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attaching an auscultatory tube to the instrument a characteristic
sound may also be heard.
With the cystoscope in the hands of an expert it is possible to
orient one’s self definitely concerning the size and location of a
calculus, but much information can also be obtained by the use of
the ordinary searcher.
It has occasionally happened that calculi have been discovered by
accident, either during a suprapubic or some other pelvic operation.
Treatment.—The presence of vesical calculus being established,
there is but one rational treatment, i. e., its removal. It
remains, then, only to select the method of operation and to perform
it. Vesical calculi are removed by two general kinds of operations: by
crushing and evacuation of fragments through the natural passages,
or by a cutting operation and extraction entire. The former is known
as lithotrity, or, as now performed in one sitting, litholapaxy, and the
other as lithotomy, which may be performed either above the pubis,
through the perineum, through the vagina, or through the rectum.
Each method has certain obvious advantages. Thus in favor of
crushing there is freedom from an open wound, with its dangers of
infection and of hemorrhage, while it appeals to the sentiment of
those patients who “dread the knife.” One objection to it is that even
when performed with skill assurance cannot be given that the
bladder shall be freed from all calcareous particles, one of which
may, by remaining, serve as a nidus for another calculus. In favor of
the cutting operations are their brevity, i. e., the celerity with which
they may be performed, the relief afforded by drainage, which can be
carried out through the lithotomy wound, and which is often indicated
in bladders that have been long tortured by the presence of calculi;
while, finally, their simplicity, at least in most instances, makes
lithotomy attractive to the operator of limited ability. It may be added
that certain calculi, especially of the oxalic type, are so dense and
resistant that even when secured in the grasp of an instrument they
can scarcely be crushed. It may be urged also that septic urine is
just as harmful in a bladder whose mucous membrane has been
slightly injured here and there in the process of crushing as in one
which has been more or less opened by a lithotomy.
 Between cutting methods choice varies also according to the taste
and views of various operators, as well as the nature of the case.
When the prostate is large a suprapubic operation was held the
simpler for the removal of calculus, and this earlier teaching is not
abandoned. In the young the urethra is small and the bladder lies
high in the pelvis, and both these conditions favor the suprapubic
method. Again it enjoys repute because there is no danger of injury
to the prostatic urethra or the seminal ducts or vesicles, and because
it leaves the genital apparatus absolutely untouched. It is also free of
possibility of harm to the rectum, which was by no means unknown
in the hands of the older operators who resorted to the perineal
route. But the removal of a large stone by the suprapubic route
entails an opening of considerable size, and it is not unlikely that a
large calculus may need to be fragmented and removed in pieces
rather than leave a large opening at a point where urinary fistulas
would likely ensue. It will be seen, then, that even lithotomy is not
always to be performed without crushing of the calculus.
Of the perineal routes only two are in vogue today, the median and
the lateral. The median is resorted to for stones of moderate
dimensions, while the lateral will be required for large calculi. The
vaginal route is often selected in women, although, rather than make
an extensive opening between the bladder and the vagina, it will
probably be easier and better to dilate the urethra, and, through it,
crush a calculus which, in the female, could thus be made more
accessible than in the male. Therefore in the female the suprapubic
route or a litholapaxy is usually adopted. The operation through the
rectum has been long since abandoned.
After a calculus has been removed by crushing a self-retaining
catheter should be inserted, for at least a day or two, and the bladder
washed, while at the same time treatment for the cystitis, which is
still present, should not be discontinued. After opening the bladder
the wound is drained for at least a day or two. Drainage has this
disadvantage, that if long continued it leaves a urinary fistula, often
