struction of a stone from two inches to two inches of this kind are evidently beyond the domain of and a half in diameter, and moderately hard, is lithotrity; and other cases of hard calculi are to often difficult, and followed by unfavourable symp-be rejected whenever we have reason to suspect that the hardness of the stone, whether alone or

toms.

The late Mr. Key, who at one time was no joined to other circumstances, may exercise an unadmirer of lithotrity, says: "I know of no limit favourable influence over the result of the operato the size of a calculus removable by lithotrity, tion. but the power of the lithotrite. If a powerful It is clear that a very hard calculus cannot be instrument can be brought to embrace it, and the disintegrated without a considerable number of bladder be healthy, the operation may, as far as operations, and the possible consequences of such my experience goes, be attempted, with propriety." repeated manoeuvrings in the bladder are sufficient The opinion of Mr. Key requires some qualifica- to make us incline to the side of lithotomy. tion; very great size is no contra-indication, pro- On the indications connected with the form and vided the calculus be very friable, as phosphatic position of calculi, little need be said. The stone deposits usually are, and provided the bladder is must be seized and fixed before it can be crushed, not closely contracted over the surface of the and there may be some difficulty in grasping a foreign body. If, however, the stone be large, very flat calculus; but with our curved instruand at the same time dense, I would unhesitatingly ments this difficulty is, I believe, very rarely insay that lithotomy should be preferred to litho surmountable. The position of the stone may be trity, even admitting, with Mr. Key, that the considered when I treat of encysted calculi. urinary organs are healthy. Remember what I The condition of the urinary organs, gentlemen, said about the necessity of our being able to is the next point to be examined in reference to operate without the danger of over-exciting the the indications of lithotrity. It is almost unnecesbladder. A large dense stone cannot be reduced sary for me to remind you that a healthy state of to fragments either by percussion or crushing the urinary organs is the most favourable condition without a considerable number of operations. As that can present itself in connexion with lithotrity, the calculus occupies a great part of the cavity of while, on the other hand, any serious organic disthe bladder, it is not easily seized; the mani- ease of the bladder or its appendages contra-inpulation of crushing must be more or less painful, dicates the operation. Still, few calculus patients and is always long; the danger of exciting inflam- are altogether free from some disorder of the mation of the bladder or kidneys is proportioned urinary apparatus, and many affections of the to the number and length of the operations; such bladder merely influence the results of lithotrity danger is always imminent, the quantity of detritus without absolutely contra-indicating it. Hence is likewise great, and retention of the fragments it is a matter of great importance (although much after fatiguing operations may give rise to serious casier in theory than in practice) to ascertain constitutional disturbance. From these and other what morbid conditions of the genito-urinary reasons, I would lay it down as a rule that litho- system are incompatible with the safe and successtrity is contra-indicated in all cases where the ful application of lithotrity. calculus is at the same time large and dense. The state of the prostate first demands our atcases where the foreign body is moderately hard, tention, for it may influence the simple introducand does not exceed two inches and a half in tion of the instruments, as well as the operation diameter, other circumstances being favourable, and its results. In my last lecture I described to the operation is not altogether contra-indicated; you the different morbid conditions of the prostate but if had recourse to, the greatest caution is re- which have been found in connexion with vesical quired, and the operator must be prepared to calculi; one or both of the lateral lobes may be abandon any further attempt at crushing as soon increased in size, the middle lobe also may be as unfavourable symptoms arise. In these and enlarged, and form a more or less prominent other cases, which occupy what I would call tumour, which projects backwards into the cavity neutral ground, or the limits between the applica- of the bladder. The substance of the gland may bility and non-applicability of the operation, much be inflamed, its vesical surface may be the seat of will depend on the skill and experience of the ulceration, or, finally, abscesses may exist in the operator. One surgeon will succeed where another body of the prostate itself. fails; and unless the practitioner has full confi- Partial or total enlargement of the prostate dence in his own resources, it will perhaps be must necessarily cause some deviation of the more prudent for him to follow the beaten track, prostatic portion of the urethra, and thus create and have recourse to lithotomy in the doubtful a greater or less obstacle to the introduction of cases to which I now allude. instruments. When the enlargement is moderate,

In

The density of the calculus is next to be noticed. you will generally succeed in overcoming the The mulberry or oxalate-of-lime calculus is the obstacle by depressing the handle of the instruhardest variety, and often presents such a degree ment a little when its point arrives near the pubic of density, that no force will produce any effect arch; and a greater degree of enlargement will on it. Professor Velpeau mentions a case of mulberry calculus, where 2000 strokes of the percussor were had recourse to without exercising any perceptible influence on the foreign body. Calculi

require a corresponding amount of depression. The curve of the instrument is thus carried over the enlarged gland without any considerable difficulty, but great care and gentleness are indis

pensable; you must avoid dragging the parts too much, which would excite severe pain; and you must also avoid injuring or perhaps lacerating the superior surface of the prostatic portion of the

Fig. 60.

