to; examples worthy of imitation to all succeeding students of scientific surgery. But from Continental experience alone could we derive so extended a record as the one in question, inasmuch as on the Continent only is the full application in practice of lithotrity made; and its source is one which possesses the highest order of reliability. At the thirty-second annual meeting of "the German Naturalists and Physicians" (the institution which suggested our own British Association), held at Vienna in September of last year, Dr. Ivanchich of Vienna read a paper in the Surgical section, embodying a statistical account of one hundred cases of lithotrity treated by himself; the great majority of patients being males of fifty years old and upwards.

With very few exceptions indeed, Dr. Ivanchich gives the name at length, the residence, and occupation of each patient; so that it is competent to any inquirer to investigate any one of his statements of detail. The age, the peculiar complication present, if any, the composition of the calculus, the weight of the detritus removed, the number of sitings required, the number of days occupied by the treatment, and the final results, are recorded.

From this document I have extracted all the male cases of fifty years and upwards, and have tabulated them in order to give a statistical result in a few lines here.

Eighty-one male patients were operated upon by lithotrity, of the following ages:

In fifty-three the calculus was uric acid; in twenty-four phosphatic; in two mixed; and in two the composition is not stated.

Of the eighty-one patients, eight died within a short period after the operation from fever, shock, &c. ; but in one the disease was complicated with stricture of the urethra and renal calculi; in another with large renal calculus. Most were above 70 years of age. One, aged 75, exhibited "a remarkable example of valvular prostatic disease." It would not be fair to say that in every one of these eight instances the cause of death was altogether attributable to the operation.

Besides the eight, one died two months, and another six months after the operation of diseased kidneys; and a third died of cancer at the end of a month.

Of the seventy remaining cases, four or five are reported incomplete, and the remaining sixty-five as successful. In some instances the sittings were numerous, and the treatment protracted; but these cases were few and exceptional.

But of the eighty-one cases, eight had notable hypertrophy of the prostate: two of these had been operated on three years before. In one the results were "incomplete; " all the others were successfully treated; one only, alluded to above, dying with great enlargement at the age of 75. In five of these the stone was phosphatic; and in three, of uric acid. *

Taking the most unfavourable view of eighty-one cases of patients above 50 years of age here recorded, the deaths amount to not more than one in ten; a result which, it is needless to say, is vastly superior to our experience of lithotomy in patients of corresponding age. The experience of our metropolitan hospitals, at this period of life, records a fatal result in at least two out of every five cases subjected to the latter operation.

We now come to a consideration of the method to be adopted in the management of that which I have heretofore characterized as constituting, in some of these cases, the

most troublesome part of the process, viz. the withdrawal of the calculous fragments from the bladder.

There are four methods of proceeding, each one of which may be brought to bear in cases where any difficulty is apprehended, or encountered. All may be employed under certain circumstances conjointly, and with advantage.

These are—the employment of the scoop lithotrite; repeated injections of water, returned through a full-sized catheter with a large opening near its extremity, with or without a special exhausting apparatus attached; the position of the patient during subsequent acts of micturition; and the injection of solvents into the bladder. Each of these we may now examine in detail.

1. The application of the scoop lithotrite.

The use of the scoop lithotrite is so obvious, and its characters so well known, that it is necessary to do little more than mention it here. By its aid we may in some cases remove a good deal of fragmentary or of semi-solid calculous matter, without injury to the narrow passage through which it is to be withdrawn. It is, however, a slow process: involves a great deal of passing and repassing along the urethra, and may do much mischief when rough spiculæ are caught between its jaws, and project a little beyond their borders; an occurrence which will sometimes happen, and is not always absolutely to be guarded against; although it may be in a great measure prevented by invariably screwing home the male blade completely, before attempting to withdraw the instrument. The mechanical action of hard bodies within the bladder, however, is always to be avoided when not strictly necessary. In the management of stone in the bladder, no axiom is better established, or more religiously to be followed, than this; viz. the smaller the mechanical power expended in the attainment of any given effect, the more successful will be the final result. The lithotrite is to

be employed for no purpose which can be attained by milder and better agencies. We, may perhaps, find means of a mechanical nature which are superior even to the lithotrite under certain circumstances,

in the attainment of the object desired; while in others we may have a safer and a better resource in the more subtle dynamics of chemical action.

2. Injections of water and the evacuating catheter.

The catheter usually employed immediately after a calculus has been crushed is one not smaller than No. 12, if it can be easily introduced; it may be even larger if the urethra will readily admit it, which is not unfrequently the case. An oval aperture, about three-quarters of an inch in length, is made in its concavity, through which fragments of moderate size may make their escape. This instrument. being introduced when the lithotrite is withdrawn, the patient may stand upright or lean forwards a little, when a

FIG. 20.*

*This, which is by far the best apparatus for injecting the bladder with wateror other fluids, not exerting a chemical action on metal, is an adaptation of a recently-invented enema-pump, by means of which the fluid is propelled by a powerful spring at the will of the operator, and independently of any effort or his part, except for the purpose of regulating the force of he current, which, by simply placing a finger on the stop-cock, is done in the most perfect manner.

few ounces of tepid water are quickly injected, and permitted instantly to flow out, before the débris, stirred up by the act of injecting, can subside; when some of it usually escapes, although more commonly less passes than one might at first thought suppose. The process should, however, in order to prove successful, be rapidly repeated three or four times, if not productive of uneasiness to the patient. In this manner much débris may be removed, and many small fragments, if the stone has been well crushed, and not merely broken. The catheter is then withdrawn, care being taken, in commencing to remove it, to recognize the occurrence of any degree of obstruction, while its extremity is passing through the neck of the bladder, as a fragment may be lodged in the opening described, but with a rough or sharp angle protruding beyond it; and great pain, if not some mischief to the neck of the bladder, may result if the possibility of this contingency be not remembered and provided against. If, therefore, on beginning to withdraw the catheter, anything like obstruction is felt, or a sharp pain is complained of, it is better to inject again, which will, probably displace the fragment, and enable us to remove the catheter with ease. If this fails, however, a flexible but strong stilet, of a size sufficient to fill the catheter, with which it should always be provided, may be passed down to the end of the instrument; this will always succeed in getting rid of the obstacle, and the removal of the catheter follows without difficulty. The catheter of Heurteloup is, perhaps, preferable to that just described. This instrument, made of steel, possesses two long oval openings, situated near to the extremity. Each should be about three-quarters of an inch long; and, placed laterally, one rather nearer to the point than the other. It is represented in connection with other instruments by fig. 23, page 298.

Sir Philip Crampton has applied with success an ex