In selecting evacuating tubes, the object should be to use the larg est the urethra will receive, provided it can be moved about easily. In some persons the meatus is so contracted that it is necessary to incise it before a sufficiently large tube will pass. Referring to the size of the evacuating catheters, Dr. Bigelow remarks : " Thirty-one is very rarely needed, and the French sizes, 28 and 29, are generally the most convenient. For a final washing or sounding without anms thesia, when it is desirable to give the patient the least discomfort, even so small a calibre as 26 is sometimes useful." " A too tightly fitting catheter may damage the deeper portion of the urethra, which is less tolerant of injury than the bladder.
I have not found a small quantity of air obstruct manipulations, for the reason that it and the stone fragments occupy opposite quar ters in the bladder. If enough air enter the bladder to interfere with the withdrawal of the fragments, or to provoke spasm, it is easily dis placed by disconnecting the evacuating tube from the aspirator, and making pressure with the hand over the pubes.
When using either the lithotrite or the aspirator, the bladder, even when the patient is deeply etherized, sometimes exercises a violent expulsive effort. Until this is over, all manipulations should be sus pended, otherwise an accident may possibly happen. "Even deep anaesthesia," as Billroth observes, "is not always sufficient to obviate spasmodic action of the bladder." " When manipulating with a con siderable quantity of water in the bladder, if spasm comes on, all ten sion should be taken off by allowing an escape to take place—a sort of safety-valve action. These are some of the points in connection with breaking the stone with the lithotrite and removing it with the aspirator. The best test for the last fragment is the suction power of the aspirator bottle, as the piece is almost sure to be felt impinging against the eye of the catheter, claiming permission to escape in a re duced form. At the conclusion of an operation the bladder should be washed out with warm boracic lotion until it returns free from dis coloration with blood. After lithotrity care must be taken that the urine is not retained beyond a reasonable time, and, if this should be the case, a catheter must be passed. Hence it is a good plan, when the stone has been removed and before the patient has become conscious, to ascertain what catheter passes most easily, which will probably be a soft one. Thus all further trouble in the selection of an instrument,
should one be required, is avoided. Some surgeons leave a rubber catheter in the bladder for forty-eight hours after a lithotrity, allow ing the urine to drain away continuously into a bottle in the patient's bed. If the operation has been a prolonged one and the urethra is probably sore, or if the patient is more or less dependent upon the catheter, this is not a bad plan, as it also allows of the bladder being washed out with some antiseptic lotion without disturbing the patient. In ordinary circumstances, when the operation has been simple and the bladder and prostate are tolerably normal, I have not found this expedient necessary. When the operation has been a long one and the bladder is irritable, it is well to introduce a suppository contain ing a grain or so of opium into the rectum before the patient is re turned to his bed.
Reference will presently be made to some accidents which have occurred in the course of a lithotrity. It may, however, be well to say here that it is a good rule never to undertake lithotrity without having lithotomy appliances at hand. Unforeseen events connected with the stone, the bladder, the urethra, or the instruments, have rendered the lithotomy operation unexpectedly necessary, and by re course to it a fatal termination has been averted. In two of my own cases, within a recent period, I know this result would probably have supervened if I had not been able to adopt the alternative without delay. In one of those instances the immediate change from lithotrity to me dian lithotomy was necessary by reason of a large triangular frag ment becoming suddenly forced by the spasm of a powerful bladder into the membranous urethra. By the latter operation, with the aid of crushing forceps, all the stone was removed as well as the impacted fragment, and the patient made a speedy recovery. In the second instance, in performing lithotrity for an elderly man, the size of the stone felt and crushed was so out of proportion to the duration and character of the bladder symptoms, that I was sure other stones were concealed somewhere beyond the reach of the lithotrite. I therefore performed a median cystotomy, which enabled me to feel a distinct cavity, immediately above the prostate, communicating with a • sac, out of which, with a pair of long forceps, I removed thirty-four fasci culated lithate stones, weighing altogether an ounce and a half.