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to two or three or perhaps five minutes. The like solicitude seems to have led Sir Henry Thompson, in his admirable and standard work upon this subject, to assign two minutes as the proper average duration of a sitting, -a period which his exceptional skill has often in his own practice enabled him materially to reduce. I have been gratified to find, however, that since he has availed himself of the advantage of etherization he recognizes the benefit to be derived from somewhat more prolonged manipulation. My own conviction is that it is better to protract the operation indefinitely in point of time, if thus the whole stone can be removed without serious injury to the bladder. I believe that in any case as favorable to lithotrity as the average, in these days when stones are detected early, this can be effected, and that if the bladder be completely emptied of detritus, we have as little to apprehend from the fatigue of the organ consequent upon such manipulation as from the alternative of residual fragments and further operations. The duration of the longest sitting among the cases reported at the end of this paper was three hours and three quarters. The same result can be now accomplished in a shorter time. In a majority of cases the bladder can be completely and at once evacuated. The stone, after crushing, can be removed through the urethra by a tube contrived for the purpose.
But has not this result been already attained by evacuating instruments variously devised and modified? The following quotations from the latest authorities sufficiently answer this question in the negative.
"We may here say, without fear of being accused of exaggeration, that evacuating injections practised after sittings of lithotrity have no apology for their use. The whole surgical arsenal invented for their performance is absolutely useless.. It should be well understood that the best of evacuating catheters is worthless." (Article Lithotritie, by Demarquay et Cousin, in the Nouveau Dictionnaire de Médecine et de Chirurgie Pratique. Paris, 1875. Pages 693, 694.)
"The practice of injecting the bladder to wash out detritus is obsolete. This apparatus of Mr. Clover should not be employed, if it is possible to dispense with it, as its use is quite as
irritating as lithotrity itself." (S. D. Gross, Diseases, etc., of the Urinary Organs. Philadelphia, 1876. Page 232.)
'Having used it [Clover's apparatus], very frequently, I would add that it is necessary to use all such apparatus with extreme gentleness, and I prefer to do without it, if possible.” (Sir H. Thompson, Practical Lithotrity and Lithotomy. 1871. Page 215.)
"All these evacuating catheters are little employed. They require frequent and long manœuvres, which are not exempt from dangers; besides, they give passage, as a rule, only to dust, or to little fragments of stone, which would have escaped of themselves without inconvenience to the urethra." (Article Lithotritie, by M. Voillemier, Dictionnaire Encyclopédique des Sciences Médicales. 1869. Page 733.)
In short, the "evacuating apparatus" and the evacuating method hitherto employed do not evacuate. This fact is beyond question.
Such apparatus is not of recent contrivance. From the earlier days of lithotrity, the operation of breaking the stone has been followed by the obvious expedient of introducing a large and special catheter, through which water was injected and allowed to escape, bringing away a little sand, with a small fragment or two. This attempt at evacuation was aided by suction. With this object, and before the year 1846, Sir Philip Crampton employed an exhausted glass globe. For the same purpose a syringe has been used, or a rubber enema or hydrocele bottle, with which fluid could be also injected and the bladder washed. By entering the catheter well within the bottle or syringe, fragments were dropped inside the neck, where, lying below the current, they remained when the bottle was again compressed. When this neck was made of glass, by Clover, the fragments became visible, as in Crampton's globe, and to this neat arrangement the accomplished lithotritist, Sir Henry Thompson, refers as Clover's bottle. But neither the previous practice nor the efficiency of evacuation by suction through a tube had been materially advanced. In the mean time the syringe was modified in France by a rack and pinion attached to the piston, so that water could be injected and withdrawn with great force, a procedure not only useless, but detrimental to the bladder, if inflamed and thickened.
Before describing my own instruments, it may be well to say a word in regard to the introduction of large instruments into the bladder. The successful introduction of the large straight tube is so important that it deserves especial mention.