slow to close, but a metal, glass, or hard or soft rubber tube may be
placed in a median perineal opening, around which should be
packed gauze to check oozing, and left in this condition for two or
three days. Usually within a week after its removal the deep
sphincters have recovered their retentive power, and the patient can
retain urine for some time, while generally within two weeks the
entire wound is closed. In all these cases a sound or bougie should
be passed at suitable intervals for the purpose of preventing stricture
formation in the deep urethra at the site of the operation.
Litholapaxy is performed by first crushing the stone between the
beaks of an instrument known as the lithotrite, which is constructed
in various forms, yet all conforming to one type, which is introduced
into the bladder through the urethra, after which its blades are
separated and manipulated until the stone is felt to be entangled or
secured between them. By a device at the handle the blades are
then locked, and screw power exerted, also from the handle, by
which the blades are forced together and the stone between them
more or less broken (Figs. 652 and 653). By repetition of this
process each fragment is seized separately and crushed until the
bladder contains more or less debris resulting from the manipulation.
The lithotrite is then removed and a washing tube or catheter of large
dimension inserted, and connected with a so-called washing bottle,
which is compressible and permits a stream of water to be violently
thrown into the bladder, thus stirring up the fragments and particles,
and which is an instant later withdrawn by suction in such a way as
to carry them with it. Escaping into the washing bottle they drop by
gravity into a glass receptacle at its base, where they become at
once visible. This process is repeated until everything has been
washed out of the bladder which will come. The lithotrite is then
substituted and the maneuver repeated, and as many times as may
seem desirable. In this way calculi, especially soft ones of large size,
may be disintegrated and removed in small fragments. The final test
of success is failure to aspirate any more particles or to discover
them with the cystoscope (Fig. 654). The time consumed in the
operation will depend on the operator’s skill and the size or hardness
of the stone. It is frequently performed under local anesthesia, the
bladder being injected with a weak cocaine solution, or under spinal
anesthesia.
Lithotomy, by either of the above methods, is performed by
utilizing a grooved sound known as a staff, which is first inserted into
the bladder, and serves not merely the purpose of a grooved
director, but to indicate the course of the urethra.
For the suprapubic operation the staff is passed deeply, and its
handle depressed between the thighs, so that the end of the
instrument rises behind the pubis and carries the bladder up toward
the surface. A median incision above the pubis permits access
between the recti muscles to the prevesical space (space of
Retzius), which is more or less filled with fatty and connective tissue.
If the bladder has been previously distended with fluid and elevated
on the point of the staff, there is but little danger of wounding the
peritoneum, although its reflection may be sought and carried out of
harm’s way. It is a convenience to pass a silk suture with a stout, full-
curved needle through the bladder wall after it has been exposed, on
either side of the point of the staff which elevates it, and to pass this
through in such a way as to have thus a double loop, or two
retractors, by which it may be more conveniently manipulated after it
has been opened and would otherwise collapse. The bladder should
be opened upon the point of the staff, whose groove may then serve
as a guide in still further nicking or incising it, the silk sutures on
each side preventing it from collapsing as it otherwise would after the
gush of escaping fluid. The surgeon should now endeavor so far as
possible to dilate rather than to merely cut this opening, and thus
give it a size sufficient to permit the introduction of the finger, by
which intravesical exploration and orientation are effected. Calculi
having been identified and located, suitable forceps are then
introduced, and with them the stone or stones seized and withdrawn
through the opening, which may be stretched still farther for the
purpose unless their size make it advisable to crush them and
remove them in fragments.
 Fig. 652

