ment of the middle lobe of the prostate, and what has been said in relation to the latter may be applied to the former.

Chronic inflammation, or catarrh of the bladder, is of very frequent occurrence in calculous patients, and it is therefore of importance to examine how far such a condition may influence our choice of the operation to be selected.

If we were to reason à priori, we might readily conclude that the use of lithotritic instruments in a bladder already inflamed must inevitably aggravate the inflammation and give rise to serious accidents; and hence that catarrh of the bladder is a positive contra-indication of lithotrity. During the early period of his practice, even M. Civiale himself was influenced by this preconceived notion, and rejected all cases in which catarrh of the bladder existed to any extent. Experience soon proved that his fears were unfounded. Simple and mild catarrh of the bladder, instead of being aggravated by lithotrity, is almost always alleviated by comminution of the calculus-I allude, of course, to that form of catarrh which depends on the presence of a foreign body in the bladder.

This fact has been fully established by experience in hundreds of cases, and I do not think it necessary to dwell on it. Indeed, were the fact not so, lithotrity must have been abandoned long ago, for few calculous patients are entirely free from vesical catarrh under some form or another.

It is only where the chronic inflammation of the bladder has been of long standing, or is complicated with other lesions, that it becomes necessary to reflect whe

ther the state of the vesical mucous membrane be such as will admit of our employing instruments without danger.

Whenever catarrh of the bladder is complicated with any serious disease of the neck or body of the organ, it will be prudent to abstain from lithotrity. The necessary manipulation might in some cases, aggravate the chronic inflammation, and rapidly compromise the life of the patient. I would also abstain from the use of lithotrity in cases where catarrh of the bladder is accompanied by any well-marked signs of irritation, such as pain and difficulty of micturition, a frequent desire to evacuate the bladder, &c.

Purulent catarrh of the bladder is, according to my experience, a very positive contra-indication to lithotrity. It is not so much that the presence of pus in the urine denotes an advanced degree of inflammation in the mucous membrane, but from the fact that purulent secretion from any portion of the urinary system becomes a determining cause of purulent infection under the influence of lithotrity. The pus contained in the urine may be derived not only from the inflamed mucous lining of the bladder, but from the surface of a cyst, from the ureters, from the pelvis of the kidney, or from the kidneys themselves; in all these latter cases, purulent infection is liable to supervene, and this complication is almost inevitably fatal.

When catarrh of the bladder exists, we must, therefore, take into account its nature and its degree. If not very severe. and if unaccompanied by any serious organic lesion, it does not contra-indicate lithotrity. Still, experience teaches us that certain precautions must be

observed to prevent the chance of failure or the occurrence of secondary accidents. The calculus must be a small one, unless it be phosphatic, which species is rapidly crushed. The operations or sittings, as they are technically called, must be short, and great care must be taken to relieve the bladder of detritus by frequent injections of tepid water. The principle we have to look to, in short, is to avoid anything which may aggravate beyond measure the irritation which already exists; and if this principle be adhered to, the catarrh will gradually subside with the expulsion of the fragments, instead of being increased by the operation.

Another condition of the bladder which frequently exists in old or severe cases of stone, and which contraindicates lithotrity, is hypertrophy of the organ, with diminution of its cavity, and excessive irritability. Here I may repeat what I said relative to one of the conditions essential for successful lithotrity, and it will be seen at once why the state of the bladder just mentioned is a contra-indication: The play of the instruments in the bladder must be sufficiently free to allow of our crushing the stone without inflicting any injury on the walls of the bladder, or irritating that organ in any dangerous degree.' Now this condition evidently cannot be attained whenever the walls of the bladder are hypertrophied so as to give great force to their contractions, and so irritable that they contract on the slightest stimulus, firmly grasping the stone, and resisting the introduction of a few ounces of fluid. It were manifest folly to attempt an operation under circumstances which are diametrically opposed to it. The existence of a certain space between the walls of the

bladder and the surface of the calculus, is necessary for the safe performance of lithotrity. This space is filled with fluid to keep the walls of the bladder permanently out of the way of the instrument, and prevent any injury from friction. When the hypertrophied bladder closely grasps the stone, as the French say, like a "nightcap," and is at the same time irritable, no space can be obtained, no fluid is retained in the bladder; if we operate, we do so without the protection of a fluid medium, and no prudent surgeon would undertake the risk of such a proceeding.

Hypertrophy of the bladder is often accompanied by abnormal development of the muscular fibres at certain points, which stand out in bundles, like the fleshy columns of the heart, giving the bladder the appearance denominated vessie à colonnes. Although this state may present some obstacle to lithotrity, it is not a positive contra-indication ;-but it will be more convenient to examine the lesion in connexion with cysts or sacs in the bladder.

CHAPTER IX.

INDICATIONS AND CONTRA-INDICATIONS OF LITHOTRITY.

THE various conditions of the bladder naturally exercise a very great influence over the results of lithotrity. It requires no reasoning to prove that there must be an immense difference between breaking up a calculus in a healthy bladder and in one whose textures and sensibility have been altered by disease. In a certain condition of the bladder, the muscular fibres Fig. 62.

Fig. 62.-Hypertrophy of the muscular tissue of a portion of the bladder.