INTERNAL URETHROTOMY 
AND 
LITHOTRIPSY 
At the same Sitting, in a Patient Seventy-nine Years of Age; 
WITH REMARKS ON 
RAPID LITHOTRIPSY, 
AND ON 
THE EVACUATION OF DETRITUS FROM THE BLADDER. 
BY 
J. W. S. GOULEY, M.D., 
Professor of Diseises of the Genito-Urinary System in the Medical Department of the University 
of New York; Surgeon to Bellevue Hospital, etc. 
Reprinted from “The Medical Record;” October 18th, 1879. 
NEW YORK: 
TROW’S PRINTING & BOOKBINDING COMPANY, 
201-313 East Twelfth Street. 
1879. INTERNAL URETHROTOMY AND LITHO- 
TRIPSY 
At the Same Sitting, in a Patient 79 Years op 
Age; with Remarks on Rapid Lithotripsy, 
and on the Evacuation of Detritus 
prom the Bladder. 
For the facts connected with the previous history of 
the case detailed below, I am indebted to Dr. Ramon 
L. Miranda, who obtained them from the patient. I 
take great pleasure here in making my acknowledg- 
ments to Dr. Miranda for his valuable aid in the 
management of the case. 
Doctor , an eminent surgeon of Havana, Cuba, 
seventy-nine years of age, of spare build, but of great 
energy, has of late years become invalided on ac- 
count of dysury and of vesical irritation ; but he has 
nevertheless been able to perform his usual labors, 
and his general health has suffered but little. Without 
antecedent urethritis, he has had symptoms of ure- 
thral stricture ever since 1886, when J. Cloquet, of 
Paris, detected a narrowing in the pendulous portion 
of the urethra, for which, however, nothing was done, 
and he seldom suffered more than ardor in urination, 
principally during the night, or after having taken 
more than his wonted exercise. 
On the 80th of June, 1878, after an obstinate con- 
stipation of four days, he was seized with complete re- 
tention of urine, from which, in twenty-four hours, he 
was relieved by the introduction of a gum catheter No. 
Compliments of 
J. W, S. GOULEY, M. D. 8 (French scale), which was kept in for three days. Its 
removal caused much pain, owing to alteration of its 
surface by the urine. It was replaced by another cath- 
eter, which was renewed every day, but retained only 
from four to eight hours. This was continued eighteen 
days, and the bladder regularly irrigated with sundry 
solutions—of acetate of lead, phenic acid, etc. Baths, 
cataplasms, leeches to theperinaeum, etc., were also em- 
ployed. From that time he began to experience, 
during each act of urination—which was unduly fre- 
quent and difficult—much pain at the anus and in the 
urethra, especially in the fossa navicularis, and the 
urine became purulent. These symptoms have ever 
since persisted with more or less severity. He has 
never had pain in consequence of riding on rough 
pavements, and twice he rode one mile in a carriage 
to see me, without suffering the least inconvenience. 
He had consulted many surgeons, most of whom were 
of opinion that his troubles were caused by prostatic 
enlargement and urethral strictures. About a year 
before I saw him, gradual dilatation was suggested, 
and then internal urethrotomy, which was done in 
September, 1878, with Maisonneuve’s urethrotome. 
The incision made was very superficial (“ nothing 
more than a scarification”), and a “straight metallic 
sound, No. 11 (French), was introduced with much 
force—causing intense pain without entering the 
bladder.” In the course of an hour the extravasated 
blood in the surrounding connective tissue formed 
a tumor on the right side of the body of the penis, 
extending to the pubes; this hrematoma gradually 
disappeared, but left at the base of the penis an in- 
duration which has remained very tender to the 
touch, and which has seemed to the patient to be the 
starting-point of the great pain he has suffered while 
urinating. 