Method of seizing the stone behind the prostate.

Fig. 653

Ordinary position in seizing the stone.

 Fig. 654

Bigelow’s lithotrites, catheters, and evacuator.

This is suprapubic cystotomy or epicystostomy, according to the

purpose for which it is intended. It serves not only for removal of
calculi but for extirpation of tumors, or enlarged prostates, and
perhaps for permanent drainage. By the silk loops at first introduced
the bladder wall may be attached to the abdominal wound, while
other stitches may be added to any desired extent. In most instances
it is desirable to reduce the opening, for which purpose buried and
superficial sutures may be used. As leakage, however, may produce
infection it is customary either to provide for drainage by insertion of
a catheter through the urethra, or by the implacement of a small
tube, whose lower extremity shall reach the base of the bladder and
serve for drainage, which latter may be made more effective by
siphonage.

PERINEAL LITHOTOMY.
Perineal section for exploration, drainage, or stricture is practically
accomplished as follows: The patient is first placed in the so-called
lithotomy position, i. e., upon the back with the limbs flexed and
knees parted, the feet or legs being held either by assistants or in
suitable leg holders upon the operating table. This is the position in
which nearly all perineal operations in both sexes are made.
A grooved staff, with large curve and long beak, is introduced into
the bladder, and not only held in the vertical position by an assistant,
but in such a manner as to make its curve bulge the perineum as
much as possible toward the operator. The rectum, which should
have been previously thoroughly cleaned, may be utilized for
identification or for necessary assistance during the operation. The
scrotum is held up out of the way by the assistant who holds the
staff. The perineum being thus put upon the stretch may be most
quickly opened by a straight, sharp-pointed bistoury, which is
inserted a little posteriorly to the scrotal junction, its point driven
through the tissues and made to engage in the groove of the staff,
from which it should not escape until finally withdrawn. As the
instrument is pushed backward the handle is depressed; a
triangular-shaped opening is thereby effected, whose apex is in the
membranous urethra and whose base occupies the raphé of the
perineum, to the extent of perhaps one and a half inches. The entire
incision may be made with one effort. Its effect is to open the
membranous urethra. Into the groove of the staff, the knife being
withdrawn, may be introduced either a species of grooved director or
the finger-nail of the index finger, which may be passed backward
and made to enter the prostatic urethra, while at the same time the
staff is withdrawn. If the prostatic urethra be constricted it will be
difficult to enter the bladder with the finger, otherwise it will readily
yield to pressure, and it is thus possible to enter the bladder within a
few seconds after the first incision is begun (Fig. 655).
 It is preferable in all these cases to have first washed out the
bladder, and then to have filled it with a mild antiseptic solution. This
will escape instantly an outlet is made from below. If there is a small
calculus within the bladder the effect of the stream will be to carry it
toward this outlet, where it is identified by the finger.
The prostatic urethra will bear a considerable amount of gradual
dilatation, which will make it more than easily accommodate an
ordinary finger. In this way a sufficient channel is made, through
which forceps may be introduced and calculi of small or medium size
withdrawn. They should be seized as carefully as possible within the
proper grasp of these instruments, so that a minimum of laceration
may be effected as they are extracted. A small calculus will be easily
removed; a large and soft one may crumble in consequence of the
pressure made upon it during its extraction. In this event the
fragments should be separately removed, the bladder then
repeatedly washed out, and the finger finally used to make sure that
no particles remain.
Whether one stone or several be present the opportunities for the
purpose of their extraction afforded by this median operation are the
same. The bladder having been emptied and washed out a self-
retaining drainage tube, or a hard rubber or metal perineal tube
should be inserted, with such gauze packing around it as may be
necessary for its retention and for the checking of hemorrhage. The
intent of the tube is a double one, it being intended to serve for easy
drainage and for gentle pressure. Sometimes the prostate is more or
less torn in the process of dilatation, and in this case will bleed more
freely than is comfortable. Such oozing may be checked by plugging
gauze around the drainage tube.
Lateral lithotomy may be combined with median section, by
deliberately passing a blunt bistoury into the prostatic urethra, and
making with it an incision in the prostatic substance, the cut being
directed toward a point midway between the anus and the ischiatic
tuberosity, and carried to a depth of one-half or three-quarters of an
inch. This affords a much larger opening through which to remove
larger calculi. Obviously it will bleed more freely and will usually
require packing. The old lateral method was to begin the external
incision at a point, in the middle line, a little behind the scrotum, and
direct it for one and a half or two inches backward and outward to a
point between the tuberosity and the anus. The incision was then
deepened through the perineal fascia until the index finger-nail of the
left hand could identify the staff within the urethra, after which the
urethra was opened at this point (i. e., just behind the bulb), when
the knife was again introduced and made to divide the prostate
obliquely as above. In this way the membranous urethra and lateral
aspect of the prostate were divided to the requisite depth. If such
incision be extended too far backward and outward the internal pudic
artery might be divided, which would at least be awkward and
necessitate ligature, and this would be somewhat difficult because it
would require further division of tissues.
 Fig. 655

Second stage of lithotomy. (Erichsen.)

The same management is required after lateral as after median

operation. Except only when a long and seriously inflamed bladder
requires almost permanent drainage the perineal tube should be
removed within forty-eight hours, and the external opening allowed
to close as rapidly as possible.

TUMORS OF THE BLADDER.

