In commencing to crush and evacuate, the operator should en deavor, as far as possible, to render the proceeding a bloodless one, by causing damage neither in the introduction of instruments along the urethra, nor in his efforts to seize and crush the stone. It is often possible to conduct an operation of this kind, even of some duration, with but little discoloration of the water in the aspirator. This is difficult to accomplish when the prostate happens to be large and ob structive. Any extensive damage of this kind proves a serious ob stacle to the success of lithotrity, and when unavoidable, is a suffi cient reason for the immediate substitution of some form of lithotomy. Much time may often be saved in performing lithotrity, not by any sacrifice of safety to speed, but by previously seeing that the nurses are well versed in clearing the lithotrites when not in use, filling the wash-bottles (without air), and in recognizing and handing the exact sized evacuating tube the operator is using. Where I have had to operate with excellent nurses by me, but unused, by reason of want of practice, to this kind of work, a quarter of an hour, or even more, has easily been lost, and anaesthesia unnecessarily prolonged. This is the only kind of economy of time that can be justified.
Stones of an elliptical or ovoid shape more commonly lie with their long diameter in a direction corresponding with the line of the urethra, and are generally first seized in this axis by the lithotrite. Hence calculi may appear larger than they really are. My attention was first directed to this point by my friend Dr. Freyer, whose op portunities of judging in reference to all matters connected with stone have been extensive in India. Naturally our object is to seize the stone in its shortest diameter, if we are going to crush it, as simplify ing the operation and throwing less strain on the lithotrite. Conse quently this may necessitate a change in the first position of the lithotrite relative to the stone, for which, in addition to other reasons, some fluid in the bladder is required. In lithotomy, on the other hand, this rather constant position of oblong stones relative to the outlet from the bladder is favorable to their more speedy withdrawal.
The bladder having been cleansed and the lithotrite introduced, the surgeon taking his place on the patient's right-hand side, the stone is carefully sought for. This may render it necessary to reverse the position of the instrument so as to enable the operator to feel for and pick up anything which may be lying behind the prostate in the most dependent portion of the bladder. The stone having been seized and the screw power adjusted, the lithotrite should be slightly and gently rotated with the left hand, so as to see that it is quite free from the coats or rugm of the bladder. I consider this the most important movement in connection with the process of lithotrity. It may be almost imperceptible to the casual observer by reason of its delicacy, but it should on no account be omitted. Its full recognition makes all
the difference between an almost bloodless operation and otherwise; and further, it is the means of preventing the introduction of much cicatricial tissue within the bladder wall. Probably there is no opera tion where more fineness in manipulation and patience are required than in lithotrity, as it is entirely dependent for its success upon that kind of touch which is unaided by sight. A rough cicatrix within the bladder may not only act as a foreign body, but prove the nucleus upon which a phosphatic stone may concrete.
When operating in a bladder of fairly normal shape, with reason able care, there is little risk of doing damage to the mucous mem brane; where, however, the prostate is enlarged and the surface of the bladder rendered irregular by trabeculee, elevations of its surface, and depressions in which residual urine has been lodging, the difficulties arising are not inconsiderable. The operator should be careful to ascertain that the stone or fragments when seized by the lithotrite are perfectly free, and that within the grasp of the instrument an elevated portion of the wall is not also included. In Fig. 58 it will be seen that, though the female blade is in direct contact with the stone, the male blade is really in a pouch behind the enlarged pros tate. This is a very deceptive position, as the operator feels that he has the fragment within the grasp of his instrument. The slight ro tary movement of the lithotrite by the left hand of the operator, to which reference has been made, will invariably be found sufficient to detect this false position, before the instrument is screwed up and serious damage done.
As a rule the operator should continue to use the lithotrite so long as he can pick up fragments readily. When this ceases, or he feels that his movements are embarrassed by the presence of too much debris, the aspirator should be substituted, filled with plain water or boracic lotion. In using the lithotrite and seizing very large frag ments, as in the earlier introductions, when the stone is hard, it is a good plan to screw it up until the resistance offered by the calculus is felt to be considerable. If the operator will then wait for a mo ment or so, he will often find the stone yield without further force; in this way we may avoid putting the maximum amount of strain on the instrument. This is a matter of some importance in grasping hard stones of, say, nearly two inches in diameter. Then again, in picking up stones or fragments in bladders which are more or less pouched behind the prostate, it is convenient to alter the position of the calculus relative to the bladder before pulverizing. I sometimes say, " If you take a stone out of a hole or depression, put it on the bank to break, and then you may the more easily deal with the re maining portions of it." I have often demonstrated how readily this can be clone, and how it simplifies an otherwise difficult manipulation.