FIG. 60-A calculus in the prostatic portion of the urethra, and a second one in the depression behind the prostate. The point of the sound passes over both.

canal, which might occur if the handle of the instrument be depressed too low.

It is easy to understand how any considerable enlargement of the prostate-particularly of its middle lobe-must diminish the cavity of the bladder, and thus impede the free play of instruments within this organ. The tumefaction of the middle lobe, which projects backwards, deepens the floor of the bladder, and the calculus is thus often concealed in a kind of artificial cavity; the antero-posterior diameter of the bladder is also more or less altered and prolonged backwards. These circumstances are calculated to impede the manipulation after the introduction of the lithotrite. The rotation of the open blades is cireumscribed, and the seizing the calculus is thus rendered more difficult. Indeed, when the middle lobe of the prostate is greatly enlarged, it may be impossible to grasp the stone without executing a movement of complete rotation, and turning the concave surface of the instrument against the gland. The same disposition of parts which prevents you from seizing the calculus with facility must also impede the ready discharge of fragments from the bladder; and this is an objection of great importance.

FIG. 61.-Effect of enlargement of the prostate gland, throwing up the point of the sound. Enlargement of the prostate gland is an unfavourable circumstance for the performance of lithotrity, but it is no absolute contra-indication, as some writers assert, nor, on the other hand, is it to be regarded with indifference. The main points to be ascertained, before deciding on the propriety of operating, are the nature and extent of the obstacles which the enlargement of the gland may oppose. These can only be determined by a very careful examination of the patient with the sound. By introducing the finger into the rectum, &c., you must obtain as correct notions as possible relative to the size of the gland; you must ascertain whether the whole or a part only of the prostate, be enlarged, and if a

part, whether it be the lateral or middle lobe; you must observe how the urethra has become altered, whether to the right, or left, or upwards. You must endeavor to find out, if possible, how far the middle lobe of the prostate projects backwards into the cavity of the bladder, and what is the form or extent of the pouch in the floor of the bladder, on which the calculus rests. All this requires dexterity and judgment, but you must obtain such preliminary knowledge, unless you prefer going to work in the dark; and it has been clearly established, that the want of success, in many cases of lithotrity, mainly depends on the operator having neglected to ascertain beforehand certain facts, on an acquaintance with which

the ultimate success of the operation intimately thotrity in cases where catarrh of the bladder is depends. Let us now suppose that on examina- accompanied by any well-marked signs of irritation you have discovered some enlargement of the tion, such as pain and difficulty of micturition, a prostate, but not to any considerable extent. frequent desire to evacuate the bladder, &c. Here you may proceed to operate, provided the stone be of moderate size, and the organs not very sensitive. On the other hand, when the increased size of the prostate is considerable, and the bladder contains several calculi or a single large one, lithotrity is contra-indicated.

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 serious disorder of the urinary organs co- any portion of the urinary system becomes a deexisting with enlargement of the prostate, should, termining cause of purulent infection under the in my opinion, be also regarded as a contra-indi- influence of lithotrity. The pus contained in cation. Thus the neck of the bladder is often the urine may be derived not only from the invery irritable in cases of the kind now under flamed mucous lining of the bladder, but from consideration; there may be chronic catarrh of the surface of a cyst, from the ureters, from the the bladder, or that organ may be in a state of pelvis of the kidney, or from the kidneys thematony, &c. selves; in all these latter cases, purulent infecLithotrity has been successfully employed in tion is liable to supervene, and this complication spite of these complications; but whenever they is almost inevitably fatal.

When catarrh of the exist in conjunction with enlargement of the pros- bladder exists, you must, therefore, take into actate, I should, for my part, prefer having recourse count its nature and its degree. If not very seto lithotomy. vere, and if unaccompanied by any serious orChronic inflammation, or catarrh of the blad-ganic lesion, it does not contra-indicate lithotrity. der, 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.