Continuous dilatation was afterwards tried with 3 
Beniqu<s’s catheters, from No. 6 to No. 12, changing 
the instrument every twenty-four hours. Dining this 
course of treatment of twenty-one days there was the 
most profuse suppuration, and finally on the twenty- 
first day a free haemorrhage. From that time until 
July, 1879, a sound was introduced every second day, 
but without the slightest benefit. The only relief he 
experienced was from frequent vesical irrigations with 
tepid water. Meanwhile the bladder was several 
times explored, but no calculi were detected; still the 
patient himself thought that there might be stones. 
Once the bladder was injected with a strong solution 
of nitrate of silver on account of “ recto-vesical neu- 
ralgia.” This he thinks made him much worse. He 
finally concluded to come to New York to be treated, 
and on July 21,1879, called upon me at the sugges- 
tion of, and with, Dr. Ramon L. Miranda. I detected, 
with a soft bulbous bougie, three urethral strictures— 
one in the fossa navicularis, the second at two inches 
and a half, and the third at four inches from the 
meatus; this last admitted No. G (Eng.). I made 
dilatation to No. 8 steel sound, and, wishing to ascer- 
tain whether he could empty his bladder, I passed a 
No. 6 (Eng.) Mercier soft catheter, and as soon as 
it entered the bladder grated against a hard bpdy, 
which I thought was a stone; very little urine flowed 
—not more than an ounce—and no bleeding ensued. 
Rectal exploration revealed hypertrophy of the pros- 
tate to double its normal size. There was no median 
prostatic hypertrophy, as afterwards ascertained. My 
mind was made up as to what should be done, but as 
the patient was very nervous and timid from his pre- 
vious sufferings, and as, besides, he required preparatory 
treatment, I said nothing of the necessity of a cutting 
operation, but simply advised daily vesical irriga- 
tions, and the introduction of sounds partly to dilate 
the strictures, partly to blunt the extreme sensitive- ness of the urethra, and enable me the better to ex- 
plore the bladder. Full doses of quinine were pre- 
scribed. On the following day I passed a No. 8 sound, 
and as it entered the bladder its point came in contact 
with a calculus. Dr. Miranda took the sound, and 
also felt the stone. I then introduced a Mercier cathe- 
ter and irrigated the urethra and bladder with a solu- 
tion of biborate of soda. This was repeated daily 
until August sth. Twice during that time I was 
obliged to push back with the sound a calculus which 
was engaged in the urethro-vesical orifice, where it 
had been creating much irritation for several hours. 
Nos. 9, 10, and 11 sounds caused much pain, which 
was, however, well enough tolerated, and no rigor, 
no hemorrhage, at any time followed the hse of these 
instruments. 
He rested each day, but was able to call at my 
house to be catheterized. I thought further attempts 
to dilate the strictures out of the question, as they 
were extremely resilient, and advised internal ure- 
throtomy and lithotripsy at the same sitting, and the 
7th of August was appointed for the day of operation. 
A cathartic on the 6th, and an enema on the morning 
of the 7th were ordered. Assisted by Drs. Miranda, 
Lewis, Roberts, Sayre, Jr., and Goodwillie, who ad- 
ministered nitrous oxyde, I made free division of 
each of the three strictures, from behind forward, with 
Giviale’s urethrotome, and was able to introduce a 
steel sound ten millimetres in diameter; then, with a 
flat-bladed lithotribe, seized and crushed four phos- 
phatic calculi, one of half an inch, and three of three- 
eighths of an inch in diameter. I also caught and 
crushed seven fragments (some of these may have 
been small stones) each of a quarter of an inch in di- 
ameter, and four of one-eighth of an inch—fifteen 
seizures in all, including the four stones. The litho- 
tripsy proper occupied less than five minutes, during 5 
which time the lithotribe was twice introduced, and 
brought out charged with detritus. I noticed, while 
passing the instrument, that its point became engaged 
in the mouth of an old false route on the right side in 
the sinus of the bulb, but by altering its direction it 
went in without further impediment, and in the sub- 
sequent introductions of all instruments I always 
succeeded in avoiding this cul-de-sac. There were 
columns in the bladder, from hypertrophy of the 
muscular coat. Aspiration with Bigelow’s elastic 
pear was then made, but very little detritus was 
brought out. The entire operation—that is to say, the 
exploration, the urethrotomy, the catheterism, the as- 
piration of detritus, etc., lasted twenty-eight minutes. 
