If before using the lithotrite the surgeon desires to add or withdraw water from the bladder, this may be done through a common-sized catheter coupled with the bulb,- thus obviating the necessity for a syringe, and rendering this part of the operation as dry as the rest.

Instead of the metal ball-and-socket joint in the stand of my former instrument, I have substituted another, of which a strong glass trap forms the ball. This is supported in a metal socket, which allows all necessary motion or, if it is desirable, fixes the trap upon the flat disk.

The operation is as follows. The urine is drawn through a small catheter, and replaced by water from the bulb. The lithotrite is then introduced, and the stone is crushed. A large tube is next passed into the bladder to evacuate the fragments. Before the tube is introduced, its stop-cock must be closed. If during the pumping the bladder indicates, by repeatedly stopping the tube, that its parietes are hanging loose and acting as a valve, it should be distended by a little water injected from the bulb. This water is retained in the bladder by closing the cock of the evacuating-tube; while the bulb is replenished through the small hose.

When the empty evacuating tube is first introduced, a few bubbles often rise from it, and are caught in the bulb by elevating it; but when the current is established, air takes care of itself, and goes to the air space in the top of the bulb. In fact, there is none unless by accident. By opening the cocks and compressing the abdomen, it is easy to drive all air out of the bladder through the bulb.

In pumping, only a couple of ounces of water need be moved between the bladder and the bulb, backward and forward gently, without a jerk, once in a second or two. The tube is advantageously held just off the floor of the bladder, a little higher at first, when the débris clogs it, and lower when only a few fragments remain.

As regards the amount of time necessary for an operation under ether, take as much as is necessary, precisely as in an amputation or excision. I usually add to the evacuation a thorough sounding. This requires more time. Some operators leave a few fragments in the bladder, to make the sitting shorter; but I doubt the expediency of doing so. Great care is essential, also practice. How to pass instruments, large and small, curved and straight, with absolute facility, should be learned upon the dead body before practising upon the living. Notwithstanding an occasional assertion to the contrary, I am sure that if a common tin sound bent successively into a variety of different irregular curves can be introduced with ease into the bladder of a dead subject,-not empirically, but with a reason for each movement (and a few hours' intelligent practice, based upon anatomical considerations, will enable this to be done), a catheter can be adroitly passed in any difficult case upon the living subject, and the accidents avoided that sometimes follow the introduction of common instruments, such as laceration of the mucous membrane and false passage. Obstructions from strictures or the irregular walls of an enlarged prostate will also be skilfully dealt with.1

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1 The evacuator of Thompson illustrates the objections mentioned in the text. Latterly (Gazette Hebdomadaire, Oct. 31, 1879), Thompson has arranged a single stop-cock to do the duty of two in closing its lower orifices to keep the bed dry; but the instrument is virtually the same. (1) The bulb, or bottle, like Clover's, is above the catheter, so that the water has to be drawn up into it; and if the cocks happen to be simultaneously opened for a moment, it will all run into the bladder and distend it. (2) Its weight must be supported by the operator, or rest upon the catheter. (3) Being rigidly fixed to the catheter, it communicates the jar of pumping to the bladder, this old "short connection" thus retained between catheter and bulb, upon which Thompson insists, yielding, so far as I can discover, no equivalent advantage. (4) Lastly, the mouth of the catheter enters low down, into the narrowest part of the bulb. Consequently fragments, after rising into the bulb with the current, must, on their way to the glass trap, again crowd in front of the catheter; and thus débris is needlessly returned to the bladder. It

would be better, if it be desired to connect the catheter low down, to prolong it a couple of inches inside the bulb, and to let the fragments escape at a higher point, where the cavity is wider, as is represented in the lowest tube of the annexed diagram (Fig. 2). With such an instrument I experimented some time ago. This arrangement also keeps the contents of the trap quiet, and there is no return of fragments.

