the tube away from the floor, aspirating them quickly while on the wing, just above the comminuted mass. In the latter part of the process, and after the smaller debris has been removed, the tube may be made to indent the floor so as to gather instead of separating the fragments; and as a final measure the tube should be raised towards a perpendicular in order to carry the orifice nearer the prostate. Some of the chips are apt to collect behind the tube orifice. The tube thus raised

(FIG. 5.) The trap is here placed in a stand upon the table. The remaining fragments are few, and the capacious bladder is depressed to assemble them. The operator stands on the patient's left, and supports his right hand firmly upon the pubes. This position is, on the whole, the most advantageous. lies behind these chips. An advantage of the inverted curved tube is that it keeps the prostatic region clear; but the orifice of the straight tube may be occasionally turned forward with the same result. A very slight movement of the tube sometimes makes much difference in the rapidity of the evacuation, so that when it is on the floor of the bladder, or quite near it, and steadied by the hand upon the pubes or the thigh, if any one expansion of the bulb proves more successful than another, the precise position then occupied by the tube should

be carefully maintained. On the other hand, when the tube is choked at each expansion, if it be withdrawn or tilted up a quarter or even an eighth of an inch, it may happen that a shower of debris at once appears in the trap. Higher in the

(FIG. 5.)

(FIG. 5.) The operator is here supposed to sit between the thighs of the patient. The bulb has been compressed, and by its immediate expansion will aspirate a part of the abundant debris suspended in the fluid above the fragments. This Figure illustrates the advantage of dispersing the fragments for aspiration, when too abundant. But the same result can be better accomplished by withdrawing the tube a little from the floor, with the hand supported on the pubes as in Fig. 4. (After a photograph from a frozen section, in which the rectum and the bladder were previously distended with plaster.)

cavity, while the debris is abundant, the orifice may be turned downward or partly sideways, so as to project horizontal currents around the bladder, the fragments being aspirated as they whirl. During the earlier part of the operation there should be no interval between the compression and the expansion of the bulb, the object being to catch the fragments while suspended. If there be any pause, it should be after the expansion, to give them time to settle into the glass trap. Later, when the fragments are too few instead of too many, a second or more may be allowed before aspirating, to gather them into the depression in the floor of the bladder,—especially as even a teaspoonful of water lightly injected on the floor shoots the debris to every part of the cavity. This artificial depression, which is made by very slight

force, plays an important part both in gathering the fragments for crushing, and, at the end of the process, for evacuation. In placing the tube at the different stages of the process, there is opportunity for a little tact, as in discovering fragments with a lithotrite.

(6.) Immediate recognition and removal of obstruction in the tube. It has been said that when the trap is held upright, as in its stand, fragments should appear in rapid succession; so that, if a short interval elapses without the fall of debris, it may be presumed that there is obstruction. This happens not only when the bulb will not expand, when the dimple disappears reluctantly and when compression is difficult, but also when the current passes so freely that an impediment would hardly be suspected.

Obstruction occurs in several ways.

(1.) In the elastic tube, which may be accidentally bent at an angle or compressed. This should be looked at first. A bit is sometimes lodged by the injected current at the end of the elastic, and can be displaced by pinching it.

(2.) In the bladder, the most common obstruction is at the orifice of the evacuating tube. A little practice will enable the operator to distinguish the encouraging rattle of debris passing this tube to appear at once in the trap (if upright) from the valvular click of fragments too large to enter it. This click is quite constant at the end of the process, after the smaller chips have been sifted off. If the orifice be choked, an effort should be made to expel the fragments in the ordinary way: first raising the tube into clear water above the debris, and then compressing the bulb with a short and forcible jerk. A half dozen such efforts rarely fail; but the rod may be introduced, if necessary.

(3.) It sometimes happens that nothing appears in the trap, although the current passes quite freely, and the click of the abundant debris is still felt. A scale or angular chip is then wedged inside the evacuating tube, which admits water, but excludes fragments. This is worth remembering. The rod

removes it.

(4.) If a fragment rattles back and forth in the evacuating tube without reaching the trap, there is obstruction high up. (See 1.)

(5.) The only other source of obstruction, and not an uncommon one, is by the wall of the bladder, when drawn against the tube with a dull thud, or a rapid succession of jerks, not unlike the bite of a fish. The tube orifice may be moved to another part of the bladder, where aspiration is more free. Perhaps the orifice has been accidentally turned sideways; it then readily engages the floor. Or the walls of the bladder are a little slack, and more water may be advantageously introduced to distend them.1

After a dozen or more aspirations it may be found that all the fragments which can pass the tube have done so, and that many of them have its full diameter. By the usual method of crushing, the lithotrite would now again be introduced, and again be followed by the tube.

LITHOTRITE. (Fig. 8.) — It would be plainly desirable, if it were easy, to crush the whole stone before attempting to evacuate it; but this has hitherto been rarely possible. The lithotrite becomes so choked with impacted debris that the convex surface of the mass less readily receives other fragments. A clean lithotrite always works to best advantage; and the operator frequently withdraws the loaded instrument to evacuate it, sometimes with injury to the neck of the bladder. It would be obviously better, if the instrument could be emptied at will in the bladder, especially if we distinctly recognize that what can be withdrawn in a lithotrite would come through a tube, and that the province of the lithotrite should be to pulverize, or indeed merely to comminute, and not to evacuate.

Although all lithotrites are made a little loose for the purpose of working out the debris, and although I have had one constructed with an especial device for this motion, I do not find it easy to clear the female blade by a lateral movement of the male blade, chiefly because the impaction is so firm that the dense mass, instead of yielding, twists the female blade from side to side. Nor does an instrument like that of Reliquet fulfill the indications. It discharges itself, indeed, as does the

1 The process of evacuation has been improved by repeated experiment since this paper was first published; that here described shortens materially the time occupied in drawing off the debris.

old fenestrated "brise-pierre"; but, as in the brise-pierre, its high sides are an obstacle to the approach of fragments. The male blade also of Reliquet's instrument is that of the lithoclast, and we need only close the blades between the thumb and finger to be satisfied of their scissor-like action upon the bladder.

The instrument about to be described keeps its blades clear, and secures certain other desirable ends pertaining to the injection of water, the lock, handle, etc.

(FIG. 6.)

(FIG. 7.)

(FIGS. 6 and 7.) Position of the hands in holding and locking this lithotrite. Fig. 6. Lithotrite unlocked. Fig. 7. Lithotrite locked by a quarter rotation of the right wrist.

Lock. The general acceptance of the cylindrical handle of