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 (Fig. 2b); or it may be used as introduced. 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. Too large an orifice d No 30 impairs the suction and admits fragments that become wedged higher up. 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 an inverted tunnel. If 3. Manipulation of the bulb. The bulb, together with its tubes, contains about ten ounces. If compressed with one hand until the sides. meet, only about five ounces are displaced. half compressed and then worked 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. The FIG. 3.1 1 The outline here given of the orifice and extremity of the tubes I use is more correct than that of Fig. 2. If the straight tube be closed by an extremity symmetrically round or ovoid, to facilitate its introduction, the orifice ad 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. object of more water is to prolong suction when fragments are passing freely; also occasionally to stir up the débris, 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). 4. Capacity of the bladder. It is desirable, in each case, to form an idea of the habitual capacity of the bladder. The previous frequency of micturition throws some light upon it. Better than this, the tension of the urethra behind the elastic band is a valuable indication of the fluid pressure in the bladder during evacuation. If the patient strains for a moment, the bladder may become very tense, and I think it then important to let the water escape through the hose (see p. 278). The bladder can be immediately replenished. Without a hose this manoeuvre is impossible. PROCESS OF EVACUATION. Quantity of water needed during evacuation. -Unless the amount of débris is very abundant, there should be just enough water in the bladder to prevent the thud, or fish-bite, hereafter described (p. 217). While more than this needlessly scatters the fragments, a smaller amount allows the bladder to be constantly drawn into the catheter, giving rise to the quivering sensation above alluded to as the fish-bite. Nothing so facilitates evacuation as the power exactly to regulate the amount of water in the bladder and apparatus; and no contrivance so well accomplishes this desideratum as the hose. 5. Evacuation of the fragments. Evacuation of the fragments is quite an entertaining art, requiring as much skill to accomplish the desired result in the shortest time as does the act of crushing. Dexterity in the process will hardly be acquired without practice outside the bladder. No jerk is required in pumping. The compression and expansion of the bulb equally divide a second or two of time. While the tube is held just above the débris, the fragments should fall 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 efficient action of circular currents in the closed bladder, the ox-bladder may 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. Such practice is very instructive. 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. 2 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. in a shower into the trap. into a first and a last half. The operation may be divided 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 the tube away from the floor, aspirating the fragments quickly while on the wing, just above the comminuted mass. In the latter part of the process, and after the smaller débris has been removed, by raising its outer extremity the tube may be made to indent the floor so as to gather instead of separating the 1 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 débris 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. (From a photograph of a frozen section, in which the rectum and the bladder were previously distended with plaster.) fragments. Some of the chips are apt to collect about the tube orifice; but the tube thus raised is carried behind them. It is important occasionally to turn the orifice forward to wash the fragments from beneath the shoulder of a high prostate. 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. On the other hand, when the tube 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 débris at once appears in the trap. Higher in the cavity, while the débris 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. At the different stages of the process there is opportunity for a little tact in placing the tube, just as there is in discovering fragments with a lithotrite. 6. Immediate recognition and removal of obstruction in the tube. If a short interval elapses without the fall of débris, it may be presumed that there is obstruction. This happens not only when the bulb will not expand, when its 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 lodged in the elastic 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 débris |