In elderly and feeble patients and in those with enlarged prostate, particularly enlargement of the third lobe, even greater care and gentleness are necessary, and several attempts may be needed before the stone is finally reached. In such cases the stones are generally lodged in the pocket behind the third lobe, and if the jaws of the instrument are reversed in order to reach them, care must be used, as was previously directed, lest the third lobe be grasped between the jaws of the instrument or a fold of the rectovesical membrane be crushed. It is a good plan, after the stone has been seized by the lithotrite, to rotate the instrument slightly to be certain that no mucous membrane has been seized.

After the stone has been crushed, if fragments get in behind the third lobe, they are very often, after a few days, washed out. Here, as in many conditions of the genito-urinary tract of similar nature, when the patients are so much enfeebled that heroic measures cannot safely be undertaken, time is an important factor. As regards the results that may be expected from the removal of vesical calculi, these are dependent on the individual case. It is not to be expected that in an old man with a large prostate, chronic cystitis and incontinence of urine would entirely disappear after the removal of a stone, although a large measure of relief will generally follow. When, however, no complications exist, a complete cure will naturally be expected to follow. It is the writers' belief that in New York and its vicinity the treatment of stone in the bladder by litholapaxy has not received sufficient attention in the past, the tendency, in almost all cases of vesical calculi, to perform suprapubic cystotomy being on the increase. It is difficult, however, to formulate a series of rules that will be applicable to all cases. Suprapubic cystotomy, when good afternursing can be assured and the patient is in a fair degree of health, will probably, with many surgeons, be the operation of choice, since under such circumstances the danger of a suprapubic fistula forming is reduced to a minimum, and the operator can be certain that the stone has been entirely removed. On the other hand, in dealing with patients with stone in the bladder who are unwilling to submit to a cutting operation, who are aged or very infirm,

or when it is not possible to obtain good after-treatment, litholapaxy is to be preferred.

Remarks on the Removal of Vesical Calculi.-In cases of stricture of the urethra that will not easily permit of the introduction of the lithotrite, the stricture should be well dilated before any attempt is made to do litholapaxy. In elderly persons a stone in the bladder will often be found associated with enlarged prostate, and it is well, therefore, when doing a prostatectomy, to examine the bladder for stone, and if one is found, to remove it through the opening used for prostatic enucleation. In two cases seen by the writers it was found difficult to remove the stone through the opening made for a perineal prostatectomy, and a suprapubic opening was also required.

Encysted stones may frequently be detected by the searcher, or may be seen by the cystoscope, but the surgeon will find that he is unable to remove them. In attempting their removal a suprapubic cystotomy is the operation to be preferred. Chismore has found that oxalate of lime stones are those most frequently encountered; next in frequency come the phosphatic calculi, whereas the uric-acid formations are least likely to occur. Occasionally stones form very rapidly, large quantities of gravel coming down from the kidney acting as a nucleus. Sometimes the crushing must be repeated every two or three months, or the stones may not reform for several years. Dr. Chismore operated fifteen times on one man. The bladder should be inspected very carefully about a month after a stone has been removed, and, if possible, the patient should be kept under observation and be seen several times a year.

In using gomerol it is advisable that a very small quantity. of the oil-from ten to twenty drops-be used in the commencement of the treatment. If beneficial results ensue, the amount can be increased ordinarily until one-half to one ounce is applied.

Bladder Puncture. This is occasionally done for temporary emptying of the bladder, by means of an aspirating needle or a trocar. It is generally used as an expedient for temporary relief of distention preceding some operation which may have to be temporarily delayed. The puncture should be made as near the

It

pubes as possible, so as to avoid wounding the peritoneum. should be made as exactly as possible in the median line of the abdomen, so as to avoid wounding the veins on the outer surface of the bladder. Every possible precaution should be taken as to the sterilization of instrument and cleanliness of the field of operation. In doing retrograde catheterization, occasional successful attempts have been made, through the use of a trocar, to perform retrograde catheterization. The operation, however, is not one that ordinarily commends itself to the surgeon. In the past this operation was most often performed for retention of urine due to obstruction, such as that caused by an enlarged prostate. The trocar, or aspirating needle, should be made to penetrate for a distance of one and one-half to two and one-half inches from the surface of the abdomen, according to the amount of fat present in the abdominal walls. It is safer, in order to avoid wounding the peritoneum, to make a very small preliminary incision immediately above the pubes down to the bladder-wall before making puncture. When obtainable, a curved instrument should be used with its concavity pointing toward the pubes.

SUPRAPUBIC CYSTOTOMY

This operation of opening the bladder through the abdominal wall has come into more general use within the past twenty years, and, the writers believe, its present popularity is well merited. It is now to a great extent the operation chosen for the surgical relief of stone in the bladder, and it is very frequently employed when the prostate is to be also attacked. The difficulties attending the performance of this operation have been somewhat exaggerated. There are, however, certain practical objections to its indiscriminate use. One of these is that the peritoneum may be wounded; this objection is overcome in large measure, however, if proper small catgut sutures are kept at hand, and if the wound is immediately sutured, for but little harm will result. The greatest practical objection to its performance is the difficulty with which the suprapubic wound heals after the operation. Much depends on keeping the edges of the wound clean; these are soiled by the urine that is continually flowing through

the suprapubic opening. In any given case, therefore, in which the surgeon feels assured that the patient will receive the proper attention after the operation, it is often the operation of choice. When doubt exists as to the efficiency of the nurse, or when it is questionable whether or not the wound will receive the proper

Fig. 123-Suprapubic cystotomy (Lejars).

attention, some other method of entering the bladder should, when possible, be attempted. This operation is almost never performed on the female. The technic of the operation is as follows:

The pubes and scrotum having been shaved and the operative toilet having been carefully made, the bladder should be washed out, and as much of a saturated solution of boric acid

should be injected through a catheter into the bladder as the organ will comfortably hold-usually about one pint.

After the bladder has been filled, a catheter should be tied around the root of the penis, to prevent escape of the fluid. It not infrequently happens that during an operation through the perineum for the relief of prostatic hypertrophy, it is decided to open the bladder from above. When this step is determined upon, it will not be necessary to inject fluid into the bladder, but if there is sufficient room in the urethra, an ordinary steel sound may be passed into the bladder, and the tip of the sound be cut down upon suprapubically. If for other reasons it is found desirable to open up the bladder without filling it, the same measures may here be adopted. By the latter method of performing the operation,

however, the danger of wounding the peritoneum is somewhat increased.

Having placed the patient in the proper position, a straight incision, about six inches long, beginning just below the upper border of the pubic bones and passing directly upward in the median line, should be made. The skin is cut through, and then the white line of the

cised. At the lower

part of the wound the small fibers of the pyramidal muscles may be cut through or pushed to one side, and the muscular aponeurosis of the underlying muscle cut through, when the yellow prevesical fat will appear. When this is seen, the bladder-wall is near at hand; it is well then,

with the finger or the handle of the knife, to press the fat as

Pre-
vesical
Fat.

Fig.124.-Suprapubic cystotomy (Lejars).

far as possible out of the way. In cutting through the tissues just mentioned as being surrounded by the fat, a few small vessels may be severed; there being no large ones in this region or very close to it. Such vessels as are cut through should be immediately ligated, thus keeping the approach to the bladder as clean as possible. When the bladder wall is approached or when it can be outlined with the finger, it is well to pass a sharp hook through what appears to be the wall, keeping as near as possible to the superior border of the pubes, the wound through the skin and muscles having been held open by retractors. Having hooked the bladder-wall, a very small puncture should be