There was very little loss of blood, and the immediate 
effects of the anaesthetic passed away rapidly. In 
two hours the bladder was emptied by means of a 
catheter, and in three hours after, catheterism was 
again done with a No. 14 (Eng.) Mercier gum cathe- 
ter, which was then plugged and retained for seven- 
teen hours. Every three hours the plug was removed, 
and the urine which flowed was at first fetid and 
tinged with blood, but soon became clear. The 
catheter was replaced by another, which was retained 
only seven hours. There was some tumefaction of 
the penis, which on the fourth day entirely disap- 
peared. He was up on the seventh day. Nine grains 
of detritus had been obtained, partly from the beak 
of the instrument, partly by aspiration, and in the 
first two or three days eight grains came away through 
the catheter. Probably an equal quantity was lost, as 
he urinated spontaneously several times. Free doses 
of quinine were administered during the whole treat- 
ment, and the bladder was frequently irrigated with 
a solution of biborate of soda. As on the day he 
got up (&.ug. 14th) he had a considerable amount of 
irritation at the urethro-vesical orifice, and the old 6 
ardor at the anus and in the fossa navicularis, I made 
■an exploration of the bladder with a flat-bladed litho- 
trlbe, and seized and crushed three fragments (or 
small stones) of a quarter of an inch in diameter, 
brought out a beak full of detritus, and, with what 
was passed through the catheter, obtained in all eight 
more grains (the detritus was never weighed until it 
was quite dry); at the end of two days no more detri- 
tus came away. On August 19th I sent him to take 
a ride of four miles on rough pavements; when he 
returned the urine was slightly tinged with blood, 
and he felt the old pains in the pcrinseum and urethra. 
On the 20th I made a third exploration of three and 
a half minutes, and could find only two fragments, 
one of a quarter, the other of one-eighth of an inch, 
and brought out a beakful of detritus, which, when 
dry, weighed three grains. The total amount of de- 
tritus collected weighed, when dry, twenty-eight 
grains. After this he had no more symptoms of stone. 
Still, in two days I made another exploration, and in 
two more days a final and most thorough examination 
with the lithotribe, without finding any trace of cal- 
culous concretions. Steel sound No. 15 (nine milli- 
metres in diameter) had be'en introduced every second 
day, and he was soon able to pass it himself. During 
the whole of this time he never had a rigor, nor in- 
deed any other untoward symptom. On account of 
some remaining urethro-cystitis, I several times irri- 
gated the whole urethra and bladder with a very 
weak solution of nitrate of silver, which produced 
the desired effect. 
Before his departure he was able to urinate a 
large jet, which was well propelled for a man with a 
large prostate, and on several occasions, immediately 
after urination, I passed a catheter, and only two or 
three drachms of urine came away. The patient 
flailed for Havana on Sept. 4th, in better condition 7 
than he had been for a year at least, promising to 
empty his bladder twice daily, and to make an irriga- 
tion with the biborate solution, and in case the urine 
should become alkaline, to use acetate of lead, as the 
principal means of preventing the recurrence of phos- 
phatic calculi. Once a week he is to introduce his 
No. 15 steel sound, to prevent recontraction of the 
strictures. 
COMMENTS ON THE CASE. 
I have selected for comments a few from the many 
points of clinical interest which this case possesses. 
The patient was known to have an ancient urethral 
stricture, which had contracted so slowly as to givo 
rise to but slight dysury at the end of forty-two years, 
and when at last (in June, 1878,) retention of urine 
occurred, it was caused not by the stricture, but very 
distinctly by acute engorgement of the already hyper- 
trophied prostate, resulting from the obstinate consti- 
pation of four clays. 
