CHAPTER LV
.
THE BLADDER AND PROSTATE.
Methods of recognition of surgical diseases of the bladder have been vastly improved, as well as complicated, within the past few years. The bladder has now been made accessible not alone to touch, as through the rectum or vagina, or by incisions above or below the pubis, but to sight, through the use of the _cystoscope_. It is furthermore possible to detect foreign bodies within it by the Röntgen rays. _Palpation_ is chiefly of value in thin persons, or when the bladder is greatly distended; still, infiltration of the base of the bladder can be detected through the vagina or through the rectum, as can also certain foreign bodies. Much of value is learned by both chemical and microscopic examination of the urine. This may be passed by the patient or withdrawn by the catheter. It has already been indicated how much of value can be learned by separating the urine drawn from each kidney. The difficulties of this procedure are greater in the male than in the female, owing to the complications in the requisite manipulation of the instruments. Nevertheless there is no accurate method of such estimation save by ureteral catheterization. The method of Harris, by the use of the so-called segregator, is of occasional assistance, but is never accurate nor always satisfactory. If the catheter alone be used it should be of metal, if it be desired to have it serve the purpose of a probe, as in the search for a foreign body (calculus and the like) or as a means of estimating the size and shape of the bladder. For the latter purpose an ordinary sound will serve as well, preferably one with a short beak, ordinarily known as a stone searcher. In cases of prostatic enlargement it is of great advantage to estimate the amount of residuary urine after the patient has apparently emptied his bladder. This may be withdrawn by a sterile catheter under aseptic precautions. The use of the catheter is also necessary for lavage of the bladder, a measure of great value in many cases.
The attempt will not be made here to picture nor go into a minute description of the various forms of the _cystoscope_. Their use, like that of the ophthalmoscope, requires special aptitude and training. With the latter they are of great value; without them they confuse and complicate. The cystoscope may be used for ordinary purposes of inspection, for aid in introducing the ureteral catheter, or even for photographic purposes, for it is now possible with the latest instruments to photograph the image thus obtained of the bladder interior. To one not accustomed to viewing the field seen in such an instrument these revelations are of little interest. To the expert, however, they may be made of the greatest value. Without further description, then, allusions made below to the use of the instrument must presuppose some familiarity with it, and the advantages and even necessity of securing special training in its use.
CONGENITAL MALFORMATIONS OF THE BLADDER.
The lesser malformations of the bladder include mainly irregularity in shape or the formation of _diverticula_, which are not extremely rare. These are especially likely to be met during hernia operations. I have repeatedly in operating for inguinal, and once in operating for femoral hernia, found a diverticulum of the bladder complicating the situation. Its possibility, then, should be borne in mind. It may be thin and lie in such close relation to the hernial sac as to be mistaken for the latter. When opened urine will escape and contaminate the wound. It would probably be best to close the bladder opening and discontinue the operation rather than run the risk of contamination of the peritoneal cavity, postponing further work for a few days. As the result of allantoic defects a _double bladder_ may be met, each perhaps having one ureter opening into it. More or less complete partitions in the bladder are more frequently met. These conditions could not be appreciated previous to opening the viscus or the use of the cystoscope.
More complete forms of acquired vesical hernia may be found in such conditions as _cystocele_, common in women after perineal lacerations, and frequently constituting a most serious condition.
=Ectopia or Exstrophy of the Bladder.=--By far the most serious and extensive of the congenital malformations are those constituted by more or less complete defects of the anterior portions not alone of the bladder, but of the abdominal wall which should cover it, and which are known as _ectopia_, _exstrophy_, or _extroversion of the bladder_. Of this condition there are different degrees, from a small cleft just behind the symphysis pubis, to that which is complicated by prolapse of the remaining posterior wall, the umbilicus being situated just above it, while the pubic arch itself is defective or rudimentary. Thus in the male there is usually _epispadias_ of a more or less _rudimentary penis_, while in the female the _clitoris_ is _cleft_ and the _vulva more or less opened_, the urethra being defective or entirely wanting, the vagina often small, and the uterus generally infantile. Extreme cases of this condition constitute one of the most serious and deplorable congenital defects which are not inherently fatal. Obviously, with these conditions, there is constant escape of urine, usually with complete mechanical impotence, although in the female the ovaries are usually present, and practically always the testicles in the male. In the latter the opening of the seminal ducts may be frequently seen on the floor of the urethra, more or less concealed by folds of cystic mucous membrane. The condition is much more frequent in males than in females. The prostate is usually at least rudimentary and may be wholly wanting. Occasionally the testicles are undescended. Double uterus has also been seen in these conditions.
Regarding its causes there is but little known. Doubtless these have to do with allantoic defects, but the allantois is such a temporary organ that there would seem to be some other contributing cause not yet recognized.
