without thought, as in swimming, bicycling, writing, or playing a musical instrument, is then of the greatest value. It insures to the patient, as no mere good intention can, the advantage of what Cadge has called "all the little knacks and tricks which go to make up successful lithotrity." I think, with the improvements here shown, the operation becomes safer for the general surgeon. I often hear of successful operations upon large stones by the new method in the hands. of surgeons who have scarcely done lithotrity before; but I am satisfied that patients are yet safer in the hands of a surgeon who makes lithotrity in some measure a special study.

LITHOLAPAXY.

REMARKS MADE AT A MEETING OF THE BOSTON SOCIETY FOR MEDICAL IMPROVEMENT.1

DR. BIGELOW, in opening the discussion, said he had been much interested in the cases reported. Dr. Cheever's case was that of a hard stone, while Dr. Gay's was that of a large The results which they had obtained might be expected.

as a rule.

In reply to the inquiry how often it was necessary to slit the meatus, Dr. Bigelow said that the necessity was only exceptional. If the meatus is small, and the operation is to be a long one, it is a convenient and harmless expedient; it is well to take a little care afterward not to engage the mucous edge of the urethra upon the catheter and strip it up.

Air in the bladder does no harm. The amount contained in the catheter is legitimately there; beyond this amount no air can enter the apparatus unless from leaky joints. A little air is often as comfortably trapped for a time in the top of a large bladder as in the evacuator. The only harm the air does is to take up room which is better occupied by water if the bladder is not a capacious one. It is easy to remove it from the evacuator through a stop-cock and small hose at the top of the bulb, through which also the amount of water can be regulated.

Asked how long cystitis lasted after the operation, Dr. Bigelow replied that it depended on the relation it bore to the stone; that is, if the stone were the disease, and the cystitis were dependent on its presence, it would be cured. If, on the other hand, there were a previous cystitis with enlarged pros

1 The Boston Medical and Surgical Journal, March 23, 1882.

tate, and the stone were the result of these conditions, the relief, though often considerable, would be partial. Cystitis with a large secretion of mucus is a troublesome complication. The mucus plugs the urethral orifice, causing painful tenesmus until the tenacious mucus comes away in a mass, and the bladder is relieved.

In answer to further inquiries, Dr. Bigelow said that perhaps the most difficult part of the crushing operation is picking up pieces behind the vertical wall of certain forms of enlarged prostate. As a rule the stone is easiest secured by pressing down the floor of the bladder with the heel of the lithotrite, which then occupies a pocket into which the stone gravitates; or by carrying the instrument well back, opening it, turning it to one or the other side, and closing it. A stone or fragment behind the prostate can be usually caught by depressing the floor beyond it; although if the perpendicular wall of the prostate is high it may be difficult to reach it even by inverting a short blade. One difficulty with the old lithotrite was the obliquity of the heel, so that when the crushing force is applied the stone is urged forward in the blades. The clearing out of an obstruction in the straight tube can easily be accomplished by passing through it an ordinary tin sound. A curved tube sometimes gives more trouble, but can be freed by an elastic catheter. Any resistance, however slight, in withdrawing the tube should lead the operator to suspect that a dangerously large fragment is engaged in its extremity.

In reply to a question as to whether he had ever known injury to result from nipping the walls of the bladder, Dr. Bigelow said that he knew of one case in which he believed a fatal issue was due to that accident. In the ordinary instrument, with blades fitted at their extremities as accurately as forceps are, and with a female blade having no projection. to keep away the wall of the bladder, the latter must often be seized. If only the mucous membrane were torn, no serious

effect might ensue; but if, in a thin bladder, the whole thickness of the walls were pinched, he thought there must be danger. For this reason he himself felt easier in using his own instrument, which guards against this accident. The long female blade is especially useful to those not operating habitually.

In regard to the choice of a straight or curved tube, Dr. Bigelow thought neither was safer; the danger depends on the relation in size between the catheter and urethra. The tube, if large, must be introduced with great care and with a perfect understanding of the anatomy of the parts, directing it downward until it reaches the layer of fat lying between the urethra and the rectum, then coaxing it through the aperture in the triangular ligament, and finally reaching the bladder by a corkscrew motion of the straight tube in the axis of the body. In only two or three cases had Dr. Bigelow found any trouble in introducing a straight tube. Sometimes the curved tube can be easiest introduced by hugging the pubes, and thus passing the upper instead of the lower part of the opening in the triangular ligament. The introduction of the straight tube is usually easier to the surgeon, but perhaps not quite so comfortable to the unetherized patient. After the curved tube has entered the bladder the shaft occupies the urethra, and is of course straight.

Aided by the blackboard, Dr. Bigelow described at some length the difficulties of attaining a perfect and convenient evacuator, and explained the faults of all those now in use. The question is one of physics, and involves the separation of air, water, and fragments in the most effectual way by the simplest means. He believed that he had at last devised a satisfactory instrument. To suppose that experiments to this end, out of the bladder, have no value, is like supposing that the edge of a surgical knife can be tested only on the living tissues.

LITHOTRITY, WITH EVACUATION.

REMARKS MADE AT A MEETING OF THE NEW YORK ACADEMY OF MEDICINE.1

DR. BIGELOW said that when asked some time ago by the president to present this subject before the Academy, he felt that it was one which had already become old, and so familiar to most surgeons that he could offer but little of interest in connection with it; and it was only when the request was again urged, at a subsequent time, that he had reluctantly consented to do so. He believed, however, that his own accumulated experience, and especially that of the New York surgeons, had now thrown added light upon the operation. He could not forget also that it was in New York that the procedure which he had labored to perfect had received its first distinct approbation, and that at a time when it needed friends. The profession here had then tested the matter by practical experiments; and he could not refrain from mentioning his special obligation to the distinguished Professor Van Buren, among others, for his interest and assistance.

The subject, he continued, was one relating distinctly to operative surgery, a mechanical one; and it was to the mechanical part of it a mere matter of physics — that whatever advances had been made in lithotrity of late were really due. He should confine himself therefore, during the limited time at his disposal, to the mechanical procedure, because he believed it was what the Academy would perhaps prefer now to discuss. There were a number of points in regard to which he would like to have an expression of opinion from some of

1 The Boston Medical and Surgical Journal, May 25, 1882.