curved, should be pressed fairly through the indurated neck, or prostate, in the direction of the axis of the body, by the hand on the perinæum, a most efficient manoeuvre when the prostate is large. If there be further difficulty, the tip should of course be sought and guided in the rectum (see p. 206). 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.

Anaesthesia in lithotrity. My own practice has always been to etherize for lithotrity.

Position of the operator.— Each operator prefers the position to which he is accustomed; and when the urethra is healthy, this is of very little importance. But 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.

Passage of a lithotrite. The lithotrite is to be passed as a straight instrument, and not as a curved catheter. When it reaches the triangular ligament, the tip is insinuated into its aperture, and then the handle previously perpendicular, or nearly so, is depressed to an angle of about 45°. In this position it should remain, with but little further depression, while the blades are gently urged forward through the prostate. The convexity of the heel thus depresses the lower wall of the canal as it moves along and makes room. It moves as a boat, rising neither at prow nor stern (see Fig. 19, p. 313).

Water to be injected before crushing. — In injecting water before using the lithotrite, the capacity of the bladder may be estimated by the tension of the urethra behind the point of constriction. By attention to this indication we prevent overdistention. In the etherized subject a short pipe or nozzle suffices for introducing water. I have usually 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. A distention by five or six ounces suffices. The smaller the injection of water the more readily, indeed, do crushed 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 separate the walls 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. Water may be introduced as often as necessary; but care should be taken to guard against the serious injury to a contracted bladder which might result from suddenly injecting the contents of the syringe or aspirating bottle when it is already distended. On the other hand, distention of the bladder is a common symptom of retention. When extreme, it is often followed by inflammation and atony. But in a common case we do not anticipate such serious results, even when micturition has been frequent, and the bladder by inference small. It has occurred to me whether a moderate forced distention might not be of service in certain cases of contracted bladder, as it is in a permanently contracted anus.

Water retained by an elastic band. - 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.

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. The shape of its receiving extremity.

3. Manipulation of the bulb. 4. Capacity of the bladder. 5. Evacuation of the fragments. 6. Immediate recognition and removal of any obstruction in the tube.

G.TIEMANN & GO

FIG. 1.1

1. A large calibre of the evacuating tube.-Whether or not we adopt the view of Otis that the average calibre of the normal urethra is 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 been stated by Sir Henry Thompson,

1 Evacuating Apparatus. 1. Elastic bulb. 2. Curved rubber tube. 3. Curved evacuating tube of silver. 4. Straight evacuating tube, which is preferable to the curved one. 5. Front view of same. 6. Glass receptacle, with bayonet joint for débris. (Tiemann and Co., New York.)

but with a different significance. He recommends for the glass cylinder or trap which is to admit this tube a "perforation at the end the size of only a No. 14 catheter," = 25 Charrière. 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 catheter, the rubber tube with its metal attachments should have a calibre of at least seven sixteenths of an inch, 31 Charrière, and there should be nowhere any approach to a shoulder inside.

=

My evacuating tubes are of thin nickel-plated metal of sizes 27, 28, 29, 30 and 31 filière Charrière, respectively. These are the sizes, including also perhaps 26 and 32, which I have designated as "large" in distinction to the calibre 21 of previous apparatus.

2. The shape of its 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

1 Diseases of the Prostate, p. 337. Fourth edition, 1873.

lie almost in contact with the tube. A very slight obstacle impedes the entrance of a fragment; and this fact renders inefficient all tubes like catheters with orifices along the side or upper wall. 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 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 (Fig. 2a). The tube is then practically straight, while the orifice,

which is slightly

FIG. 2.1

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 should be insinuated through

1 Evacuating tubes, with unguiform extremity. 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. The straight tube is preferable.