 The most common benign tumor of the bladder is papilloma, which
here assumes almost invariably the villous form and grows even
luxuriantly. It may be solitary or multiple. In the beginning it is usually
more or less pedunculated, but may grow in great numbers, as in the
mouth. A class of denser tumors are the fibromas, which are covered
by a more or less thickened mucous membrane. Myxomas grow
mainly in children. Adenomas have been described, but are rare.
Dermoid cysts in or about the walls of the bladder have also been
described. The malignant tumors of the bladder are mainly of the
epithelial type, usually adenocarcinoma, of a somewhat peculiar
type, due to malignant degeneration of an original papilloma, an
unfortunately common event (Fig. 656).

Fig. 656 Fig. 657

Villous tumor (papilloma) of bladder. (Musée Tumor of bladder as seen

Dupuytren.) with cystoscope. (Nitze.)

Symptoms.
—The symptoms due to tumor in the bladder do not differ much from
those of calculus, except that there is at first less pain. In nearly all
cases there will be hemorrhage, occurring independently of exciting
causes, as during sleep, not only abundant but often frequent. In the
early stages pain is rarely severe. In cancer it is largely proportionate
to involvement of the bladder wall and the adjacent organs, and is
more common in cases of basal tumors. It is both local and referred.
With a bladder filled or filling up with a tumor mass there will be
reduction of capacity and frequency of urination, while in nearly all
instances the essential features of cystitis are superadded. The
actual evidences of tumor are its detection by the cystoscope, its
discovery by vaginal or rectal palpation, or its recognition by
fragments discovered in the urine.
When the cystoscope is used in these cases it usually reveals the
location, size, vascularity, arrangement, and character of the tumor.
Its use, however, is often difficult or impossible, because the
manipulation by which the bladder is so distended as to permit its
use causes hemorrhage and obscurement of the field of vision (Figs.
657 and 658).
With the cystoscope has been recognized also an early condition
of leukoplakia, corresponding to that seen in the mouth and on the
tongue, which may be regarded as a precancerous condition.
Treatment.—The only treatment which can be made effective is
complete operative removal. There is no reason why
any benign tumor of the bladder should not be attacked, the most
unpromising cases being those of general papillomatous
involvement, where only small areas of the bladder mucosa are left
uninvolved. Such a villous condition as this is serious, and may later
justify an effort at extirpation of the bladder. Palliative treatment will
include the arrest of hemorrhage (for which a few drops of turpentine
oil are often effective), with gentle lavage of the bladder and removal
of clots, securing their disintegration by injecting an emulsion of
pepsin or of papain; while tenesmus, irritability, and pain are to be
controlled by cannabis, suppositories, morphine, or whatever may be
needed. In inoperable cases cystotomy for drainage purposes may
be the final measure for relief purposes.
 Radical measures include opening of the bladder, either above or
below the pubis, as the cystoscope may indicate; or the former,
when the cystoscope cannot be used, as it affords better means for
exploration. Through this opening, which may be made larger than
for mere exploratory or lithotomy purposes, and aided by artificial
light (small electric lights introduced by suitable mechanism, as
within a test-tube), there may be removed with scissors or curette, or
even with the finger-nail, by enucleation, such growths as are met,
while in nearly every instance it will be an advisable precaution to
cauterize their bases with the actual cautery. Through more
extensive incisions, with the patient in the Trendelenburg position
and the prevesical space widely opened, the bladder mucosa may
be excised, and ample drainage provided both by retention of a
catheter and insertion of a siphon tube through the lower part of the
opening. The suprapubic route affords better opportunities for
thorough work than does the perineal, the latter being suitable only
for a limited class of cases.

Fig. 658

Illumination of anterior vesical wall by Nitze’s cystoscope.

 Finally comes the question of extirpation or a complete
cystectomy. This radical and difficult measure has been added to the
list of possible surgical procedures. In a case of general
papillomatous disease it might be successful, but it is questionable
whether any case of cancer which would call for such a measure can
be cured by it. The operation has been done much oftener in women
than in men, and usually by a combined procedure of suprapubic
opening, which may be vertical or transverse, with attack from the
vagina. If the vaginal wall be involved it may also be cut away. The
ureters should be isolated and preserved, when, the affected tissues
being removed, it becomes a question of what to do with them. They
may either be left to drain into the vagina, which is thus utilized
simply as a conduit, and which may be closed later and the urethra
thus utilized, a urinal being worn, or they may be immediately or by a
secondary operation turned into the rectum. The latter procedure
introduces fresh complications, though, if successful, it would
minimize the unpleasant features of such a case.[69]
[69] Symphysiotomy may, when required, be combined with suprapubic
operation as in the case of young children, for removal of very large stones
or tumors, as has been recently demonstrated by Palmer, of Persia.