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 If we were to reason à priori, we might readily phosphatic, which species, as I told you before, is conclude that the use of lithotritic instruments in rapidly crushed. The operations or sittings, as a bladder already inflamed must inevitably aggra- they are technically called, must be short, and vate the inflammation and give rise to serious ac- great care must be taken to relieve the bladder cidents; and hence that catarrh of the bladder is of detritus by frequent injections of tepid water. a positive contra-indication of lithotrity. During The principle we have to look to, in short, is to the early period of his practice, even M. Civiale avoid anything which may aggravate beyond meahimself was influenced by this preconceived no- sure the irritation which already exists; and if tion, and rejected all cases in which catarrh of this principle be adhered to, the catarrh will grathe bladder existed to any extent. Experience dually subside with the expulsion of the fragsoon proved that his fears were unfounded. Sim- ments, instead of being increased by the operaple and mild catarrh of the bladder, instead of tion. being aggravated by lithotrity, is almost always Another condition of the bladder which frealleviated by cominution of the calculus-I al- quently exists in old or severe cases of stone, and lude, of course, to that form of catarrh which which contra-indicates lithotrity, is hypertrophy depends on the presence of a foreign body in the of the organ, with diminution of its cavity, and excessive irritability. Here let me repeat what I said relative to one of the conditions essential for successful lithotrity, and you will see 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 your crushing the stone without inflicting any injury on the walls of the bladder, or irIt is only where the chronic inflammation of ritating that organ in any dangerous degree." the bladder has been of long standing, or is com- Now this condition evidently cannot be attained plicated with other lesions, that it becomes ne- whenever the walls of the bladder are hypertrocessary to reflect whether the state of the vesical phied so as to give great force to their contracmucous membrane be such as will admit of our tions, and so irritable that they contract on the employing instruments without danger. slightest stimulus, firmly grasping the stone, and Whenever catarrh of the bladder is complica- resisting the introduction of a few ounces of fluid. any serious disease of the neck or body It were manifest folly to attempt an operation unof the organ, it will be prudent to abstain from der circumstances which are diametrically oplithotrity. The necessary manipulations might, posed to it. The existence of a certain space in some cases, aggravate the chronic inflamma- between the walls of the bladder and the surface tion, and rapidly compromise the life of the pa- of the calculus, is necessary for the safe perform tient. I would also abstain from the use of li-ance of lithotrity. This space is filled with fluid

bladder.

This fact, gentlemen, 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.

ted with

Fig.65.

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, gentlemen, is a positive contra-indication
of lithotrity. It were useless, to say nothing else,
to seek in the bladder a foreign body which you
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 justifia-
ble. 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 inapplica-
ble. Some surgeons recommend to us at all events
to endeavour to remove that portion of the calcu-
lus which may project into the bladder beyond
the neck of the sac.
the relief is very partial, and the risk great. I
would advse you not to 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 you abstain from operating.

This has been done; but

Let us now examine in what manner a columnar state of the bladder and encysted calculus affeet 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 pinchTumours of various kinds are occasionally met ed between the blades of the instrument, and that with in the bladder of calculous patients. True the fragments become entangled in the fibrous fibrous cancer, originating in the tissues of the network, thus rendering their removal from the organ, is, according to my own experience, exbladder difficult, and increasing the danger of recessively rare; I have never yet met with an exlapse. For my own part, I should be inclined to ample of the kind. Simple polypous tumour may adopt the opinion of M. Blandin, and many other also present itself; this form is likewise rare. Dr. eminent surgeons, and prefer lithotomy in cases Baillie says that he has seen only one case of of stone complicated with columnar hypertrophy polypus growing from the internal surface of the of the bladder; but I must at the same time in- bladder. bladder. The growth most commonly met with, form you that the extensive experience of M. is the one known as medullary fungus, or hæmaCiviale has led him to a different conclusion. Ac- todes, the nature and appearances of which I need cording to him this condition of the bladder does not describe to you. These tumours usually ocnot contra-indicate lithotrity, but should only cupy the neck of the bladder, but they may grow render us more cautious while endeavouring to from other parts; they are sometimes covered seize the stone or cominute the fragments. It is Fig66. 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. These sacs or cysts usually occupy the fundus 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 foetid, and gives rise to purulent inflammation of their walls, or to the deposit of calculous matter. But the chief point which concerns the operator,