are abnormally developed. The hypertrophy of the muscular tissue is sometimes general; in other cases it is confined to particular fibres, which appear to be collected together in bundles, and form fleshy columns somewhat similar to those of the heart. This constitutes the state which French writers have called "vessie à colonnes."

Fig. 63.-Hypertrophied and sacculated bladder; one of the cysts to the right contains three calculi.

The frequent and powerful contractions of the bladder often give rise to another morbid condition connected with the one I have just mentioned. In the intervals of the muscular bundles, the mucous wall of the bladder is weak and unsupported; it may yield during the contractions of the bladder, and form

pouches of various kinds, which have been denominated cysts or sacs. A bladder in this condition is said to be "sacculated," and when the calculus is enclosed in one of these sacs, we term the case one of encysted

Fig. 64 represents a bladder with three cysts.*

Let me now examine in what manner a columnar state of the bladder and encysted calculus affect the indications of lithotrity. The majority of surgeons are of opinion that lithotrity should be rejected for all cases of hypertrophy of the bladder with irregular development of the muscular fibres. It has been alleged that the projecting and irregular bundles might be readily pinched between the blades of the instrument,

I am indebted to the kindness of my colleague, Mr. Lane, for this drawing; the preparation is in his museum.

K

Fig. 65.-Back view of the bladder with three cysts.

and that the fragments become entangled in the fibrous network, thus rendering their removal from the bladder difficult, and increasing the danger of relapse. For my own part, I should be inclined to adopt the opinion of M. Blandin, and many other eminent surgeons, and prefer lithotomy in cases of stone complicated with columnar hypertrophy of the bladder; but I must at the same time state that the extensive experience of M. Civiale has led him to a different conclusion. According to him, this condition of the bladder does not contra-indicate lithotrity, but should only render us more cautious while endeavouring to seize the stone or comminute the fragments. It is a very common state in calculous patients; and this we are prepared to admit, on considering how often powerful contractions

of the bladder are excited by the presence of a foreign body. M. Civiale has operated on many patients affected with columnar hypertrophy of the bladder, and the cases have terminated favourably.

The sacculated condition of the bladder is a much more unfavourable circumstance. The sacs or cysts usually occupy the floor of the organ, but they may exist at any point. They are often single, and of considerable size; in other cases, they are small and numerous; the orifice of the sac may be wide, or it may be contracted; the urine often stagnates in these cysts, becomes fœtid, and gives rise to purulent inflammation of their walls, or to the deposit of calculous matter. But the chief point which concerns the operator is to determine whether or not the foreign body be enclosed in the cyst; that is to say, whether the calculus be really encysted or not.

Encysted calculus is a positive contra-indication of lithotrity. It were useless, to say nothing else, to seek in the bladder a foreign body which we cannot seize. Lithotomy is equally inapplicable to such unfortunate cases; attempts have often been made to afford relief by the knife, and by crushing instruments; but the results have not been such as should encourage a prudent surgeon to repeat experiments that almost inevitably hasten death. There is only one case in which any attempt at lithotrity appears to be at all justifiable. In some rare instances, the abnormal position of the calculus is not permanent. The orifice of the sac is wide, and the stone small. Here the foreign body at one time remains within the sac, and at another may be detected free in the cavity of the bladder, having

escaped from its place of concealment. The stone, in fact, then ceases to be encysted, and lithotrity ceases to be inapplicable. Some surgeons recommend us, at all events, to endeavour to remove that portion of the calculus which may project into the bladder beyond the neck of the sac. This has been done; but the relief is very partial, and the risk great. My own opinion is, that we should not meddle in any way with an encysted calculus; the sufferings of the patient are often moderate, and life may be prolonged for a considerable time if we abstain from operating.

Tumours of various kinds are occasionally met with in the bladder of calculous patients. True fibrous cancer, originating in the tissues of the organ, is, according to my experience, excessively rare; I have never yet met with an example of the kind. Simple polypous tumour may also present itself; this form is likewise rare. Dr. Baillie says that he has seen only one case of polypus growing from the internal surface of the bladder. The growth most commonly met with is the one known as medullary fungus or fungus hæmatodes, the nature and appearances of which I need not describe. These tumours usually occupy the neck of the bladder, but they may grow from other parts; they are sometimes covered with calcareous incrustations, and sometimes the calculus itself seems to grow into their interstices.

The diagnosis of fungous tumours of the bladder is not easily made at an early period; and even when the surgeon has succeeded in determining the existence of such a growth, he still finds great difficulty in obtaining any precise knowledge of its seat, form, size, or mode of attachment to the bladder.