The two courses within a year of continuous dilata- 
tion had the effect of making the strictures worse, 
more resilient, though a certain amount of dilatation 
was maintained by frequent catheterism. Neverthe- 
less, in the end of July I found it impossible to dilate 
them beyond No. 11 (English scale). This, with the 
great sensitiveness of the canal, rendered ordinary 
lithotripsy impracticable. It does not appear that 
cystitis existed prior to June, 1878; this complication 
was provoked by the presence of the catheter, which 
was retained three days, and from that time date the 
vesical symptoms which became so distressing in 
1879. 
I have every reason to think that the age of the 
stones which I crushed in August, 1879, was thirteen 
months, and firmly believe that their nuclei were the 
concretions which fell from the retained catheter at 8 
the moment of its withdrawal. But it is known that 
such phosphatic calculi grow rapidly, and it might 
be asked whether in a year’s time they would not 
have attained a greater size ? Without intervention, 
most decidedly yes; they would have been each at 
least one inch in diameter but for the fact that the 
urine was drawn off and the bladder for a long time 
irrigated every day, and occasionally too with a solu- 
tion of acetate of lead, than which there is no better 
reagent for the disintegration of phosphatic calculi. 
This, it seems to me, is a sufficient explanation of the 
diminutive size of the stones. 
Two symptoms of stone were wanting in this case: 
frequent hsematurias, and pain while riding in a car- 
riage ; but these symptoms are often absent in the 
aged. Two operations were indicated: internal ure- 
throtomy and lithotripsy. Thinking that lithotripsy 
would be impracticable without the urethrotomy, prin- 
cipally on account of the great urethral irritability, I 
decided to combine the two operations, and, with the 
aid of an anmsthetic and of aspiration, hoped to be 
able to do them both at a single sitting of not more 
than twenty minutes, but succeeded in extracting only 
a very small amount of detritus, and two additional 
sittings were necessary to complete the operation. 
These sittings were, however, very short and well 
borne, though it was difficult to seize the last frag- 
ments owing to the bladder being hypertrophied 
and columnar, and neither anmsthetic nor aspiration 
was used. The aspiration was here a failure, but I 
am sure that if I had persisted and made another in- 
troduction of the lithotribe I would have succeeded 
in removing the entire detritus; but I did not wish 
to prolong the sitting. 
In another case I also failed to extract the detritus 
by aspiration, but it was because there existed a false 
route in the deep urethra which absolutely prevented 9 
the passage of any of the catheters belonging to 
Bigelow’s aspirator. The lithotribe was, however, 
always introduced with ease and all the detritus 
evacuated through one of Tiemann’s India-rubber 
catheters. Six sittings were required, and the patient 
made an excellent recovery without having suffered 
the slightest untoward symptom. 
In a third case, on account of a small oxalate of 
lime calculus which had caused inordinate vesical 
and urethral irritation, I employed anaesthesia, and 
aspiration with Bigelow’s bag, and at one short sit- 
ting completely relieved the bladder of the detritus 
made by several crushings of the hard concretion. 
Long sittings are justifiable in many cases, but I 
would not be willing to resort to them in aged per- 
sons, such as the patient of seventy-nine years who is 
the subject of these remarks; in like cases I believe 
that several (three, four, or five) sessions of one or 
two minutes, without anaesthesia, are safer than a sin- 
gle long one of an hour or more, with the aid of an 
anaesthetic. 
Among the requisites for the successful performance 
of lithotripsy is an ample urethra, or one that can be 
safely and easily rendered so, that the detritus may 
be expelled or extracted without inflicting serious 
injury to the canal. This operation was for a long 
time believed to be contra-indicated in cases of nar- 
row or resilient strictures of the deep urethra; but 
since Heurteloup gave the first impulse to rapid litho- 
tripsy and showed its applicability to such cases after 
dilatation or internal incision, a change of opinion 
has gradually come about, so that at present it may 
be considered good surgery, in case of obstinate stric- 
ture complicating a calculous affection, to make 
divulsion or internal urethrotomy, and at the same 
RAPID LITHOTRIPSY. 10 
sitting to introduce a lithotribe, to crush the stone, 
and forthwith to extract all the detritus or the greater 
part ot it, without molesting the wounded urethra by 
gravelly matter or by urine. 
