to eject the smallest quantity of fluid introduced. Here the injection must be conducted with extreme slowness-a small quantity at a time only being thrown in-and the patient allowed to repose between each injection; or the urine may be allowed to accumulate naturally in the bladder. If the irritability continues, we must cease our attempts for the moment, and adopt other means, as leeching, hip-baths, opiate clysters, &c. Chloroform has been tried in some cases of this kind, but without effect, the contractions of the bladder remaining undiminished, though the patient was completely insensible.

The instruments employed for injecting the bladder are a large-sized silver catheter with a stop-cock, and a metallic syringe, capable of holding half a pint, and of being accurately fitted to the catheter.

We now arrive at the introduction of the instrument. The early ones were all perfectly straight, for curved instruments were not introduced into use until 1831 or 1832. It is necessary to remember that the curve of the lithotrite differs considerably from that of

the ordinary catheter. The elbow is very abrupt, the ascending part is much shorter, and in many instruments the forceps portion is much flattened, to give solidity to the branches. In introducing the instrument the abruptness of the curve must not be forgotten; and the principal point which the operator has to attend to is to keep this curved portion constantly in the direction of the canal, especially while the instrument is passing under the arch of the pubes, and through the neck of the bladder. He must proceed with the utmost gentleness, feeling his way as he goes along. When he arrives at the bulbous portion of the urethra, the penis and handle of the instrument should be brought to a right angle with the body of the patient, by which he brings the curve of the instrument under the pubic arch. This done, he slowly depresses the handle, advancing it at the same time until the bladder is reached. The amount of depression will depend on the curve of the instrument we use; the shorter the curve, the less we need depress, but the principle to be followed is that of endeavouring to make the curve of the lithotrite follow the natural curve of the urethra.

There is seldom any difficulty in passing the instrument, at least in ordinary cases. When the prostatic portion of the urethra is healthy, the lithotrite, such as we now use, passes readily enough; but if there be any tumefaction of this gland, we must depress the handle of the instrument proportionately, so as to throw up the point and clear the obstacle. Here I must again caution the operator against using the slightest force during any of these proceedings. The young operator should never forget that it is very possible to lacerate This book is the pr

COOPER MEDICAL COL

SAN FRANCISCO, CAL

and is not to be removed from the

the lining membrane of the urethra, and that this accident may occur without any great amount of force, especially while the instrument is traversing the membranous portion of the canal.

The

We have now the instrument in the bladder. next step is to seize the stone. This is easily done when the calculus is small, and the blades of the lithotrite large. The closed instrument is first directed towards the floor of the bladder, along which the curved part is made to pass, the point being gently turned, now to one side now to another; as soon as the instrument touches one of the sides of the stone, the female branch is fixed, the male branch is slowly drawn back, and the instrument is cautiously inclined towards the calculus. Should any difficulty be experienced in seizing the stone, from depression of the floor of the bladder or other causes, then the blades are moved in a sweeping direction, with the convexity downwards, from before backwards, along the bas-fond and posterior surface of the bladder; they are then drawn back a little, and the convexity directed to the right or left side, each of which is explored in its turn; lastly, the point of the instrument is directed upwards and then downwards to the space immediately behind the prostate. The instrument should then be carefully rotated, in order to come in contact with the foreign body. This found, the blades of the lithotrite are cautiously opened, and the instrument is pressed on the stone laterally, after which the blades are closed with the same caution, every effort being made to seize the stone as much towards its centre as is possible. This is an affair of dexterity which practice and great tact alone can attain.

It is of importance to remember that the female branch should be kept perfectly immovable while

closing the instrument, otherwise we run the risk of displacing the stone, which generally lies against its ascending portion.

Having seized the stone, the surgeon must next satisfy himself that nothing besides the stone is included between the branches of the instrument. At an early period of lithotrity, the mucous membrane of the bladder was more than once pinched up, and ground together with the stone; but such an accident, which mainly depended on the imperfect nature of the instruments then employed, is, I believe, unknown at the present day.

Once firmly fixed between the blades of the lithotrite, the calculus is generally broken down without any difficulty. Many surgeons employ pressure with the hand only; and this answers well enough when the stone is not too large or hard. In other cases the use of the screw becomes necessary. Its slow propulsion soon causes the calculus to yield; and if we employ the rack-and-pinion system, a rapid succession of slight jerks may be communicated, which produce many of the effects of percussion. Should the stone from its hardness, resist pressure, we must have recourse to percussion as an auxiliary, and Charrière's instrument admits of our employing this mode without withdrawing the lithotrite from the bladder. It is, in fact, both a a percussor and a crusher at the same time.

Before withdrawing the instrument from the bladder, it is essentially necessary to ascertain that the branches are perfectly closed, and that no detritus has accumulated in the forceps portion. If this be not done, the operator may encounter an unexpected obstacle on arriving at the urethra. A few turns of the screw backwards and forwards will usually suffice to clear the instrument, or Mr. L'Estrange's stilet may be used, if the male branch be grooved to allow of its passage.

It is only in exceptional cases, and when the stone is both small and very friable, that we can expect to break it up at a single operation. The first sitting should also be short, about five or six minutes, and when the passage becomes accustomed to the instruments, or less irritable, the operation may be prolonged for ten minutes at a time. This is a rule from which M. Civiale never deviates, and his opinion in this matter deserves the