It was was not as simple in construction as was desirable. provided with a stand. He had often felt it a relief to stop once in a while in a long operation to see how things were going on, which the self-supporting character of the instrument enabled him to do with ease. With regard to the rubber hose which was attached to the top of the bulb and provided with a stop-cock, he regarded the device as a great advantage, and had continued to employ it in all his evacuators up to the present time. Its purpose was not only to dispose of the air, but especially to add or remove water. As had been stated, the only air legitimately held in the bulb was that contained in the catheter. If it were desirable to get rid of even this amount of air, it could be promptly accomplished by compressing the bulb and filling its place with water by means of the hose. Another point in this connection was, that all bladders were not of the same size or the same elasticity. In a small bladder it was difficult to evacuate completely because the walls were liable to fall against the catheter. This was owing to the fact that there was not enough water in the bladder. It could easily be added by means of the hose, and the quantity graduated exactly according to the desire of the operator. Sometimes during the operation the patient strained or vomited, so that everything became very tense; and in that case we had only to open both stop-cocks and deliver the water temporarily. He believed, therefore, that the hose was a valuable addition, both for the purpose of getting rid of air and of regulating the amount of water according to the circumstances arising from time to time during the operation. Finally, Dr. Bigelow exhibited the new and simple instrument which he said he had now settled down upon, and which could be used with either a single stop-cock or with two, as might be preferred. In the first place, it had a spherical bulb acting as a handle in the axis of the catheter. In the second place, it was quite short from end to end. In the third place, the obliquity of the tube carried the receptacle high in the air, one advantage of which was that it brought it nearer the level of the eye of the surgeon. In the fourth place, the whole thing fitted well into the cavity of the hand which held it. In regard to the use of stop-cocks, he preferred to have two instead of a single one. He then gave a demonstration of its manner of working, — it being shown, after a moment or two, that there was not a fragment left remaining in the glass vessel used to represent the bladder. The simple method by which this desirable result was accomplished, he said, could readily be understood. There was a cylindrical strainer that prolonged the catheter inside the bulb; and inasmuch as any strainer may get clogged with fibrin, resulting from an inflamed state of the bladder, this was so arranged that it could be readily removed and cleaned by brushing. The strainer could be replaced in an instant. The fragments enter the bulb from the bladder through the main orifice, by reason of the momentum which the current has acquired in coming from the bladder. But the combined area of the small apertures along the tube being much larger than that of the principal orifice at its extremity, most of the water returns by these apertures, and is strained. Dr. Bigelow then spoke briefly in regard to the lithotrite. He stated that the most convenient instrument of any sort was that which was best adapted to the movements of the hand. In devising his own instrument, therefore, he had first considered which was the easiest motion of the latter, and had arrived at the conclusion that this was its rotation. He had, therefore, not only made the handle of a size adapted to the hand, but so that it could be worked by rotation. He had also provided the lithotrite with a lock, by means of which any position of the blades could be maintained as long as desired, without the necessity of changing the position of the hand. The blades were made at as near a right angle as would admit of their introduction into the bladder with convenience and safety, and are thus found to work at a much greater advantage than the more oblique blades formerly sometimes employed. As the greatest impaction always took place at the heel of the instrument, he had abandoned the idea of crushing much at this point, and passed a flange through it, in order to bisect the detritus and discharge it laterally. The crushing was mainly done in front of the heel. When the patient was in good health, he believed that the safety of the procedure depended simply upon the surgeon's skill; and that with the facilities now at our command, if proper care were observed, there would very rarely be any bad consequences. In cases where the kidneys were affected, however, favorable results were not, of course, always to be anticipated. A SIMPLIFIED EVACUATOR FOR LITHOLAPAXY.1 THE operation for the immediate removal of a calculus. through a catheter, like many other surgical operations, can be accomplished more or less satisfactorily by any one of several instruments which much resemble one another. But it can be done better by employing a more perfect apparatus than those now generally in use. It has been said that "no new form of instrument is required by this operation," which is true so far as it implies that neither a lithotrite nor an evacuator is a new instrument. But it would be a mistake to infer that the operation could have been done with the instruments of the old lithotrity, and that they needed no change to adapt them to what is now required of them, or that they cannot be still further modified to advantage. The new operation cannot be performed with the old instruments. It requires a larger evacuating catheter than that of Clover, through which the usual product of the lithotrite could not pass, except as powder and sand, and then only in limited quantities, because the other detritus obstructed the entrance of the tube. Though at first received with a good deal of 1 The Lancet, January 6 and 13, 1883. 2 Sir Henry Thompson says (Diseases of the Urinary Organs, Philadelphia and London, 1882): “The evacuating catheter to be attached to the aspirator should be as large as the urethra will admit; usually No. 15 or 16 of the English scale [26 to 28 French] may be used without any danger. Sometimes No. 17 or 18 [30 and 31 French] are admissible; but such sizes are quite unnecessary for small stones, and may produce mischief; hence they are only to be used where the presence of a large stone demands corresponding instruments." Or, it might be added, to expedite the operation, when the urethra is large and healthy. The size of the normal urethra, according to Otis, is, if we except the meatus, 32 of the French scale. Clover's evacuating catheter was 21. Those now in use distrust, the large catheter has been finally adopted by all the surgeons who have performed the operation, and in fact cannot be dispensed with. It should be combined with a thoroughly efficient aspirator. But no particular form of aspirator has so far met with general approval. Though improvement has been made, surgeons have no aspirator which entirely satisfies all requirements of the operation, and is at the same time compact and convenient to handle and simple in construction. This part of the evacuator still needs improvement. The usual parts of an evacuator, not including the catheter, are these: 1. The exhaust, the best form of which is an elastic bulb. 2. A space or trap for air, at the upper part of the instru ment. 3. A glass receiver at the lower part, to collect and show the débris. In drawing out fragments from the bladder through the large catheter, one bulb or aspirator, if strong enough, is about as efficient as another. An aspirator of almost any shape and having almost any combination of its parts will do this. So will a mere elastic bulb attached directly to the catheter, without joints or receiver, if it is placed lower range from 26 to 31. Care, however, and often special skill may be required to introduce safely the largest sizes; 31 is very rarely needed, and the French sizes 28 and 29 are generally the most convenient. For a final washing or sounding without anesthesia, when it is desirable to give the patient the least discomfort, even so small a calibre as 26 is sometimes useful. Through a catheter of this calibre Mr. Teevan has removed calculi weighing six or eight hundred grains; but such cases should be regarded as showing what is possible, rather than as establishing a rule of practice. Here I may add that although no lithotrite compares in size with the larger tubes, it is yet true that long-bladed lithotrites, especially if they have the sharp extremity of the old instruments, are more difficult than tubes to introduce with safety. Although since 1878 my lithotrites have been made in three sizes, I have rarely had occasion to employ any other than the middle size. |