It is thus possible to successfully extirpate the entire bladder

proper, conserving the ureteral orifices or not, as well as the urethra,
although the resultant condition can hardly be considered brilliantly
satisfactory.[70]
[70] In a recent case I have been able to more easily effect this
procedure by raising a flap, including the tissues of the mons, exsecting a
portion of the symphysis containing the insertion of the recti, by oblique
division, in such a way that when replaced the bone could not be easily
displaced, and in this way uncovering the space of Retzius so that, by
combined manipulation, it was easier to detach the bladder wall from its
surroundings.

THE PROSTATE.
The prostate, with the duct extremities of the seminal vesicles, are
enclosed in a fibrous sheath or capsule, of more or less density,
which has been called by Belfield the broad ligament of the male. In
structure this body is composed of a mixture of adenomatous and
muscular (involuntary) fibers, with considerable connective tissue, so
that in many respects it is the homologue of the uterus. It not only
serves as the portal of the bladder, but through it pass the prostatic
urethra and the seminal ducts. Infection proceeding from either
direction may, therefore, travel along either one of several paths,
spreading disaster and causing a variety of troubles. Such infection
may be tuberculous, gonorrheal, or of the ordinary septic type. There
will ensue in consequence various forms of prostatitis: the acute,
which may lead to abscess, and the chronic, which will always lead
to hypertrophy.

ACUTE PROSTATITIS.
Acute prostatitis is generally the result of gonorrheal infection, the
consequence of extension from the urethra into the mucous follicles
and the prostatic structure. Primary tuberculous disease in this
location is rare. Septic infection comes either from the use of
unclean instruments, from the presence of infected urine, or from the
extension of cellulitis from some adjacent structure. It is not
infrequently seen in connection with deep and tight strictures and
accompanying cystitis, or in connection with the presence of small
concretions, i. e., prostatic calculi.
Acute prostatitis is an exceedingly painful affection, made so
particularly by inelasticity of the capsule, which affords no
accommodation for the swelling due to the inflammation. In addition
to the inevitable pain and tenderness the swelling will sometimes
practically close the urethra in such a manner that urination becomes
almost impossible. To nearly every case will be added some of the
symptoms of acute cystitis, which may have preceded the prostatitis.
Prostatic inflammation can be made known by the exquisite
tenderness of the organ, discoverable by digital examination through
the rectum. This feature, with tenderness in the deep perineum, and
the above symptoms make diagnosis easy.
According to the intensity of the lesion will be the liability to
suppuration. Prostatic abscess is a frequent result, and its presence
is evidenced by accentuated pain and tenderness, with perhaps
considerable febrile disturbance. In some cases fluctuation can be
detected through the rectum. Such cases sometimes evacuate
themselves spontaneously, although often in an undesirable way,
when left untreated, or unrecognized, discharge taking place usually
into the rectum, but perhaps into the bladder or into the urethra.
Should pus burrow into the pelvis there will arise a deep pelvic
cellulitis, with probable disastrous consequences.
When a prostatic abscess is suspected the patient should be
anesthetized, the sphincter dilated, the exploring needle used if
necessary, and any collection of pus, no matter how detected,
should be either completely emptied with the aspirator or by free
incision.