But even an imperfect or inconvenient apparatus may suffice to empty the bladder. The only feature of an evacuator absolutely essential to rapid lithotrity is the large evacuating tube I have elsewhere described, which Thompson has adopted without change. It is this that enables his instrument to evacuate. The want of this large catheter (in combination with good suction and a trap) was fatal to the success of previous instruments, and to all attempts at the immediate evacuation of any considerable amount of débris. With such a catheter Clover's instrument could have evacuated the bladder slowly, and might have led, in the face of traditional prejudice, to the discovery of the tolerance of that organ, and of lithotrity at a single sitting. But the catheter of Clover's instrument was too small, being only 21 French (12 English), beyond which the English scale did not go. Its eye was also defective. The new method was impossible to those who were using this small catheter. They could not empty the bladder of all its fragments, and therefore knew nothing of its great recuperative powers after the complete removal of this source of irritation. Authorities agreed that evacuating instruments were worthless. When Otis directed the attention of surgeons to the fact (see a paper by R. F. Weir in the New York Medical Journal, April, 1876) that the capacity of the average urethra was very nearly 33, rapid lithotrity was made easy. Sittings were lengthened from a few minutes to an hour or two.

LITHOLAPAXY.

FROM A CLINICAL LECTURE.1

GENTLEMEN, Within ten days we have had two cases of litholapaxy, one of which you saw. After both, the temperature rose from 98° to above 100° F. On the third day it fell to 99° F., and now, three days later, it is normal. This reaction is like that from the effect of a bougie, and the temperature like that of urethral fever. A patient readily recovers from the operation of litholapaxy if we remove from the bladder all the fragments of the stone. In fact, the new method has succeeded beyond expectation.

Small stones are easily ground up, especially if soft, and then come away of themselves. Serious consequences may follow if fragments are left in the bladder. In former times cases that did not admit of lithotrity had to be cut; likewise those in which, from any reason, lithotrity was hazardous. A recent number of the London "Lancet" reports a case in which Mr. Smith, of St. Bartholomew, removed four ounces of stone from the bladder of an elderly man, who left the hospital in a week. This is the largest quantity of débris ever removed by litholapaxy.

The operation, of course, is purely mechanical, and any reference to it is chiefly to its mechanics. The principles of litholapaxy and of complete evacuation are pretty well settled and accepted. It is now mainly a question of certain minor details of convenience in the apparatus. I am satisfied that one point which contributes as much as, if not more than, any other to rapid and complete evacuation is the power of regulating and of frequently varying the quantity of water in the

1 The Boston Medical and Surgical Journal, March 4, 1880.

bladder. You require just enough water to prevent the thud of the slack walls when they are drawn into the eye of the catheter. When you feel that, the bladder must have a little more water to distend it. Too little water crowds the fragments together. When there is too much, you may have to chase a single fragment a long time.

The arrangement of hose I show you here is the only one that allows the operator to diminish the quantity of water in the bladder without disturbing the apparatus. If one end of this hose, which is not much larger than a pipe-stem, be kept in a tumbler of water it does not in the least interfere with the convenience of the operator; but on the other hand it does enable him, by turning the cocks, to vary from one minute to another, if he please, the amount of water in the bladder. There can be no doubt of the advantage of being able to do so.

Another point relates to the size of the tubes. The smallest tube used in litholapaxy is larger than the largest tube that was used for evacuation in previous operations. But you will find that the largest tubes I use are sometimes not preferred by other surgeons. They are in the habit of using a No. 28 or 29 tube, and these often serve the purpose. The fact is this: a stone after evacuation is found to have been mostly reduced to powder and minute fragments; large fragments are rather the exception. Now, the fine débris may be evacuated through a 28 or 29 tube, though perhaps not quite so rapidly as if the tube had a calibre of 30 or 31. It then remains only to crush the larger fragments and repeat the process. I prefer a larger tube, when there is no objection to its introduction, because it not only evacuates the dust more rapidly, but at the same time allows me to remove the large fragments without having to crush them again.

I am sure that in the end operators will all use a stand to support the weight of the bulb, because it is very inconvenient