these, the cure would be rapidly expedited were such means taken as I have described in the lecture referred to. I need not at present dwell on that subject, but I repeat, that the practice cannot be followed without the slender instruments then described, and some of which I now exhibit. With those in common use nothing of the kind can be effected.

Certain dogmas have prevailed regarding lithotrity which had been hurriedly fixed, but which have now been dispelled by experience. Thus it was said that the operation was scarcely practicable or proper unless eight or twelve ounces of fluid could be retained; indeed, the more the better! This was under the impression that the stone could be more readily seized, and that the distended mucous membrane would be less likely to be nipped between the blades, or between these and the stone. If sufficient urine were not already in the bladder, the first step of the operation was to inject tepid water. Now I think it may be set down as a rule, that a capacious bladder and large quantity of water are objectionable. They certainly do not preclude the operation, but they assuredly make it more difficult and uncertain. A stone or fragment moves so freely in a large quantity of water, the slightest touch causing it to change its position, that it eludes the blades; and, again, where such a der as is here implied is nearly empty, the mucous tesse may possibly be in folds, between which tagme 18 are liable to escape the closest search. To ch, however, I have little faith in the

pre

sence of so-called folds of the mucous membrane of the bladder. For twenty years or more I have rarely used injections as a preliminary step, and I have often drawn off urine with a catheter when, in accordance with these views, I have fancied the quantity too large. A small proportion of fluid is decidedly better than a large, but care should be taken that the blades of the lithotrite can be used with facility, and without the chance of contusing and abrading the mucous surface.

Paralysis of the bladder, such as requires the daily use of the catheter, has been generally considered a positive bar to lithotrity. But with the small scoops which I have recommended the condition is positively favourable to that process; for there is generally in such cases an apathetic state of the mucous membrane, which permits a free use of instruments required for the removal of fragments.

Some years ago we were, on nearly the highest authority, positively prohibited from turning the point of a lithotrite downwards behind the prostate gland. If this organ be somewhat enlarged, particularly in its middle lobe, there is always a kind of pouch behind; and even when of its normal size the bladder in old persons is capacious at this part. Doubtless, as a patient stands, the stone usually lies in this place. Even in the horizontal position it keeps there, unless the pelvis be raised. In early days it was the custom to lower the shoulders and elevate the pelvis, for the sake of getting the stone towards the upper part of the viscus, where it was thought it could be more readily

and more safely caught. Occasionally even yet this position seems desirable; but the fallacy of not searching behind the prostate has been long since exploded. The best of modern sounds, that with the short curve. recommended by Heurteloup, was constructed with the view of being turned point downwards into this pouch, and to catch a small stone or fragment in this locality with a lithotrite or scoop, a peculiarly eligible manœuvre. These two sketches illustrate my meaning. Fig. 70 shows the lithotrite with its beak upwards, in a position.

Fig. 70.

not likely even to touch the stone; the other (fig. 71) shows the blades pointed downwards, so that if opened

Fig. 71.

and dipped a little lower they could not fail to catch it. Further, I can affirm, from ample experience, that there is no more risk or danger in moving the blades here judiciously than in any other part of the bladder.

The attitude of a patient, the question if he was to

lie on a bed, a sofa, or on a table made expressly for the purpose, were all thought matters of very great importance. Every now and then some little variety of attitude, from the horizontal to the erect, is desirable; but generally, in private practice, a hard-stuffed bed or sofa is all-sufficient. A pillow under the pelvis is sometimes an advantage; more, however, to keep the handle of the instrument above the mattress than with the intention of influencing the position of the stone. In hospital practice, the ordinary operating table answers all requisites, and that constructed for the special purpose of lithotrity may now-a-days be considered as a remnant of a certain amount of clap-trap which was associated with the early history of the operation.

The question as to the propriety of giving chloroform in lithotrity seems still a moot one in certain quarters; but I have none regarding it, and having used it in the greater number of the cases I have had ever since anæsthesia was introduced, I can speak of it in unqualified praise. There are many instances in which it is not requisite, but I am certain that without it the operation would be well-nigh impossible in a considerable number.

But, sir, the subject of lithotrity cannot be treated as I think it deserves without reference to lithotomy; and such further remarks as I wish to make I must reserve until I speak of the latter theme, which I intend to do at my next lecture, when I shall state the results of that experience which has enabled me, from my own practice, to form this collection of calculi, which I have now the honour to place before you.

LECTURE IX.

ON LITHOTOMY.

MR PRESIDENT AND GENTLEMEN,-The observations on lithotomy which I made last year had reference to patients under puberty, and were in a manner special, because I was desirous of giving expression to certain views of my own, which I had long entertained and taught in my hospital and professional labours.

I purpose to-day to speak of lithotomy in the adult, this being, perhaps, the best time and opportunity of adverting further to this absorbing subject. It is indeed marvellous how much has been said and written about this operation, and most surgeons of experience have evinced the greatest interest regarding it. Mr Crosse, in his celebrated prize essay on the subject, appended a list of authors who have written about stone and its cure sufficient to appal the most zealous bibliographer. Eight hundred and nine authors, or sources of information, have been referred to. Mr Crosse's own work is of no small magnitude, and since he wrote the numbers have increased probably by hundreds. There have been writers about it, from the