cessful results. The operation is usually performed by an incision from the perinæum; but sometimes it is necessary to adopt the high or suprapubic incision. The former method is termed perineal lithotomy, and, as the incision most commonly made by the surgeon is a lateral one, it is ordinarily spoken of as lateral lithotomy. Lateral lithotomy consists of two distinct stages,—(i.) cutting into the bladder and (ii.) removing the stone. The patient is placed on a table and brought under the influence of an anæsthetic. A grooved staff is passed along the urethra into the bladder to act as a guide for the knife, and the patient is then "tied up in the lithotomy position." An assistant holds the staff in the middle line of the body and the surgeon makes an incision an inch and a half in length deeply into the perinæum, until the knife enters the groove of the staff, and then passes it along the groove, thus making an opening through the bladder-wall. The bladder having been thus cut into, a pair of lithotomy forceps is introduced by the perineal wound, and the stone is caught and removed by gently withdrawing the forceps by a rotatory movement. A lithotomy tube is now passed through the wound into the bladder and fixed in position; the patient is untied and carried back to bed. The operation of lithotomy is not a difficult one to perform, nor is it in itself dangerous; sometimes, however, there is a fatal termination, due commonly to one or other of the following causes—hæmorrhage (either primary or secondary), organic disease of the urinary organs, or blood poisoning. Hæmorrhage may be the result of unskilful operating, the incision having been incorrectly made; or one of the larger vessels in this neighbourhood may have had an abnormal distribution, so that, lying in the line of the incision, it was divided and gave rise to the bleeding which proved fatal. If the stone be a very large one, or the perinæum very narrow, it is necessary to perform the suprapubic operation.
Litholapaxy.Litholapaxy.—Lithotrity too can be best described if considered under two headings, (i.) the crushing of the stone and (ii.) the removal of the detritus. The two stages are now carried out at "one sitting," instead of allowing an interval to elapse between them, as was formerly the practice, and the term litholapaxy is used to designate this method. The patient having been anæsthetized, the urethra is dilated by the passage of large-sized bougies. Then a few ounces of a warm neutral aseptic fluid are injected into the bladder, and the crushing instrument, the lithotrite, is passed along the urethra into the bladder. The lithotrite has two blades,—a "male" and a "female,"—the latter fenestrated, the former solid with its surface notched; these blades can be approximated both by a sliding and a screwing movement. The sliding movement is used to grasp the stone; but when the stone is fixed between the blades the screw action is used, as it enables great pressure to be applied evenly, gradually, and continuously. The lithotrite is made of very tough steel, so that even very hard stones may be crushed without any danger of the instrument breaking. It is passed into the bladder with its blades closed; they are then opened and an attempt made to grasp the stone. The stone having been fixed between the blades by the sliding movement, it is then crushed with the screw action, great care being taken not to catch the bladder-wall with the lithotrite. This danger is avoided by raising the point of the lithotrite immediately after grasping the stone and before crushing is begun. The stone breaks into two or more pieces, and these fragments must next be caught and crushed one by one, until they are all reduced to a very small size. If the stone be large and hard, half an hour or longer may be required to crush it sufficiently. When the surgeon fails to catch any more large portions of stone, the presumption is that it has been broken up into small enough pieces; the lithotrite is then withdrawn and the second stage of the operation must be begun. This consists in removing the detritus by means of an aspirator, the best form of which is that invented and used by Sir Henry Thompson. It consists of an elastic bag connected with a trap, into which fragments of stone will fall and not pass out again on the instrument being used at later periods in the operation. A large catheter, with the eye very near the distal end of the short curve, is passed into the bladder; the aspirator, full of an aseptic fluid, is attached to the catheter, and a few ounces of the fluid are expressed from the aspirator into the bladder by squeezing the india-rubber bag. When the pressure is taken off the bag, it dilates and draws by suction the fluid out of the bladder, and with it some of the detritus of the crushed stone, which falls into the trap, and is not expelled on the fluid being re-introduced into the bladder. This manoeuvre is repeated again and again, until all the fragments and detritus of the stone have been removed. After the operation the patient sometimes suffers from pain and discomfort; but these are not at all severe unless some fragments have been left in the bladder. If the pain be severe, it can very generally be relieved by hot fomentations or a sitz-bath. The patient must be kept in bed for some days after the operation, and in cases where the stone has been large and the bladder irritable the surgeon should insist on him remaining in bed for at least a week. Judging by statistics, the dangers of the operation, if it be gone about with care, are not nearly so great as those of lithotomy, and certainly in those cases which go on favourably the patients are much sooner able to perform their ordinary duties. Fatal terminations, however, do now and again occur, sometimes as a result of injury to the bladder-wall setting up inflammation, which extends to the kidneys, sometimes from suppression of urine. Those cases in which there has been a fatal result most frequently have been complicated with old-standing kidney disease.