I beg leave to take this opportunity to state a few 
facts bearing upon the history of rapid lithotripsy, 
and also of the aspiration of detritus from the blad- 
der, as they are now both attracting the attention of 
lithotriptists. In tracing back the history of the sun- 
dry methods of lithotripsy carried out as they were 
at first by ponderous engines—so to speak—with drills, 
saws, scrapers, and many other devices to reduce vesi- 
cal stones to dust and small fragments, at a time, too, 
when anaesthetics were not used, it has seemed to me 
marvellous that this operation should have so formid- 
ably rivalled lithotomy, and should be what it is, and 
no longer militant. The truce between the two ended 
in its becoming firmly established as a surgical pro- 
cedure of the greatest value, equal to lithotomy and 
often combined with it. 
To bring lithotripsy to its present state has required 
the best thoughts and labors of many. No one man 
has accomplished the task. Civiale, Amussat, Leroy, 
Brodie, Jacobsen, Heurteloup, Mercier, Fergusson, and 
others of the same period, have performed the bulk of 
the work, and have established the great principles 
by which we are now guided. Minor details, but no 
new principles, have since been given, and from time 
to time modifications and improvements of existing 
instruments have been made by faithful students of 
lithotripsy. From an early period of the age of lith- 
otripsy, nearly all of those surgeons above named 
began their endeavors to simplify the operation and 
the instruments necessary for its execution, and to re- 
duce it to one sitting. Prominent among these men 
was Heurteloup who, having recognized that angular 
fragments made by his percussor “often caused grave 11 
accidents, wished to make it possible to extract them 
without danger.” He experimented to that end for a 
number of years with a spoon lithotribe, which he had 
invented in 1833, and published in 1840 the result of 
his labors in a work bearing the title of “ Lithotripsie 
sans fragments, au moyen de deux procCdCs de I’extrac- 
tion immediate ou de la pulverisation immediate dcs 
pierres vSsicales par les voies naturellcs.” In his me- 
moir of 1832, on the destruction of vesical stones by 
percussion, he says: “ Lithotripsy is the art of crushing 
stones in the human bladder, in order that the powder 
and fragments may be expelled with the urine, or that 
their exit may be provoked by artificial means.” To 
these artificial means he gave the name of lithocc- 
nosis, which signifies evacuation of the stone, from 
Atdor, stone, ksvcoctis, evacuation. In this same work 
he cites Meyrieux as having been the first to attempt 
to make an instrument capable of reducing a stone 
entirely to powder, but says that this was without 
success. He also speaks of Tanchou’s unsuccessful 
effort in the same direction, and of that of Yidaland 
of Amussat. These instruments were designed to 
grind or rasp the stone from the surface. Our coun- 
tryman, Dr, E. M. Moore, has for many years been 
laboring to perfect an instrument designed to reduce 
vesical stones of considerable size to powder by at- 
tacking the surface. The object of all these proced- 
ures was to reduce lithotripsy to one sitting, but of half 
an hour or even much more, and it is very evident that 
each of these inventors was aware that the bladder 
containing a stone was often capable of tolerating for 
a considerable time the presence of instruments; but 
this tolerance of instruments had been fully demon- 
strated from the very beginning of the life of litho- 
tripsy. The first operation of Civiale (1824), gave 
evidence of the greatest tolerance of the bladder to 
instruments and to angular fragments. This operation 12 
required four sittings; two of twenty minutes each, 
one of thirty-five minutes, and a fourth short sitting 
whose precise time is not stated. After each of the 
first three sittings the patient had fever, but suffered 
no other serious complication; the treatment having 
lasted one month. Civiale naively says that, this 
being his first trial, he had not determined the length 
that could be given to each sitting. He afterwards, 
in many cases, shortened the sittings to ten, eight, five, 
and later, even to three minutes. 
