present, but for retention of urine where it was not possible to pass an instrument by the urethra. The argument which has been advanced in favor of this operation, that it is attended with less risk. of hemorrhage, does not seem to be entirely well founded. There is very little more risk in the lateral operation. The transverse perineal artery is divided, but with a little care it is not likely that the internal pudic or the artery of the bulb will be injured. In the old days of operation without an anesthetic, it was quite possible that one of these arteries might be wounded in the struggles of the patient. The artery of the bulb can be avoided by striking the staff as far back as possible. The hemorrhage from which I have had trouble has been from the prostatic plexus of veins, and this is quite as likely to occur in the median as in the lateral operation, and, indeed, I have seen very profuse hemorrhage from this source after median section.

The supra-pubic operation, although just at present the fashionable method, I should reserve for very large stones, or for cases in which there was some complication, such as tumor, in addition to the stone. Cases of vesical tumor are more satisfactorily dealt with through the supra-pubic incision, but where the case is an uncomplicated one of stone, I have not seen any reason to prefer this to the lateral method.

In the female, the operation of lithectasy or rapid dilatation is the one to be chosen, and in almost all cases will be sufficient. Mr. Bryant has shown that stones of considerable size can be removed by this method. In children, stones up to half an inch in diameter, and in adults stones up to one inch in diameter, can be thus removed. If the stone is larger, it can be broken into several fragments before removal. I believe that the results of this method will be more satisfactory than if an attempt is made to remove the calculus by litholapaxy or by any form of lithotomy. The vesico-vaginal section may leave a permanent fistula. The high operation may, of course, be required for very large stones.

As regards the operation of lateral lithotomy, the points which are to be observed are, in the first place, to make a large external

wound. I have seen very serious trouble result from too small an external incision. There is no objection to a large wound through the skin and superficial fascia; if hemorrhage occurs, it is easier to deal with it through a large wound, and drainage is more satisfactorily effected. In the second place, I think that it is of great importance to strike the staff as far back as possible. Instead of striking it where it is most superficial, I endeavor to get as far back toward the horizontal portion of the staff as possible. In that way you avoid wounding the artery of the bulb, and obtain plenty of room where it is needed. My preference is to have the staff firmly hooked up under the pubis, instead of having it made to project in the perineum. I believe that in this way it is more firmly held, and that the surgeon can fix the position of the anatomical points better, and therefore cut with more precision. Having struck the staff, I think, following the advice of Sir William Fergusson, that the deep incision should be made small. I believe that there is a decided advantage in this plan. I do not say that the surgeon should not make the wound in some degree proportionate to the size of the calculus, and in cases where there is a large stone, I am in the habit, as I withdraw the knife, of bringing it slightly away from the staff, so as to enlarge the deep wound. In children, the knite should be withdrawn in close contact with the staff; but in the adult I drop the knife a little, so as to enlarge the wound in the prostate. The finger is then introduced, and the prostatic enlargement completed by dilatation. I do not at all agree with the view of Mr. Teevan, that it is safer to cut the prostate than to stretch it. In the introduction of the finger, I lay stress upon its introduction above the curve of the staff. In children this is very important, for if it is not done, the finger may not enter the bladder, but may pass into the rectovesical space. The surgeon cannot miss the bladder if he passes the finger above the staff, as it is well held up under the pubis.

In my earlier operations I had a great fancy for the scoop in removing calculi, using it as the obstetrician uses the vectis, getting the scoop behind the stone and the finger in front of it, and bringing all out together. Of late years I have used the forceps more and

the scoop less, although at times it answers a useful purpose. the withdrawal of the stone, a mistake that I have often seen made is in not carrying the forceps far enough backward toward the coccyx. The portion of the wound where there is plenty of room is far back. I have seen surgeons try unsuccessfully to remove the stone through the anterior portion of the wound, when it could have been readily removed if the forceps had been dropped toward the back.

In the high operation, it is a great advantage to have the bladder and the rectum distended, though, perhaps, not absolutely necessary. There is an advantage, too, in lateral lithotomy, in having a moderate quantity of fluid, say about four ounces, in the bladder before the operation, as a gush of water, when the bladder is opened, will bring the stone down on the end of the finger. If, however, the bladder is intolerant, I do not care to have it much distended.

