FIG. 1.

ably below it. The exhaust then acts as a siphon, and readily draws off the water. The fragments gravitate to the bottom of the bulb, and are there collected in a glass chamber. (See Figures 1, 4, 5.) To prevent the possible return to the bladder of some single fragment while on its way to this receptacle, the rubber tube, if long, should be provided with a small glass trap containing a wire-gauze or perforated tube, to deliver the current and strain it on its return, but with a short rubber tube (Figs. 1, 4, 5), which is more convenient, this is not essential. One or two smaller bulbs might perhaps be provided for a contracted bladder.

The successful evacuation of the bladder depends upon several conditions, both in the apparatus and in its use, which for distinctness may be enumerated separately. (1.) A large calibre of the evacuating tube.

(2.) Its shape.

(FIG 1.) Evacuating Apparatus. 1. Elastic bulb. 2. Curved rubber tube. 3. Curved evacuating tube of silver. 4.

(3.) The shape of its receiving Straight evacuating tube, which is pref

extremity.

(4.) Manipulation of the bulb.

(5.) Evacuation of the fragments.

erable to the curved one. 5. Front view of same. 6. Glass receptacle with bayonet joint for debris. (Tiemann & Co., N. Y.)

(6.) Immediate recognition and removal of any obstruction in the tube.

(1.) A large calibre of the evacuating tube. Whether or not we adopt the view of Otis, that the average capacity of the normal urethra is at about 33 of Charrière, there can be no question that it will admit a much larger tube than that commonly attached to either Clover's or the French apparatus. The efficiency of the process of evacuation depends much upon using the largest tube the urethra will admit. This fact has

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been stated by Sir Henry Thompson. But he recommends for the glass cylinder or trap which is to admit this tube a perforation at the end, the size of a No. 14 catheter," 25 Charrière.1 This perforation is too small; and the tube which is designed to enter it is further reduced by its collar to the diameter of only 12,21 Charrière. In fact, this is the calibre of the evacuating catheters now attached to Clover's instrument, and is of itself fatal to their efficiency. An effective tube has a calibre of 28 to 31 or even 32 Charrière, and the meatus, which is the narrowest part, may, if necessary, be slit to admit it, if the urethra is otherwise capacious. Again, in the instrument, as sometimes constructed by Weiss, a joint is made by inserting an upper tube into a lower one, thus obstructing the calibre by a shoulder. The joints should become larger as the tube approaches the bottle, so that the tube may deliver without difficulty fragments of its own calibre. Whatever be the size of the evacuating tube, the rubber tube, with its metal attachments, should have a calibre of at least seven sixteenths of an inch, 31 Charrière.

My evacuating tubes are of thin silver, of sizes 27, 28, 29, 30, and 31, filière Charrière, respectively.

(2.) Shape of the tube. Works upon lithotrity enumerate and figure a variety of tubes through which fragments are to be aspirated. Many of these are useless. The best tube is a straight one. (Figure 2 a.) That which is curved quite near the extremity is designed to be used with the curve inverted and directed downward, the orifice then looking forward.

(3.) Shape of the receiving extremity. The receiving extremity should depress the bladder when required to do so, and thus invite the fragments, while its orifice remains unobstructed by the mucous membrane. Upon the floor of the bladder, when not indented, a fragment of stone, lying at the distance of half or even quarter of an inch from the tube extremity, may not be attracted by the usual exhaust of the expanding bottle, which requires that the fragment should lie almost in contact with the tube. A very slight obstacle also impedes its entrance; and this fact renders inefficient all tubes like catheters, with orifices along the side or upper wall. Chips will not

1 Diseases of the Prostate, 4th edition, 1873, page 337.

FIG. 2.

surmount their edge. Again, the orifice of a tube cut square is at once occluded by drawing in the vesical wall, while the spoon-shaped beak of the French instrument, made like the female blade of a lithotrite, allows fragments to lie too far from the opening in the tube. The best orifice is at the side of the extremity, and is made by bending the tube at a sharp right angle, carefully rounding the elbow, and then cutting off the bent branch close to the straight tube. (Figure 2 a.) The tube is then practically straight, while the orifice, which is slightly oval, delivers its stream laterally. The edge should be a. Straight tube. b. Curved tube. The dotted lines show thickened and round- the false floor of the extremity. The tubes are here of a diameter 31 Charrière. The straight tube is preferable. ed to slide smoothly through the urethra; any rim inside the orifice should be masked by a false floor; but the calibre should be nowhere contracted. If the side walls of this orifice be removed a little, it gives an unguiform extremity to the tube, which is advantageous; and in introducing such a straight tube this tip should be insinuated through the triangular ligament by rotation. If a couple of inches of the end of such a tube be bent, it may be inverted after introduction, and will bury itself in the floor of the bladder, which it depresses, while the orifice looks forward and is unobstructed. (Figure 2 b.) This form is tolerably efficient; although I prefer the straight tube, as less liable to lodge fragments, and more readily cleared by a rod, as safer, because it involves less risk of injury to the bladder than is incurred by the rotation of a curved extremity, and especially because it is easy to know exactly where the extremity