Neoplastic growths .Neoplastic Growths.—The commonest neoplasms found in the bladder are vascular fibromata (often called villous cancers) and epitheliomata; more rarely malignant growths occur. The symptoms produced by tumours vary; but they may cause obstruction to the flow of urine and chronic cystitis, with more or less severe pain. The most important signs are the passage of blood and the presence of tumour cells in the urine. Frequently, however, microscopical examination of the urine fails to discover the presence of tumour cells. The passage of blood may be very intermittent and small in amount; but this intermittent bleeding is one of the most characteristic signs of the existence of a tumour. When the presence of a tumour is suspected, the sound is passed and an attempt made to feel it. Sometimes it can be felt, but more often doubt remains as to whether a tumour does really exist or not. In such cases the endoscope may be had recourse to; but the information derived from its use is not always satisfactory, and a diagnostic incision must then be made into the bladder to verify the diagnosis. When such a diagnostic incision is made, the surgeon must be prepared to remove the tumour, should one be present and capable of removal. Usually the diagnostic incision is perineal; but, if the bladder is capacious, or if the perinæum is deep and narrow, a more complete examination can be made by a suprapubic opening. The treatment of neoplasms is, as a rule, unsatisfactory. If the growth be pedunculated, it can be removed without great risk to the patient; more commonly, however, the tumour cannot be removed, and then only palliative measures can be adopted, such as allaying the pain and checking the hæmorrhage. Great relief is often given by washing out the bladder; but this must be done with very great care, a soft flexible catheter being used, if it can be passed into the bladder, in preference to a rigid one.
Hypertrophy and dilatation. Hypertrophy and Dilatation.—When there is long-continued obstruction to the flow of urine, as in stricture of the urethra, enlarged prostate, &c., the bladder-wall becomes much thickened, muscular fibres increasing both in size and number; the interstitial fibrous tissue is also increased. The wall on its inner surface becomes rugose, and the condition is technically known as hypertrophy. Hypertrophy may be accompanied by dilatation of the bladder, a condition which the bladder may assume when from any cause the evacuation of its contents is interfered with for a length of time.
Paralysis of bladder. Paralysis of the bladder is a want of contractile power in the muscular fibres of the bladder-wall. It may result from injuries whereby the spinal cord is lacerated or pressed upon at or below the micturitory centre situated in the lumbar region. The result may be either retention or incontinence of urine: sometimes there is at first retention, which later on is followed by incontinence, while in other cases incontinence results in the first place and then retention. Paralysis is also produced in certain nervous diseases, as in locomotor ataxia, and in various cerebral lesions, as in apoplexy.
Atony of bladder.Atony of the bladder differs from paralysis in being only a paresis or partial paralysis. It is due to a want of tone in the muscular fibres, and is most frequently the result of habitual over-distension of the bladder, such as may occur in cases of enlargement of the prostate. The patient is unable to empty the bladder, and the condition of atony gets increasingly worse.
In both paralysis and atony the indication is to carefully prevent over-distension of the bladder by the urine being retained too long, and at the same time to treat by appropriate means the cause which has produced or is keeping up the condition.
Incontinence of urine.Incontinence of urine may occur in the adult or in the child, but is due to widely different causes in the two cases. In the child it may be simply a bad habit, the child not having been properly trained; but more frequently there seems to be a want of control in the micturitory centre, so that the child passes its water unwittingly, especially during the night. In adults it is not so much a condition of incontinence in the sense of water being passed against the will, but is rather due to a difficulty in retaining the urine in consequence generally of an over-full bladder, the water which passes being the overflow from a too full reservoir. It is usually caused by an obstruction external to the bladder, e.g., enlarged prostate or stricture of the urethra. Occasionally the presence of a calculus may produce the condition. The treatment differs in the case of the child and of the adult. In the child an attempt must be made to improve the tone of the micturitory centre by the use of belladonna or strychnia internally and of a blister or faradism externally over the lumbar region, and every effort should be made to train the child to pass its water at stated times and regular intervals. In the adult the cause which produces the over-distension must be removed if possible; but as a rule the patient has to be provided with a catheter, which he can pass into his bladder and thus thoroughly empty it before it has filled to over-
