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Although many vesical and prostatic lesions are best treated by transurethral technics, procedures of this type are plagued by inherent difficulties and complications not encountered in open surgical interventions. Those seen most frequently are separation of the trigone and perforations through the bladder wall, prostatic capsule or urethra. Since the number of transurethral operations is increasing, we must anticipate a corresponding incidence of operative accidents. Urologic surgeons are well aware of these misfortunes and make every effort to avoid them. However, the possibility that perforation has occurred may either be overlooked or discounted on the basis of wishful thinking. As a result, the most favorable opportunity to correct damage and obviate sequelae may be lost. Injuries of this character usually develop during difficult transurethral resections but may complicate litholapaxy, resection of neoplasms or removal of foreign bodies. A few have resulted from sudden overdistention of the bladder by clot evacuators

To our knowledge of the very perfect operation of litholapaxy I can contribute nothing important. Indeed, I can add but little to what I said about it in 1899 before the Section on Surgery and Anatomy of the American Medical Association 1 at Newport. At that time I stated my opinion that litholapaxy was the operation of choice for the removal of most stones in the bladder. After a much enlarged experience I wish to express the belief that litholopaxy is the operation of choice in all uncomplicated cases of stone, and having seen this opinion constantly supported and confirmed by such masters of genito-urinary surgery as M. Guyon, Freyer, Keyes, Keegan, Chismore and others, it has been a source of surprise to me to find the operation imperfectly understood and little practiced among the younger generation of surgeons. So great has seemed to me the indifference toward this operation even

The operation of litholapaxy, or lithotrity at one sitting, derived much of its marvelous success from the improved rubber bulbs and metallic tubes devised by Bigelow for the evacuation of the fragments of stone. Yet Bigelow's evacuators, and also those of Sir Henry Thompson, have this serious defect: the rubber bulb makes suction only for an instant. When it reaches the limit of its expansion, it suddenly stops the outward current from the bladder, and arrests in transitu a row of fragments of stone lying along the whole length of the tube, which at the next compression of the bulb are all thrown back into the bladder. Thus a large part of the fragments are pumped out and in many scores of times before they finally escape, and the evacuating stage of the operation is tediously prolonged, often lasting thirty or forty minutes. At the same time the inflamed bladder

In order to make the drift of this paper at once clear, I wish to state at the outset the conclusions I have reached by a study of the results of others in stone operations, and from the moderate experience I have had in these cases myself. Unfortunately, residence in a region where stone in the bladder is rather rare has made the accumulation of personal observations slow, but, on the other hand, my association with Dr. Bigelow has given me unusual advantages in getting an understanding of the operation which he devised and christened "litholapaxy," and of which I shall especially speak to-day. In my opinion, we have in litholapaxy the operation of choice for the removal of most stones. While this is the rule, there are exceptions to it, and the varying conditions surrounding stone in the bladder, will now and then lead us to choose some other