When the patient has been properly fixed, the extremity of the male branch is struck with repeated blows of a small hammer, until the calculus is sufficiently disintegrated by the effects of the percussion. Baron Heurteloup's method is very seldom employed at the present day, but it may become an useful auxiliary in cases of large and very hard calculi.

The instruments generally used at the present day for performing lithotrity are, the common screw one,

Fig.46.

Fig45

Fig. 45.-M. Civiale's latest instrument for crushing with the hand or the screw,

or for employing percussion.

Fig. 46. The jointed catch, which is shown in situ, on the instrument, fig. 45 a.

(Fig. 42), the rack-and-pinion instrument (Fig. 43), Charrière's last instrument, which likewise acts through a rack and pinion, but differs from the former in the shape of the handle (Fig. 44), and M. Civiale's (Figs. 45, 46).

32

CHAPTER II.

THE PREPARATORY TREATMENT.

HAVING thus comprised, in as a brief a space as possible, the principal facts connected with the history of lithotrity, I hasten to its practical application. In a subsequent chapter I shall explain in what cases lithotrity is to be preferred to lithotomy; for the present, let us suppose that a case of stone suitable for the employment of lithotrity presents itself. How are we to proceed? What are the successive operation?

steps of the

It is almost unnecessary to insist on the fact that stone in the bladder is very frequently attended by more or less derangement of the genito-urinary organs, or of the general health. It is important, before proceeding to the operation, to remove these complications as far as possible; and hence what has been termed the preparatory treatment. I do not mean to say that we are to select our patients in such a manner as to operate only on those who are free from any complication. This would be impossible in hospital practice, and, moreover, would condemn many patients to per

petual suffering for the mere sake of enhancing one's own reputation and appearing as a successful operator. The rule I would inculcate is, that we must, by preparatory treatment, remove all such local or general disorders as are likely to exercise any dangerous influence on the result of the operation.

Whenever the calculus is small, the bladder healthy, and the urinary passages show little or no signs of irritability, the patient is in the most favourable state, and preparatory treatment need not occupy our attention. But such cases are not very frequent. Patients seldom present themselves to us, especially with the idea of undergoing an operation for stone, until the urinary organs, and subsequently the general health, have more or less suffered. Here the patient must be carefully examined, and all unfavourable symptoms removed, or at least alleviated as far as possible, before the surgeon thinks of operating.

The digestive organs often suffer in cases of stone. We must endeavour to correct this derangement, and improve the condition of the intestinal secretions. Where the patient is much enfeebled, tonics should be administered; if, on the other hand, the circulation be much excited, general or local bleeding is indicated; but we must be cautious not to reduce the patient too much, nor to waste valuable time by continuing the preparatory system too long. If we relieve the most urgent symptoms, it is all that can be expected in unfavourable cases.

An excessive disposition of the bladder to contract on the stone should be combated by the use of opiates. The condition of the kidneys must be examined with the

D

greatest care, for they are often diseased in long-standing cases of calculus. When the symptoms are uncer

tain and obscure, an examination of the urine will here be of great assistance.

The state of the urethra, prostate, and bladder, must, I need hardly say, be ascertained, and above all things we must endeavour to determine whether disease of these parts has given rise to the secretion of pus. The existence of purulent deposit in the urethra, prostate, bladder, or kidneys, is one of the most unfavourable complications which can present itself, not only with respect to lithotrity, but any other operation on the genito-urinary organs. The pre-existence of such abscess is a powerful determining cause of purulent infection, and hence I would lay down the rule that every effort should be made to remove such a complication before we think of operating for stone in the bladder; and this remark applies to lithotomy just as well as to lithotrity.

As part of the local preparatory treatment, M. Civiale insists much on the propriety of introducing a soft bougie for a few days, and during a few minutes at each time, so as to accustom the urethra to the contact of a foreign body, and diminish its irritability. He never goes beyond the natural calibre of the urethra, and rejects dilatation of that canal.

Other surgeons, however, employ metallic sounds, the calibre of which is gradually increased until a certain degree of dilatation ensues; but it is much better to leave the patient as tranquil as possible until the appointed time for operating arrives. The urethra, like other parts, will bear irritation to a certain extent only, and it never can become habituated to much violence;