A syringe facilitates the copious use of oil both in the urethra and within the tube. Into the normal urethra a straight instrument can be introduced with more accuracy than a curved one. Either may be passed rapidly as far as the triangular ligament, unless the instrument is very large, in which case great care is required not to rupture the mucous membrane. Having reached this point, which implies that there should be no premature endeavor to turn the instrument, but that it should be passed as far as it will go in the general direction of the anus before its direction is changed, the extremity of the instrument depresses the floor of the urethra in front of the ligament. Traction upon the penis next effaces this depression, and adds firmness to the urethral walls; so that if the instrument be withdrawn a little, and again advanced after lowering the handle, it can be coaxed without difficulty through the ligament in question, a natural obstruction which physicians often mistake for a stricture. The straight tube may be advantageously rotated through the aperture like a corkscrew. This obstruction passed, the rest of the canal is short, and corresponds to the axis of the body, to the line of which the instrument is now depressed. Even the enlarged prostate can often be traversed advantageously by a straight instrument. In fact, the metallic prostatic catheter, before it was superseded by the modern rubber one, consisted essentially of an inch or two of straighter tube added to the extremity of a common catheter, to reach through the unyielding prostate before the hand was depressed and the beak turned up. In passing either a sound, catheter, or lithotrite, the extremity of a straight instrument, and, curiously enough, the convexity of a curved one, is sometimes arrested just at the entrance of the bladder by the firm lower edge of the inner meatus. The fact that water now dribbles through the inner meatus thus dilated, or that a stone is felt with the tip of the curved instrument, which has really entered the bladder, may lead the operator into the mistake of supposing that the instrument is
fairly within; and I have known its further entrance, after sliding over this obstacle, to be erroneously explained by assuming the existence of a second or hourglass cavity in the bladder itself. To obviate this difficulty, and so soon as the triangular ligament is passed, a catheter, if curved, should be pressed through the indurated neck or prostate in the direction of the axis of the body, by the hand on the perinæum, — a most efficient manœuvre, when the prostate is large. If there be further difficulty, the tip should of course be sought and guided in the rectum. After introduction, a straight tube or the shaft of a curved one often returns to an angle of about 45° with the recumbent body, and, if the patient is not etherized, a feeling of tension may then be relieved by depressing, with the hand upon the pubes, the suspensory ligament of the penis, · an expedient also useful during the passage of the instrument. My own practice has always been to etherize for lithotrity. Each operator prefers the position to which he is accustomed ; and when the urethra is healthy, this is of very little importBut if there be obstruction, a position at the patient's left side enables the operator to introduce a catheter or lithotrite to advantage with the right hand, leaving the left hand free to act in the perinæum. After the instrument is introduced, and both hands are required above the pubes, they are most available, if the surgeon changes his position and stands upon the patient's right. I also introduce the straight tube on the right side.
It is important by a preliminary injection to ascertain carefully the capacity of the bladder by emptying it and then refilling it slowly with warm water previously measured, until the water is expelled through the loosely held urethra by the side of the tube. In this way we prevent its over-distention. In the etherized subject a short pipe or nozzle suffices for this purpose. I have for many years employed a common Davidson's syringe. An unetherized patient may for a moment resist this injection through a short tube by contracting the sphincter of the bladder; but this readily yields. Except in a large bladder, a distention by eight or ten ounces suffices for breaking the stone. The smaller the injection of water, the more readily, indeed, do fragments fall into the blades of the instrument. But, unfortunately, so also does the mucous membrane. In
fact, with too little fluid in the bladder the use of a lithotrite in unpractised hands is attended with danger; and in a long sitting an injection which will render the walls moderately tense is the only really safe way of keeping the bladder from between the blades. A careful examination of the action of a lithotrite through an opening in the summit of the bladder, has confirmed me in this opinion, which was that of the older writers on this subject. From time to time the diameter of the collapsing bladder should be estimated by slowly opening the blades of the lithotrite, and water introduced when necessary; but care should be taken to guard against the serious injury to a contracted bladder which might result from injecting the contents of the syringe or aspirating bottle when it is already distended.
A tape or an elastic band wound lightly once or twice around the penis near the scrotum retards the escape of injected water, and yet allows the movements of the tube or lithotrite.
In order to ascertain the maximum calibre of the urethra before introducing a tube, it should be measured by an instrument which will enter more readily than the tube. Such instruments we have in Van Buren's sounds, which are slightly curved at the end, and a little conical. Being made of solid metal, and nickel-plated, they traverse the urethra with singular facility. Both Otis's sounds, and the conical probepointed elastic bougie also answer admirably for this purpose.
EVACUATING INSTRUMENT. (Figure 1.) — The following points are worthy of consideration in connection with any evacuating apparatus. The ten-ounce elastic bulb or bottle supplied with the usual instrument is inadequate to the exhaustion for which it is designed. It will barely sustain, without collapse, a vertical column of water of the length of a catheter. A thick flask fatigues the hand of the operator. The bulb is also an awkward weight at the top of the catheter. These difficulties are obviated by interposing between the catheter and bulb a piece of rubber tube, varying in length, as the surgeon may prefer, from six inches to two feet, to relieve the bladder from the force of any movement of the apparatus, and, what is more important, to allow the operator to hold the bulb on a level with the water in the bladder, or consider