the last small chip. But if the stone is a very hard one (as are some of the oxalate of lime calculi), or if it is very large, or if the bladder or the prostate gland is in a state of advanced disease, or if the urethra is not roomy enough to admit instruments of adequate calibre, the crushing operation (lithotrity) must be deemed unsuitable, and the stone must be removed by a cutting operation (lithotomy).
Lithotomy.—Cutting for stone has been long practised; but up to the beginning of the 19th century it was performed only by a few men, who, bolder than their contemporaries, had specially worked at that operation and had attained celebrity as skilful lithotomists. Patients went long distances to be operated on by them, and certain of the older surgeons, as William Cheselden, performed a large number of operations with most excellent results. The operation was by an incision from the perineum, and is ordinarily spoken of as lateral lithotomy. It was splendidly designed, and gave good results, especially in children. But it is now a thing of the past, having almost entirely given place to the high or supra-pubic operation. In the high operation the patient, being duly prepared, is placed upon his back and the bladder is washed out with hot boracic lotion, and when the lotion returns quite clean a final injection is made until the bladder is felt rising above the pubes. Then the india-rubber tube is removed from the silver catheter by which the injection has been made, and the end of the catheter is plugged by a spigot. An incision is then made in the middle line of the abdomen over the bladder region. The incision must be kept as low as possible, so that the bladder may be reached below the peritoneum, which, higher up, gives it an external, serous coat. As the bladder is approached, a good many veins are seen to be in the way, some of which have to be wounded. The bladder-wall is recognized by its coarse network of pale muscular fibres, through which, on each side of the middle line, a strong suture is passed, so that when the bladder is opened and the lotion comes rushing out, the opening which has been made into the bladder may not sink into the depths of the pelvis. A finger introduced into the bladder makes out the exact size and position of the stone, or stones, and the removal is effected by special forceps. Bleeding having ceased, the bladder-wound is partly or entirely closed by sutures and allowed to fall into the pelvis, the catheter having been removed. It is advisable to leave a drainage tube in the abdominal wound for a while, so that if urine leaks from the bladder-wound it may find a ready escape to the dressings.
Litholapaxy.—Lithotrity consists of two parts—the crushing of the stone, and the removal of the detritus. The two stages are now carried out at one “sitting,” without an interval being allowed between them, as was formerly the practice, and the term “litholapaxy” designates this method. The patient having been anaesthetized, 10 oz. of hot boracic lotion are injected, and the crushing instrument, the lithotrite, is then passed into the bladder. The lithotrite has two blades, a “male” and a “female,” the latter fenestrated, the former solid with its surface notched. When the stone is fixed between the blades the screw is used, and great pressure is applied evenly, gradually and continuously to the stone. The lithotrite is made of very tough steel, so that hard stones may be crushed without danger of the instrument breaking or bending. Care must be 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. The stone breaks into two or more pieces, and these fragments must be crushed, one by one, until they are powdered fine enough to escape by the large evacuating catheter. If the stone be large and hard, half an hour or longer may be required to crush it sufficiently fine. When the surgeon fails to catch any more large pieces, the presumption is that the stone has been thoroughly broken up. The lithotrite is then withdrawn and the detritus is washed out by an “aspirator,” which consists of a stiff elastic ball which is connected with a trap, into which fragments of stone fall so as not to pass out on the instrument being used at later periods in the operation. A large catheter, with the eye very near the end of the short curve, is passed into the bladder; the aspirator, full of boracic lotion, is attached to the catheter, and a few ounces of the fluid are expressed from the aspirator into the bladder by squeezing the rubber ball. When the pressure is taken off the ball, it dilates and draws the fluid out of the bladder, and with it some of the detritus, which falls into the trap. This is repeated until all the fragments have been removed. After the operation the patient sometimes suffers from discomfort. His urine should be drawn off by a soft catheter at regular intervals for a few days. If the pain be severe, it can generally be relieved by fomentations. The patient must be kept in bed after the operation, and in cases where the stone has been large and the bladder irritable, the surgeon should insist on his remaining there for at least a week; in those cases which go on favourably the patients are soon able to perform their ordinary duties. Fatal terminations, however, do now and again occur from suppression of urine, the result of the old-standing kidney disease which so often complicates these cases.
To Brigade-Surgeon Lieutenant-Colonel Dennis Francis Keegan, of the Indian Medical Service, is due the fact that the operation of crushing and promptly removing all fragments of a vesical calculus is as well suited for boys as for men. In entire opposition to long-standing European prejudices, Keegan’s operation is now firmly and permanently established. The old operation (Cheselden’s) of cutting a stone out through the bottom of a boy’s bladder is now seldom resorted to, and if a stone in a boy is found too large or too hard to lend itself to the crushing operation, it is removed by a vertical incision through the lower part of the anterior wall of the abdomen, as described above. For a successful performance of the crushing operation in a boy a small lithotrite has, of course, to be used, and it must be of the very best English make. The operation has to be done with the utmost gentleness and thoroughness, not a particle of the crushed stone being left in the bladder, since otherwise the piece left becomes the nucleus of a fresh stone and the trouble recurs.
The treatment of vesical calculi by other means than operative surgery is of little value. Attempts have been made to dissolve them by internal remedies, or by the injection of chemical agents into the bladder; but, although such methods have for a time been apparently successful, they have invariably been found worthless for removing calculi once actually formed. Nevertheless, much can be done towards preventing the formation of calculi in those who have a tendency to their formation, by attention to diet, by taking proper exercise, and by the internal administration of drugs.
Rupture of the bladder may be caused by a kick or blow over the upper part of the abdomen, or by a wheel passing over it; or it may be a complication of fracture of the pelvis. If the rupture is in that part of the bladder which is uncovered by the peritoneum, the extravasated urine may be cut down upon and let out with good prospect of success; but if the rupture is in the upper or hinder part of the bladder the urine is let loose into the general peritoneal cavity and sets up peritonitis, which is more than likely to prove fatal. If the surgeon knows that the bladder is ruptured he should operate at once in order to provide escape for the urine, and also to sew up the rent. If the possibility of the bladder being ruptured be even suspected, the surgeon should pass a catheter. Perhaps he draws off an ounce or two of blood-stained urine. This makes him doubly suspicious, so he injects into the bladder five, eight or ten ounces of warm boracic lotion, and, leaving it there for a few minutes, he measures the amount which he is able afterwards to withdraw; if he finds that a certain amount is lost he is assured that a leakage has taken place and he at once proceeds to operate. If only the diagnosis is made promptly, and the operation is at once undertaken, the outlook is not unfavourable. A generation or so back nearly all the cases of rupture of bladder ended fatally.
Villous disease of the bladder is innocent; that is to say, it does not spread to the neighbouring structures or implicate the lymphatic glands. The villi are slender, branched, filamentous processes which, springing from the floor of the bladder, float in the urine like seaweed. They are freely supplied with blood-vessels, so that when a piece of a villus is broken off there is likely to be blood in the urine. Indeed, painless haemorrhage is one of the characteristic features of the disease, and when fragments of the “seaweed” are found in the urine the diagnosis is clear. If the bladder is opened from the front, as already described, the villi may be nipped off by special forceps and the disease permanently cured.