With regard to the operation of litholapaxy, the points which I consider to be of importance are, in the first place, to crush the stone. as thoroughly as can be done, and then, when using the evacuator, to make the stream enter with great gentleness. I believe that cystitis may be aggravated, or even caused, by using too much force, As regards the rapidity of the operation of litholapaxy, I have no doubt that an operator will do it with greater rapidity as he does it oftener, but for my own part, I have found it a slow operation. I think that no surgeon should undertake it who is not prepared to give as many hours to it as may be necessary. I can recall three cases in the practice of other surgeons in which the patient died as the direct result of having a stone left half-crushed in the bladder. Violent cystitis came on and the patients succumbed. Where the operation is 'undertaken, it should be completed. If the surgeon is not prepared to remove the entire stone at one sitting, he should not undertake the operation at all. This is the operation for small stones in patients with healthy bladders. Cystitis is the most dangerous condition in which to resort to litholapaxy. In the case of an adult presenting himself with stone, my first thought is litholapaxy. I then consider the various circumstances in the case.

Litholapaxy has so many advantages in cases to which it is adapted, that I think it should be the surgeon's first choice.

With regard to the objection that lateral lithotomy may render the patient sterile, I do not see why that should be, provided that the operation is confined to one side of the perineum, and that no undue amount of inflammation follows. If there were a great deal of inflammation, it is quite possible that there might be such obstruction of the vas deferens as to prevent the patient from generating with the testis of that side, but there is no more reason why the patient should be rendered sterile by the operation of lateral lithotomy than than by the removal of one testicle. In the immense number of operations performed in former years, we never heard of this objection, and I believe it is rather theoretical than practical.

I have had one case of stone weighing less than two grains, which I diagnosed by the sound, and removed by lateral lithotomy. The patient was a lad who had the symptoms of stone in the bladder, and in addition, frequent attacks of sudden and complete retention of urine, due to the calculus entering and plugging the internal meatus. The straining was so excessive that, in the effort to pass water the night before the operation, the patient ruptured sub-conjunctival vessels in both eyes.

I wish to refer to a few cases of cystotomy for other causes than calculus. I do not include cases where I have operated by Sir Henry Thompson's method of puncturing a contracted bladder above the pubis. I find I have opened the bladder by cystotomy in eight cases, six of these being cases of cystitis. Of these six, four recovered and two died, as the result of the diseased state of the urinary organs. In two instances I have opened the bladder for intense pain in the act of micturition, due to a fissure at the neck of the organ. Both patients recovered. In one case the fissure followed cystitis, the result of gonorrhea, and in the other case, the symptoms came on after the use of very large sounds.

I have had one case of cystotomy in a child for tuberculous disease of the bladder. This case was of a good deal of interest. The patient had, at one time, been under the care of the late Prof.

S. D. Gross, who had sounded the child and said that he felt a stone. It is to be observed, however, that he never appointed a time to operate, so that it is possible that he may have had some doubts as to the diagnosis. A curious feature of the case was that the father, who was a man of considerable intelligence, declared that he had himself distinctly heard the click of the stone against the instrument. I sounded the child, but was not entirely satisfied that a calculus was present, although, from the history, I thought it probable. The child had all the usual symptoms of stone, except sudden arrest of the urine. I asked Dr. Forbes to see the case with me, and we thought it right to open the bladder. No stone was found, but there were discharged twenty or thirty little bodies which I presume were what the older surgeons would have spoken of as fibrinous calculi. They looked like little pieces of catgut. Whether these were masses of tuberculous material, or of inspissated mucus and lymph, I do not know. The patient was relieved of his symptoms, but died two months afterward of tuberculous disease of the mesenteric glands.

DISCUSSION.

DR. JOHN B. DEAVER: I was glad to hear Dr. Ashhurst refer to advanced Bright's disease and cystitis as contra-indications for litholapaxy. I have been struck with the fact that concussion of the bladder walls during the washing out of the fragments must be an exciting factor in producing an uremic condition when there is disease of the kidneys. I recall one case operated on by one of the older surgeons, where uremia occurred within twenty-four hours. after the operation. I have known of one or two such instances. In other cases, apparently similar in character, lithotomy has been performed, and no trouble has followed. There is no doubt there is some connection between the operation of litholapaxy and uremia. In the cases where I have performed the operation, I have had a careful examination of the urine made to exclude cystitis and chronic affection of the kidneys before operating, in addition to making the other tests familiar to you all.

DR. H. R. WHARTON: In regard to litholapaxy in children, my experience is limited to one case, which was that of a child 6 years