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.

ance.

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

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

a

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.