the prostate and involving the neck of the bladder in males, it still requires attention, and should be combated by the ordinary means which I have already described.

The female bladder is, I believe, less liable to become seriously diseased than the male, from the effects of calculous irritation; and the obstacles arising from enlargement or disease of the prostate, are of course, entirely absent in the female. However the depression just behind the neck of the bladder, caused in the male by tumefaction of the middle lobe of the prostate, sometimes exists in the female also, though from a different cause. The lateral walls of the female bladder are naturally depressed, and in an aged patient this may be carried so far as to form a kind of sac at the floor of the bladder, in which the calculus or its fragments, are apt to lodge. In addition to this M. Civiale observes, that the uterus sometimes presses against the posterior and inferior walls of the organ, dividing its floor into two pouches, in which the fragments may likewise become engaged. It is well to bear these circumstances in mind, although any obstacle which they can create is far from having the same importance as those produced by enlargements of the prostate in the male. The canal of the urethra is so short and straight in the female that every portion of the bladder can be explored without any great difficulty, and the conditions of each case ascertained with a degree of precision which renders the task of the operator comparatively light.

The operative proceeding is the same for the female as for the male, and the indications relative to disease

of the urinary organs are also the same for both sexes. I need not, therefore, repeat what has been already said on this latter point; but I may remark that lithotrity has been successfully applied to cases of stone in the female bladder under circumstances which would certainly have contra-indicated the operation in the male. There are two principal reasons for this; in the first place, the operation can be terminated, cæteris paribus, much more rapidly in the female than in the male; it is easier to seize the calculus; it is easier to crush the calculus into fragments. All these advantages render it much less likely that the operation will be followed by irritation of the urinary organs, or by any dangerous accidents.

In the second place the fragments of the calculus are much less liable to be retained in the bladder or to become impacted in the urethra ; and I have already shown that many of the evil consequences of an opeation in the male depend on the irritation excited by these two accidents.

In the female they are rare. There is no enlarged prostate to impede the free evacuation of the detritus ; no curved canal to arrest their discharge, while the great dilatability of the urethra in the female renders it less necessary to break up the calculus into very small fragments, and thus contributes to render the operation less protracted in difficult cases.

The main objection brought forward in this country against the expediency of applying lithotrity to the female is derived from the alleged difficulty of making the female bladder retain the fluid injected into it.

It would certainly appear from many cases on record

that some operators have found it impossible to make the female bladder retain the fluid which they injected; and hence adopting the false method of reasoning from particulars to universals they reject lithotrity altogether for the female. It may happen that the bladder of a female patient is small, contracted, excessively irritable, and incapable of retaining the injection. This occurs in the female as well as in the male, though I believe less frequently, and when it does occur lithotrity should not be undertaken. But this is no reason for converting the exception into a rule. Under ordinary circumstances the female bladder will retain the injection well enough, and if the bladder show any disposition to reject it, this can be overcome by elevating the pelvis a little more than usual, and by confining the quantity of fluid thrown in to four or five ounces. The rapidity with which the operation may be completed in the female renders it much less necessary to have the bladder distended with fluid.

CHAPTER XV.

PARALLEL BETWEEN THE DIFFERENT METHODS OF

LITHOTOMY.

ALTHOUGH the lateral operation for the extraction of stone from the bladder is that to which surgeons have recourse in the great majority of cases, yet it is not altogether free from imperfection. This method necessarily exposes the patient to certain accidents, the influence of which may be illustrated by the general fact, that from one-fifth to one-seventh of the cases terminate fatally. Such is the result of the lateral operation when practised even by the most skilful surgeons in this and other countries; and although I do not mean to affirm that the fatal event should always be attributed to the operation-because it is sometimes had recourse to under such unfavourable circumstances that success is scarcely to be expected-yet the mortality is so considerable that many eminent practitioners have been induced to turn their attention to other methods, whereby the risk of the operation might, as they hoped, be more or less diminished. Besides this, certain cases occasionally present themselves to which the lateral operation is confessedly in

applicable. If the surgeon persist in an attempt at applying Cheselden's method to these cases, the safety of the patient is compromised in the most serious manner; death, in fact, is sure to be the result; and hence we are led to inquire, how in these cases, which I shall presently describe, the bladder may be opened in a different manner, and the stone extracted by some method less likely to be followed by dangerous accidents, than the lateral operation.

In the historical sketch I described the different methods for the extraction of vesical calculi which have been employed at various periods, from the days of Celsus to the present time. Omitting what may be called modifications, we find no less than six different methods, but as it would be impossible to compare each one of these six with the remaining five, I shall adopt the more simple plan of briefly noticing the advantages and disadvantages connected with each method.

They may be taken up in chronological order.

The Celsian method consists in pressing the stone against the neck of the bladder with the fingers introduced into the rectum, and then cutting directly down upon the foreign body. This was the primitive operation, the one adopted in the infancy of surgery. The objections which might be advanced against it are so manifest that they hardly require any notice. The method necessarily excluded a numerous class of patients; it is not easy to introduce the middle and fore-fingers into the rectum of a young child; and it is inapplicable to aged persons, and nearly so to adults, from the great difficulty of hooking the fingers round the prostate in such a manner as to render it