Heurteloup labored hard, but in vain, to gen- 
eralize his operation of lithocenosis. No such op- 
erations can, or ever will be, generalized, for the ex- 
ceptional cases will too often be more numerous than 
those which come within the rule. However, this 
operation of Heurteloup’s with the spoon lithotribe is 
too good to have been set aside. With slight modi- 
fications I believe it can now be applied to a large 
class of cases. This very ingenious surgeon says, in 
his work on lithotripsy without fragments, that he has 
succeeded at one sitting of less than twenty-five 
minutes in extracting the entire detritus of a stone 
thirteen centimetres in circumference, weighing twen- 
ty-eight grammes; and that though, to accomplish 
this, he was obliged to introduce the instrument many 
times, the patient bore the operation well. He fur- 
ther says that larger stones have required two such 
sittings and sometimes more. In the work in ques- 
tion, he gives a summary of one hundred and twenty- 
four cases of stone treated by rapid lithotripsy with 
immediate extraction of the detritus, and I here re- 
produce the figures. Of these 124 patients, 69 re- 
quired one sitting; 38 two sittings; 17 three sittings; 
5, four sittings; 4, five sittings ; and 1 six sittings. 
With the spoon lithotribe, and with the aid of an 
anaesthetic, I believe it possible, in half an hour, to 
extract the greater part, if not the whole, of the detri- 13 
tus of a calculus one inch in mean diameter. Very re- 
cently I felt justified in trying what I could do with 
a flat-bladed instrument, as I had no spoon lithotribe. 
Accordingly, on the 3d of October, 1879, I operated, 
somewhat after Heurteloup’s plan, upon a patient 
sixty-one years of age, and here give the result. The 
man had, for two years, been under treatment for cys- 
titis and was finally brought to me by a student of 
medicine. In ten minutes, after five introductions of 
the flat-bladed lithotribe, I had extracted thirty-two 
grains of the detritus of a stone five-eighths of an 
inch broad, half an inch thick, and one inch long. 
No anaesthetic was used, and the operation was well 
borne. The patient, who before had always been able 
to empty his bladder, did not suffer a single bad symp- 
tom, except that the sitting of ten minutes had caused 
enough shock to the bladder, and so disturbed its 
innervation, as to give rise to temporary paralysis of 
its muscular coat. I had foreseen this, and directed 
that he be catheterized at regular intervals. A few 
hours after the operation he passed a couple of ounces 
of urine, but this was evidently by the aid of his 
abdominal muscles and not by vesical contraction. 
The urine was drawn off four times each twenty-four 
hours. At the end of the third day he could urinate 
better, but was not able to empty his bladder. On the 
fifth day he emptied the bladder spontaneously. On 
the seventh day I crushed a remaining fragment three- 
eighths of an inch in diameter. He had passed, partly 
through the catheter, partly spontaneously, twenty- 
five grains of well pulverized detritus, and the detri- 
tus resulting from the last fragment weighed six 
grains. The total amount of detritus obtained was 
sixty-three grains. 
I have known sittings of two minutes, in elderly 
men, to produce this paralysis, and now make it a rule 
to catheterize such patients every few hours after each 14 
sitting, even if they soon urinate spontaneously, and 
do this to prevent over-distention of the bladder, 
which is so apt to cause atony. This precaution 
should always be taken after prolonged sittings, es- 
pecially when aspiration of the fragments has been 
made; for this must surely cause more shock than 
simple lithotripsy. 
ASPIRATION OP GRAVELLY MATTER FROM THE BLAD- 
DER, AND OP DETRITUS AFTER LITHOTRIPSY. 
