For withdrawing the fragments from the bladder rubber aspirators are commonly employed. Bigelow's original instru ment and the mode of using it is shown in Fig. 56. Morgan's aspirator " (Fig. 57) is the one I generally select. It has a decided advantage in enabling the operator to work it by grasping the top of the in strument. I have had the junction between the rub ber bag and the metal containing the trap connected by means of a bayonet joint instead of a screw, as in the original instrument, which facilitates the process of filling the bottle with water; the addition of the tap has also proved a conven ience.
I have two or three aspirators employed at an operation, one in work while the others are being refilled out of a bucket of water. All the evacuators I have tried are open to the objection that occa sionally fragments will be washed back again in spite of the trap, thus necessitating a second withdrawal.
The possibility of washing back fragments by the method of as piration, as just referred to, seems to have led Guyon and others to alter their method of procedure in crushing and evacuating stones. This consists in triturating the stone so finely by the lithotrite as to enable the powdered particles to run ont through a large eyed catheter by frequently filling the bladder with water' by an ordinary syringe. This practice, I have found, has much to commend it. It is to be remembered that as all these aspirators consist large ly of rubber, care is required that they be kept thoroughly clean and aseptic ; in fact, the same precautions should be taken in regard to them as with catheters.
Having thus referred to some of the instruments em ployed in lithotrity, I will now proceed to speak of their use, which will best be done by taking an ideal case, where, for instance, an adult male otherwise healthy, with a nor mal bladder, is suffering, we will say, from a Ethic acid calculus of moderate size. The stone having been discovered and lithotrity decided upon, there are a few preliminaries which may be noticed. In the first place, due regard should be paid to those points which we recognize as of importance in connection with all patients who are about to undergo an opera tion confining them for some days. Rest to the parts involved and regulation of the diet and the bowels are attentions which will not be disregarded as being conducive to well-doing.
When stone is complicated with a distorted bladder, as in some instances where the prostate is large, it is not a bad plan to turn the patient on his belly, after he is anmsthetized., and to slightly concuss
his body. Stones will often thus fall out of a pouch into the cavity of the bladder, and if a small sponge, secured by a tape, is passed into the rectum before the patient is replaced on his back, the seizing and evacuation of the calculus by the lithotrite and aspirator will be facil itated. I have several times found this expedient of service.
At the time of operation care should be taken that the patient is well protected against exposure, and I generally see that the legs and thighs are encased in loose flannel leggings, which can be readily slipped on, and are also a protection against wet. By this means the genitals are the only parts exposed. The patient should be placed on a suitable operating table, or its equivalent, care being taken that its height is proportionate to that of the operator. I seldom use chloroform, my preference being either for the combination of ni trous oxide gas with ether, or what is known as the A. C. E. mixture, the latter consisting of one part of alcohol, two of chloroform, and three of ether. I have never had cause to regret these selections. Mr. Lawson Tait " has observed that the administration of ether sometimes completely arrests the secretion of urine. He illustrates this by a case where for this reason he failed to detect and cure a uretero-uterine urinary fistula. When chloroform was substituted the opening was discovered and closed. Cocaine is not to be relied upon as being efficient so far as lithotrity is concerned, though it suffices for such temporary purposes as the passing of an instrument along the urethra. The patient being anesthetized by a competent administrator, he should first be placed with the pelvis slightly raised on a pillow, a position which may be altered according to circum stances. Before using any other instrument, I usually commence by washing out the bladder with boracic lotion by means of the aspirator catheter and wash-bottle. This fulfils three objects : (1) it assures to the operator a clean and not a foul bladder in which to work, (2) it permits any small stones to be withdrawn without being broken, and (3) it allows of sufficient fluid being left behind to facilitate the move ment of the lithotrite in searching and crushing, and thus affords a protection to the mucous membrane.