there be stricture or prostatic obstruction a position at the patient's left side enables the operator to hold and direct the instrument 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.

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 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 unpracticed 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. After careful examination of the action of a lithotrite through an opening in the summit of the bladder, I have returned to this opinion which was held by the older writers on this subject. From time to time the diameter of the collapsing bladder should be estimated by carefully opening the blades of the lithotrite, and water should be introduced when necessary; but care should be taken not to injure a contracted bladder by first distending it, and afterwards adding to it the contents of the syringe or aspirating bottle.

A tape or an elastic band wound lightly once or twice around the penis 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. Otis's sounds 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 sus

tain, 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 on 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 considerably below it. The exhaust then acts as a siphon, and readily

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draws off the water. The fragments

gravitate to the bottom of the bulb, and are there collected in a glass chamber. (See Figure 1, 3, 4.) To prevent the possible return to the bladder of some single fragment while on its way to this receptacle, the rubber tube, if long, may 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 (Figures 3, 4), which is more convenient; this is not essential. One or two smaller bulbs might be provided for a contracted bladder.

The successful evacuation of the bladder depends upon several conditions, both in the apparatus and its use, which, for distinctness, may be enumerated separately.

(1.) A large calibre of the evacuating tube.

(2.) Its shape.

(3.) The shape of its receiving extremity.

(4.) The manipulation of the bulb.

(5.) The evacuation of the fragments.

(6.) The 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 (FIG. 1.) Evacuating Apparatus. the normal urethra is at about 33 of a. Elastic bulb and glass receptacle Charrière, there can be no question that with brass cap, for débris. b. Rubber tube two feet in length. c. Evacuatit will admit a much larger tube than that ing tube of silver. 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 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 1 Diseases of the Prostate, 4th edition, 1873, page 337.

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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, and the tube then delivers 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.

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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 either straight, or curved quite near the extremity; the latter to be used with the curve inverted and directed downward, the orifice then looking forward. (Figure 2.)

(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 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 thickened and rounded 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

may 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 very efficient, although I prefer the straight tube as safer and more easily di

rected when in the bladder, less liable to lodge fragments, and more readily cleared by a rod. An ef fective instrument may also be made of a 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, by a bit of stiff metal. This was the original of the straight tube already described. When such an instrument is introduced the interval can be filled by a rod. In fact, 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 provided also it were kept standing upon its heel in the bladder, with the shoe 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.

(FIG. 2.) Evacuating tubes, with unguiform ex tremity. a. Straight tube. b. Curved tube. The dotted lines show the false floor of the extremity. The

tubes are here of a diameter 31 Charrière.

(4.) The 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 be still 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 is then carefully kept uppermost until attached to the evacuating tube. Air in the bladder is a disadvantage in distending 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 gently worked with a shorter movement, about two ounces are moved back and forth, so that, provided the tube itself be handled carefully and skillfully, the bladder is not greatly disturbed. At the beginning of the process the latter movement

(FIG. 3.) 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 upon the thigh or pubes. This position is a convenient one during the whole evacuation.

is sometimes effective. The object of more water is to prolong suction when fragments are passing freely, but also occasionally to stir up the débris, and especially to relieve obstruction in the tube when it occurs. A convenient 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. 3.) Or, the surgeon sitting between the supported feet of the patient, (Fig. 4) compresses the bulb with the right hand, using the left alternately to hold the glass trap and to adjust the silver tube. But in this position the hand is apt, after a time, 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 amusing art, requiring as much skill to accomplish the result in the shortest time as crushing them. Dexterity in the process will hardly