2. Lithotrity or litholapaxy is indicated in the female when the stone is over 1 inch in diameter, or when it is composed of salts deposited upon some foreign body. Fergusson gives a list of cases in which he has done lithotrity in girls with most brilliant results, nearly always removing all the fragments at the first sitting. And Walsham has collected altogether eight cases of lithotrity in girls under fifteen years of age, with and with out previous urethral dilatation, in all of which there was complete cure without incontinence. In three of these latter cases repeated operations were necessary on account of the size of the fragments. The patients are narcotized and put in the lithotomy position. Then tbe bladder is filled with three to five ounces of lukewarm water, tile instrument is warmed, greased with carbolized oil. The stone is then guided from the vagina in adults, from the rectum in children, into the jaws of the instrument, and is broken. After this more water is injected into the bladder, the smallest of Simon's specula introduced, and as many calculi as possible removed. Then search should be made for larger fragments which may have remained behind per vaginam, and the urethra dilated still further, or lithotrity repeated. The after-treatment is that of vesical catarrh.
3. The vesie,o-vaginal incision is to be employed when the stone is over 1.2 inch in size, and is too hard to be crushed. Febricius Hildanus (1628) was the first to do it. It was long the practise when the calculus was lodged in a cystocele, to incise the sac for the removal of the stone; this has been done by Rosset, and by Ruysch. Or a hollow sound was paased into the bladder, the point pressed against the vesico-vaginal sep tum, and the cut made down upon the groove. The description of Simon's T-incision, which is only needed with very large stones, is given on page 15. Walsh= states that by means of the vesico-vaginal incision 6 out of 8 children were completely cured; 2 remained incontinent from laceration of the soft parts and the urethra in extraction. The yesico vaginal incision is in the female by far the best operation for the extrac tion of calculi. According t,o Aveling there was only 1 death in 34 operations of this kind. But in children the calculus may be so large that it cannot pass through the lesser pelvis, or can only be dragged through with much laceration of the soft parts; and this may even be the e.ase in adults, as in Josephi's cases of extra-uterine pregnancy with penetration of the bladder.
4. The ve,stibular incision. We mentioned in the introduction the Celsian operation for stone in women, and saw how indefinite his descrip tion was; since we cannot understand what he means by " sed virgini sub ima sinisteriora." The statement " mulieri vero inter urinre iter et os pubis incidendum est " is clearer, and evidently means something like the opemtion which Lisfranc proposed in 1823, but did not do upon the living subject He proposed that an assistant should press down the point of a male catheter, which had been introduced into the bladder with its convexity upwards, while another assistant forcibly separates the labia minors. Then the operator cuts with a straight bistoury, begin-
fling above the urethra, and going from right to left, dividing mucous membrane, connective tissue, and the constrictor cunni. Under the symphysis, without injuring the pudendal artery, whose pulsations can be plainly felt, he enters the anterior vesical wall, and cuts it longitudi nally or transversely. But the space obtained to work in is smaller, and the hemorrhage more s,erious than in other methods. However, as we mentioned on page 194, Thomas in 1839 successfully removed a stone from a pregnant woman by this method.
5. Lateml lithotomy in the female is done either in the method of Cel sus before mentioned, or as done by Frere Jacques de Beaulieu from the left tuber ischii, against a gorget introduced into the bladder, or in the manner more recently (1854) proposed by Buchanan of Glasgow. He has an assistant hold a hollow sound introduced into the bladder, and near the clitoris begins an oblique cut through the left labium minus parallel to the left pubic ramus. As soon as he can feel the gutter of the sound he transfixes the vesical wall against it with a straight bistoury; he then en larges the vesical wound above and below without injuring the vagina, until he can pass *his finger into the bladder. He operated in this vray upon four children from four to seven years old, and quickly removed stones varying from 15 to 75 grains in weight, and without incontinence. Finally, the method by which the urethra and vesical neck is split to the left side of the vagina, along a channelled sound, has been called lateral lithotomy. During the operation an assistant fixes the left labium with one hand, while another pulls the vagina to the right, and protects it from injury. The operation may also be done with the lithotome cache; and v. Nussbaum (1861) did it repeatedly and with success before lith trity.
6. Supra pubic lithotomy, epicystotomy, sectio alta, is only indicated in the female when the size of the calculus or the number of the stones, or the narrowness of the soft parts, renders the vesico-vaginal incision inade quate. In 4 cases, done on girls 4 to 8 years old, 2 ended in death, and 2 in recovery. The method of operation is exactly the same as in the male, and its description here is unnecessary.
In any operation where an artificial opening is made into the bladder, if it is not to bo immediately closed with metallic sutures as in vesico vaginal and urethro-vaginal fistulie, a catheter should be placed within the urethra so as to promote the outflow of urine along the natuml pas sages. Still, it is not invariably necessary, and sometimes does harm; and if uriue can be passed spontaneously, it is only to be used for washing out the bladder and removing blood clots.