STONE IN THE BLADDER 365 



it is at all times difficult, and in most instances impossible, to extract them. 

 For this reason it is of the first importance that the long diameter of the 

 stone should be made to correspond with the long axis of the forceps. 

 To accomplish this the calculus is drawn well up to the neck of the bladder, 

 when, with the index finger acting between the released blades of the 

 instrument, it is carefully turned and brought into the desired position. 

 This having been done, extraction of the stone is then proceeded with. 

 The extracting force required to effect removal will, of course, depend upon 

 the size of the stone in relation to the urethral orifice. Large calculi, and 

 particularly such as are rough and catchy, require a considerable amount of 

 traction and careful manoeuvring to bring them away. Before attempting 

 removal, the stone must be firmly gripped and a good hold secured by 

 bringing both hands to bear on the handles of the forceps, whose blades 

 should be so placed that their surfaces are directed right and left, and their 

 edges upward and downward. A steady and continuous pull, gradually 

 increasing in force, is now begun and continued, with a wriggling movement 

 of the hand and an occasional slight alteration in the direction of the 

 traction, at one time pulling slightly to the right, at another to the left, 

 now upward, then downward, and so on. If the wound be not sufficiently 

 large, a touch with the scalpel here and there at the points of resistance 

 may be resorted to as a means of facilitating extraction, or an assistant 

 may be called upon to open the wound by inserting his fingers well within 

 its edges and pulling in opposite directions. Should the stone prove to be 

 too large for extraction by reasonable force, crushing must be at once had 

 recourse to. Where the calculus is loose in texture, and friable, the resist- 

 ance of the edges of the wound to the extracting force may give rise to 

 disintegration of the outer crust, which, breaking away, remains in the 

 blades of the forceps, while the main body of the stone escapes into the 

 bladder. In such an event the offending body must be again secured. 

 Having undergone a reduction of size, less resistance will be experienced in 

 the next attempt at removal. An additional advantage will also be gained 

 in the firmer hold the more compact remains of the calculus allows to the 

 forceps. 



Having removed the stone, the bladder will now require to be well 

 washed out with warm carbolized water in order to cleanse it of the blood, 

 mucus, and earthy debris, some or all of which it is sure to contain in 

 greater or less amount. This operation is best accomplished by intro- 

 ducing the three-bladed dilator (fig. 154) into the neck of the bladder, 

 and, after moderately enlarging the orifice, forcing into the cavity a fairly 

 strong stream of warm carbolized water out of a small enema syringe. 



Whether the perineal wound should be closed at once must depend 