Among its most distressing features are not only the lack of control of urine, but the irritation of the exposed mucous surfaces consequent upon friction with clothing, or decomposition of urine and consequent uncleanliness. There is, therefore, nearly always ulceration, with extreme irritability and more or less constant suffering. It is not strange, then, that for its relief surgeons have taxed their ingenuity, or that adult patients, finding the conditions unbearable, are willing to submit to even extreme measures.
=Treatment.=--So many operative measures have been devised that it is impossible to include them all. First of all the procedure should be adapted to the particular case. Much will depend, for instance, upon the extent of the defect in the abdominal wall, or in the pubic arch, and in the male upon the rudimentary condition of the penis or the extent of the urinary canal.
Operations for this condition may be divided into _palliative_ and _radical_--_i. e._, those which are intended to make it more tolerable and those which are really entitled to the latter term. Thus if only the exposed mucous surface can be covered with a skin covering, the condition may be mitigated since a urinal or some device may be worn by which its worst features may be controlled. Trendelenburg has recently called attention to the fact that a wide separation of the pubic arch not only weakens the pelvis, but constitutes a serious difficulty in closing the defect. He has, therefore, combined direct operation with separation of the pelvic bones at the sacro-iliac joints, afterward enclosing the pelvis in a comprehensive bandage, or suspending the patient in an apparatus in such fashion that the bony defect in front shall be narrowed, if indeed it be not completely obviated. This, of course, is a measure to be carried out in the early years of childhood; in connection with it the bones may even be wired at the symphysis. In fact immediately after the birth of such an infant the attempt should be made to narrow the pelvis, by surrounding that part of the body with a wide rubber band, which shall influence growth without too much interfering with nutrition. Later subcutaneous osteotomy may be done if necessary. At all events, the growing pelvis should be surrounded with an enclosure by which a constant influence may be maintained.
The various _plastic operations_ for this defect have the common purpose of affording a covering, which must unfortunately be without a sphincter to guard the outlet of the cavity. The best that can be accomplished, then, by plastic methods is the formation of a more perfect cavity without affording sphincteric control. A theoretically ideal method would be one which should permit raising of skin flaps around the margin of the defect, and so turning them in that the skin should vicariate as mucous membrane. These flaps when united, and the anterior wall when thus formed, could be covered by other flaps or by skin grafts; but from these flaps hairs will grow into the bladder. These will become encrusted with urinary salts and an amount of irritation be produced which may become not only intolerable but locally destructive.
In the selection of any plastic method much will depend on the size of the defect and its completeness, the condition of the surrounding wall, and varying complications in the surrounding structures. The general method above suggested will answer especially for the smaller exstrophies. Beck has suggested an excellent device, namely, the dissection from the pubes of the recti muscles, their insertions being severed, and the partial division of the transversalis fascia until the muscles are so mobilized that they can be reflected and united, thus forming an anterior bladder covering. By a second operation these
## partially formed flaps may be again dissected off from the wall and
a complete osteoplastic covering afforded. Practically no operation for extroversion can be completed in one sitting. Frequently repeated efforts have to be made, a little being accomplished at a time. One of the greatest difficulties met with is securing primary union along surfaces more or less bathed or in contact with escaping urine. These flaps, even if united, may separate in a few days as a result of this urinary maceration. Against this there is but little possible provision, save perhaps by catheterizing both ureters, and emptying them into a distinct receptacle.
[Illustration: FIG. 648
Roux’s autoplastic method of raising a perineoscrotal flap with which to cover the defect. Lines of incision. (Hartmann.)]
[Illustration: FIG. 649
Roux’s autoplastic method of raising a perineoscrotal flap and its fixation. (Hartmann.)]
More complicated methods of furnishing a complete cavity have been devised by Rutkowski and Mikulicz, both of whom have suggested to use a small loop of small intestine wherewith to complete the bladder cavity. In each of these methods the abdomen is opened, a loop of bowel brought down, a small portion completely separated by double division, end-to-end anastomosis of the main part being then made, while the separated part is in one method closed at one end, while the other end is fitted over the exposed bladder surfaces as a sort of cap. The method is exceedingly complicated and hazardous, and depends for local success upon a sufficient blood supply to the intestinal loop, which should be carefully ensured by caring for its vessels and mesentery. It has, nevertheless, been successful.
A far simpler method, perhaps the simplest of all, is that of Sonnenburg, which consists in extirpation of the bladder proper, with plastic closure of the opening, while the ureters are carefully separated and sutured into the upper portion of the urethral gutter. This removes all urinary cavity and provides only for continuous escape; but this latter is now provided in an accessible and convenient place, while the wearing of a urinal permits the achievement of the main purpose of the operation. Sterson operates upon young girls by suturing the loosened ureters to the labia minora, which are then sewed together in the median line, after which a urinal can be worn.[68]
[68] Cantwell has suggested the following method for bladder exstrophy, namely, to pass catheters through a perineal fistula up into the ureters, then to dissect off the bladder wall, bringing it over a small rubber balloon, pushing the whole into position, and uniting the abdominal wall in front.
