leakage, with stopcocks at all the orifices, one of them being at the highest point to let air out easily. I would add, however, that it is important not to lose sight of convenience in other respects.

The progress of the new lithotrity was most liberally encouraged, at an early period, by New York surgeons. The attention now directed to some of the minor details connected with the instruments is rapidly contributing to their perfection.

Almost the only objection I have known made to the new method, either here or abroad, has been directed to the size of the instruments I generally use, which at first impressed persons accustomed to the use of Clover's aspirator and the

English lithotrite as "clumsy" or "unwieldy." Large-sized catheters are absolutely indispensable, and are now so recog nized. With regard to the size of the lithotrite, it is to a certain extent a matter of taste. My own instrument, with a wrist-lock, ball-handle, and non-impacting blades, is not necessarily larger than others. It can be had from Tiemann and Co. of any size the operator may prefer. I think, however, that large and hard stones will be found to require a more powerful instrument than those hitherto in use. In fact, it is very possible that a calculus should break a lithotrite. This accident happened from time to time in the practice of the old lithotrity, and we are now dealing with larger and harder stones. That is one reason for avoiding a slender construction, especially of the blades; but my chief reason for using a large lithotrite is the convenient command it gives of the stone. Having learned how easy, as well as safe, with proper care and skill, is the introduction of large instruments, I prefer to use a powerful lithotrite to crush even a moderate-sized calculus, provided the blades are so constructed as not to become impacted. With a small stone or fragment the choice of a lithotrite is wholly unimportant; while a bladder or urethra, if exceptional in any way, may require an exceptional instrument. But I do not see why some operators still enjoin the use in all cases of the smallest or lightest lithotrite that can possibly be made to crush the calculus.

BOSTON, Mass.

HENRY J. BIGELOW.

LITHOLAPAXY.1

In a paper upon litholapaxy published last year, I reported twelve cases with one death. Below is a record of nine cases upon which I have since operated successfully, under ether as before:

CASE XIII.- March 9, 1878. Age, thirty-three. Stone weighing two hundred and forty grains. Time, sixty-eight minutes. Rapid recovery. The patient, for many months very ill, was at

once relieved.

CASE XIV.-Dec. 20, 1878. Age, sixty-nine.

Stone measur

ing eleven centimetres by fifteen. Time, forty-five minutes. Usual

CASE XVII.- April 7, 1879. Age, fifty-four. One hundred and eight grains of hard oxalate stone. Time, thirty-five minutes. Usual recovery.

CASE XVIII. April 26, 1879. Age, forty. Stone of the size of a marble. Time, twenty-seven minutes. Usual recovery. Only worthy of record as immediately relieved from great irritation of four years' duration.

CASE XIX. June 4, 1879. Age, sixty-five. Stone weighing two hundred and forty-two grains, mixed lithic and phosphatic. Time, forty-six minutes. Usual recovery.

CASE XX.-Small stone. Usual recovery. The only case where I was unable to pass a straight tube, from obstruction at the internal meatus.

1 The Boston Medical and Surgical Journal, Oct. 16, 1879.

CASE XXI.-July 21, 1879. Age, twenty-one. A large stone of seven hundred and twenty grains. Measurement, two and one fourth inches. Time, one hour and seventeen minutes. Usual recovery.

It is unnecessary to say that these operations were done deliberately, neither the anæsthesia, the crushing, nor the evacuation requiring haste. I have hitherto reported the time of my operations to illustrate and impress this fact, which was a new one. Surgeons familiar with the use of ether do not hesitate to continue anæsthesia almost indefinitely if there is anything to be gained by it. Nor is the bladder itself affected unfavorably by a protracted operation. Indeed," rapid lithotrity"- a name intended to designate a long sitting for the purpose of removing the whole stone through a large tube- calls for greater deliberation and care than the old dilatory lithotrity by repeated two-minute sittings, with an interval of days between them. It is rapid only as a whole, and when compared with the old operation.

The details of a case may further illustrate this, for example, the last here recorded, where seven hundred and twenty grains were removed in one hour and seventeen minutes, the stone being the largest but one as yet subjected to operation by the new method. Here four crushings occupied twelve, six, six, and four minutes; and five washings, six, four, twelve, and seven minutes, respectively, with intervals added. But a very large part of this stone was removed in ten minutes by the first two short washings; the remainder of the time was for the most part devoted to a leisurely and careful search for residuary fragments. As performed here now, the operation consists of litholapaxy, followed by thorough sounding with a tube. It may be made shorter by not completing it, by postponing the final exploration. In other words, surgeons may prefer to leave the last fragments for a second operation. This has been proposed by one of the strongest

advocates of haste, which is a habit connected with the twominute sitting, insisted on when it was erroneously supposed that damage to the bladder was in proportion to the time occupied by instrumentation. The tradition has so strong a hold on surgeons that cases of rapid lithotrity are still reported, in which the operator seems to have been under pressure of some sort to finish the sitting quickly, at all hazards, as if it were essential to do so; and yet the performance of lithotrity against time will probably be soon as obsolete as is now haste in other operations under ether anesthesia.