CHRONIC PROSTATITIS.
Chronic prostatitis may be the residue of an acute lesion or the
gradual production of a mild but more or less constant septic
infection. It leads always to more or less enlargement, is often the
basis for the classic prostatic hypertrophy, and causes dull pain,
referred in various directions, often to the sacrum and the back, with
frequency of urination and escape of a viscid mucus, the natural
prostatic mucus in excess, which the patient will usually consider
semen, but which is really the product of the overworked prostatic
glands.
This last phenomenon is spoken of as prostatorrhea, and
deserves consideration not alone from the alarm with which patients
often regard it, but because it indicates a significant condition. A
prostate whose glandular structures have been unduly active will, in
consequence, enlarge; such a prostate is compressed with the
passage of every hard stool, the consequence being the expulsion of
some of this fluid with each act of defecation, a feature interpreted by
too many patients as spermatorrhea. The two conditions are to be
differentiated in clinical study, the former being common, the latter
quite rare. Acute prostatorrhea is also frequently the consequence of
more or less prolonged sexual excitement. It corresponds essentially
to a chronic nasal catarrh, which is accentuated by exposure to cold
or to irritation of any kind, and is only the overflow of a natural fluid
under morbid conditions. With chronic prostatitis, furthermore, the
sexual appetite is often decreased, while sensations are more or
less disturbed, ejaculation being perhaps premature; the patient is
often made thereby despondent, and the case regarded by himself,
or by the quack whom he is led to consult, as at least incipient,
perhaps hopeless, impotence.
The physical evidences of chronic prostatitis are enlargement, with
tenderness not only of the prostate itself, but of the seminal vesicles
above it, and often the appearance of a few drops of prostatic mucus
at the meatus after pressure or stroking of the prostate itself has
expelled them.
Treatment.—Removal of the cause is the secret of success; if this
be a stricture it may be divided and dilated; if cystitis, it
must be combated; if chronic constipation, it should be overcome;
while excesses, either alcoholic or sexual, should be controlled.
Some one or nearly all of these conditions will be seen in nearly
every case of this character. To other manipulative features may be
advantageously added a certain massage or “milking” of the
prostate, at intervals of five or six days, by which it is emptied of its
accumulated secretion. Equally beneficial is the occasional passage
of a large sound through the prostatic urethra and into the bladder.
Its effect also is to make pressure, while at the same time it
stimulates and does good in a way perhaps difficult of explanation.
Irritation in the prostatic urethra should also be controlled by
occasional injections, with a deep urethral syringe, of a drop or two
of a ¹⁄₂ per cent. solution of silver nitrate. Improvement in other
respects may be expected from constitutional, dietetic, and hygienic
measures.

PROSTATIC HYPERTROPHY.
Many theories have been advanced as to the etiology of prostatic
enlargement. Those worthy of any consideration may be
summarized as follows:
1. That it is of inflammatory origin;
2. That it is due to senile and sclerotic changes;
 3. That it is produced by sexual excess;
4. That it is due to ungratified sexual desire;
5. That it is a secondary and degenerative change following
disease of the bladder;
6. That it is due to some perverted testicular secretion;
7. That it is to be regarded as a normal senile change;
8. That it is of catarrhal or septic origin secondary to bladder
disease;
9. That it is to be regarded as an adenoma.
Inasmuch as the prostate is to be regarded as essentially a sexual
gland, many cases of hypertrophy are the result of bad sexual habits
which produce continued congestion. Nevertheless the importance
of previous infections, e. g., gonorrheal, by which hypertrophy of
glandular and cell elements may be produced, cannot be
overlooked.
Prostatic enlargement assumes one of three principal types:
(a) True hypertrophy of gland elements, without interstitial
participation;
(b) The development of more or less distinctly encapsulated
myomatous and adenomatous masses; and
(c) A mixed condition involving both of these features.
In consequence the ensuing enlargement assumes one of the
three following clinical types:
(a) An enlarged soft prostate;
(b) A small contracted and sclerotic prostate;
(c) A mixed type.
These types do not necessarily merge into each other, but may
remain distinct. There may be atrophy of glandular elements as a
result of hypertrophy of the muscle and fibrous elements, or vice
versa.
Much confusion has arisen regarding the so-called third lobe, in
spite of the fact that the prostate is essentially a bilobed organ.
Whence has arisen the tendency to speak of the “third lobe,” or is
there such a thing? The explanation is that median enlargement is a
common expression of prostatic hypertrophy, occurring toward the
interior of the bladder at a point where the prostate has no capsule,
and where growth occurs in the direction of least resistance. That
morbid specimens show an apparent “third lobe” is true, but that
such a condition exists normally is a mistake. It should, therefore, be
spoken of as a median enlargement (Fig. 659).
 Fig. 659

General prostatic enlargement, with formation of a median overgrowth and

posterior pocket or sac. Illustrating how residual urine may be retained, as well as
the difficulties of all kinds of instrumentation, i. e., an argument, therefore, for
radical treatment. (Socin and Burckhardt.)

In addition to the more innocent and purely hypertrophic forms of

prostatic enlargement, it has been recently shown, especially by