Repeated introductions of the spoon lithotribe 
which was brought out full of detritus were the only 
means that Heurteloup employed in his operation of 
lithocenosis; he says nothing of aspiration, though 
Cornay, of Rochefort, had in 1845 published his es- 
say, “Dela lith6r6tie on extraction des concretions 
urinaires,” in which are figured several aspirators and 
large catheters, straight and curved, some of them 
open at the vesical extremity, some with lateral eyes, 
others with a single large eye on the convex or on the 
concave portion of the curved instruments, always 
within a fourth of an inch of the extremity. Some of 
these catheters are similar to those at present in use 
for the aspiration of detritus after lithotripsy. 
Cornay attempted to apply his methods of aspiration 
to lithotripsy, but was not successful. It might be 
urged that aspiration as applied to the extraction of 
small vesical concretions was known in Europe more 
than a hundred years ago, that Sanctorius used a syr- 
inge for making aspiration of the contents of the 
bladder, that aspiration of vesical calculi was centu- 
ries ago employed by the Egyptians and Arabs; nev- 
ertheless, the man who really deserves the credit for 
suggesting its use in combination with lithotripsy is 
Joseph Emile Cornay of Rochefort, One year after 
Cornay’s publication, Sir Phillip Crampton’s aspira- 
ting bottle for extracting calculous detritus became 15 
known. Later, Mercier, of Paris, used for the same 
purpose an India-rubber balloon, with thick walls, at 
one end of which is a short glass cylinder, the recipi- 
ent for calculsus detritus, and at the other the neces- 
sary littings for the distal end of a large catheter. I 
have in my possession the original instrument made 
more than twenty years ago by Charrihre. This elas- 
tic balloon is described and figured by Mercier in his 
work, “Traitement preservatif et curatif des sedi- 
ments de la gravelle, de la pierre,” etc., Paris, 1872, 
p. 373. After Mercier came Clover, whose apparatus 
was modified by Robert & Colin, and after Clover, 
Bigelow of Boston, who has given us an excellent 
aspirating elastic bag or balloon, which is constructed 
on a plan similar to that of Mercier. With Bigelow’s 
apparatus more has been accomplished than with any 
of the others. 
For the evacuation of calculous detritus Dr. Bigelow 
seems to prefer straight catheters. Rectilinear cathe- 
terism here, without doubt, has its advantages, but it 
is, in many instances, very objectionable, and the 
Doctor tacitly acknowledges this by also employing 
curved catheters, whose incurvation is not, however 
well adapted to certain cases complicated with ure- 
thro-vesical valvules. The eye in these curved.in- 
struments is near the point, so that the detritus has 
to follow the curve, a defect which, for aspiration, 
renders them inferior to the straight tubes. On this 
account I have had catheters made by Tiemann & 
Co. which combine Mercier’s rectangular catheter 
with Bigelow’s large-eyed straight tube. In other 
words, I have added the beak of Mercier’s catheter, 
slightly modified, to the straight tube of Bigelow, 
and think I have thus obtained a better instrument 
than either. The form of an ordinary lithotribe’s 
beak may be given to the vesical end of this catheter. 
These various contrivances have caused surgeons to 16 
think more about the possibilities of lithotripsy, and 
have induced many to attempt the operation with 
their aid in cases where, without them, lithotripsy 
would have been absolutely contra-indicated. While 
I think very well of the combination of aspiration 
with lithotripsy, with the improved aspirators, I be- 
lieve that it can never supersede simple lithotripsy, 
lithotomy, or perineal lithotrity, which three opera- 
tions will be in use as long as men have stones in 
their bladders. The indications and contra-indica- 
tions of these various operations seem to me perfectly 
clear. 
A few more words there are which I feel bound to 
say before dismissing this subject. The combination 
of aspiration with lithotripsy is a more difficult and 
delicate operation than simple lithotripsy, and should 
never be undertaken except by a good lithotriptist. It 
is as safe in good hands as it is dangerous when im- 
properly performed. Any surgeon who is not already an 
experienced, lithotriptist and undertakes this operation is 
guilty of a great wrong. I have uttered these expres- 
sions because some surgeons seem to have thought 
that anaesthesia and aspiration made the operation 
easy, and the consequence has been that death has 
resulted soon after the operation, and from the opera- 
tion badlv done.