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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.

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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.1 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

1 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.

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

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(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. 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

On the other hand, when the tube

(FIG. 5.)

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(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.)

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