(FIG. 2.) Evacuating tubes, with unguiform extremity.

lies. An effective instrument may be made of a straight tube cut square at the end, if a disk convex outwardly, to repel the bladder, be attached to it, at the distance of a diameter from the orifice. This was the original of the straight tube already described. When such an instrument is introduced, the interval can be filled by a rod. Indeed, the orifice of a tube should be contrived with a view to its introduction. The French tube already spoken of, shaped like the female blade of a lithotrite, would be efficient, if it were made large enough,— as it is not,

and if the shoe were bent to make a precipitously inclined plane for the fragments. It would then offer a prolongation of the unguiform tip; but, thus sharply bent, it would be less easy to introduce. Whatever be added to the extremity of the tube, in order to facilitate its introduction or to repel the bladder, should not prevent the orifice from lying, if required, in the floor of the bladder at the apex of a steep inverted tunnel.1

(4.) Manipulation of the bulb. When the capacities of the bladder and urethra have been ascertained, the evacuating tube is introduced and the bladder completely emptied. A few ounces of water are next injected, that the fragments may still be floated after aspiration, and the apparatus, previously filled with water, is attached to the silver tube. To fill the bulb and at the same time expel the air, it should be held upright and several times compressed while the curved elastic is immersed in water, the latter being then kept uppermost until attached to the evacuating tube. Air in the bladder disadvantageously distends it without floating the fragments. The large bulb, together with its tubes, contains about ten ounces. If compressed with one hand until the sides meet, only about five ounces are displaced. If half compressed and then worked

1 Too large an orifice impairs the suction and admits fragments that become wedged higher up. If the straight tube (Fig. 3) be closed by an extremity symmetrically round or ovoid, to facilitate its introduction, the hole a d in its side should have a length but little greater than the diameter a c of the tube. The curve of the inside floor b is a quarter circle described upon a as a centre. The tube is then proved by a close-fitting ball rolled through it from above. At a the edge is a little thickened on the outside, and at d rounded, to protect the urethra.

d

FIG. 3.

with a shorter movement, about two ounces are moved back and forth; so that, provided the tube itself be handled carefully and skilfully, the bladder is not greatly disturbed. At the beginning of the process the short movement is effective. The object of more water is to prolong suction when fragments are passing freely, - also 'occasionally to stir up the debris, — and especially to relieve obstruction in the tube, when it occurs. The best position for the surgeon is at the right hand of the patient, resting his left wrist on the pubes to steady the tube, while the bulb is supported in a stand on the table between the thighs. (Fig. 4.) Or, (Fig. 5,) the surgeon, sitting between the supported feet of the patient, compresses the bulb with the right hand, using the left alternately to hold the glass trap and to adjust the silver tube. In the latter position the hand is apt, when fatigued, to bear heavily on the evacuating tube, so that it is better then to use the bulb as a handle to direct the silver tube, the interposed elastic saving the bladder needless fatigue.

(5.) Evacuation of the fragments. Evacuation of the fragments is quite an entertaining art, requiring as much skill to accomplish the result in the shortest time as crushing them. Dexterity in the process will hardly be acquired without practice outside the bladder.' If the bulb be compressed and immediately allowed to expand, while the tube is held just above the debris, the fragments should fall in a shower into the trap. The operation may be divided into a first and a last half. During the first half, while the fragments are numerous, the secret is to separate and float them by the injection, so that they may enter the tube as they fall, in single file, without obstructing it. This is accomplished by keeping the orifice of

'The bladder may be imitated by the lower two-thirds of an ox-bladder (carbolized for cleanliness) suspended inside a vessel having a mouth of four or five inches diameter, to which it is tied. The vessel should be previously nearly filled with water. To show the different and more efficient action of circular currents in the closed bladder, let the ox-bladder be tied to the evacuating tube, and held before a bright light. With a tin funnel secured to the summit of a human bladder (in situ) to aid in replacing the fragments, the process of evacuation can be rapidly repeated. Calculi may be imitated by coal of varying hardness, or by a bit of old grindstone; a lighter and tough material for crushing, and liable to impact, is the cheap compressed meerschaum.