It has occurred to many operators to more completely divert the urinary stream by displacing the ureters and turning them into the rectum or the sigmoid. Operations for this purpose have been described especially by Maydl (Fig. 650), and by Moynihan, while modifications have been suggested by many others. In practically all of these procedures catheters are first passed into the ureters for their identification and control. Some would dissect out the trigone with both ureters, and, making a sufficiently large opening in the rectum, would transplant it in its entirety within that cavity, closing the opening. Moynihan improved on this by making a vertical incision and entirely dissecting away the bladder, separating it also from the prostate, thus completely isolating it. Then the portion containing the ureters is held upward, while at the bottom of the wound the rectum can either be seen or made visible. The peritoneal reflection is then lifted upward from the front of the rectum, which is opened along its anterior surface by an incision perhaps three inches in length. Into this opening the bladder is placed, being so reflected that its former anterior surface now looks posteriorly. The ureters, instead of passing forward, now pass backward and the catheters contained within them are passed into the rectum and out of the anus. The edge of the bladder and the cut edges of the rectum are carefully sutured, after which the abdominal wound is closed. The sphincter is then stretched, while the catheters remain in the ureters for four or five days.
[Illustration: FIG. 650
Maydl’s operation; diversion of ureters into rectum. (Hartmann.)]
A choice may be made, then, between some such method as that last described or that of Peters, who dissects out the ureters, retaining only a small circular patch of bladder wall, which is folded around the orifice of each, the rest of the bladder being extirpated. Each ureter, with its button of bladder wall, is then drawn through a small slip in the rectal wall, made large enough to admit it, and the end of the ureter is then left hanging for 1 or 2 Cm. into the rectum. It would probably be better to hold the ureters in place by a stitch rather than run the risk of their retraction; but care must be taken that these stitches make no unnecessary constriction. Others have substituted the sigmoid for the rectum, the procedure being otherwise the same, all of these rectal implantations having for their purpose the utilization of the rectum as a cavity, which may not only contain urine, but retain it reasonably under control. In many respects they would be ideal were it not for the attendant dangers. These are (1) those immediately connected with an operation which is serious, and (2) those connected with secondary infection of the kidneys, which seems to occur in almost all cases, no matter how apparently successful at first.
INJURIES TO THE BLADDER.
Injuries to the bladder proper may be accompanied by those of the parts without, or may be isolated. They divide themselves mainly into _ruptures_ and _lacerations_, or _penetrations_ directly connecting with the exterior. Among the causes which predispose to rupture and other injuries may be mentioned intoxication, partly because it is often accompanied by overdistention, and partly because of the partial or incomplete insensibility of the patient. _Distention_, no matter how permitted, is an important predisposing cause. The injuries usually include blows, falls, and crushes, and gunshot or other perforations.
The location of the rent is more commonly in the upper and posterior portion of the bladder--_i. e._, in its weakest part. Such tears may vary from one-half to four inches in length. When _accompanying fracture of the pelvis_ the peritoneum is more likely to be injured.
The most _significant symptoms_ are a desire to urinate and inability to do more than perhaps expel a few drops of bloody fluid. Of course the passage of any blood or bloody urine will suggest the occurrence of such an injury. Patients are usually unable to stand upright, and also show a strong tendency to flexion of the thighs. The introduction of a catheter and the withdrawal of bloody urine do not necessarily settle the question as to whether there has been any possible laceration. Some surgeons have taught that normal urine is comparatively harmless and that it is no more likely to produce infection than the catheter used for diagnostic purposes; but this is not safe teaching today. A clean metal instrument is of no more danger than a clean probe under other circumstances. Weir has suggested a valuable test, consisting of removal of all the urine possible, after which a measured quantity of sterile fluid is injected. If on using a catheter again this be all recovered it may be assumed that the bladder is not ruptured, otherwise the contrary. If hours after the injury a catheter be used and no urine secured, this fact will be most suggestive. The cystoscope is usually disappointing, since a bladder so injured cannot often be satisfactorily examined.
Another class of serious injury to the bladder includes the _perforations_, such as may be effected by gunshot or stab wounds, or, as in one case of my own, where a lad sat down upon an iron spike, about three-quarters of an inch square and nearly six inches in length. The point of the spike entered the anus, and the consequence of the injury was a perforation of the anterior wall of the rectum and the posterior wall of the bladder, with injury to its anterior wall without complete perforation. Prompt operation saved this case, as it will most such instances, although it was shown that a piece of his trousers had been carried into and left in the bladder. I opened the abdomen above the pubis, to be sure that the peritoneum was not injured, and then drained by a tube passed into the anus and out just above the pubis, after removing the piece of cloth. Prompt recovery followed.
The bladder may also be injured by rude manipulation of instruments, especially the metal catheter, by one unaccustomed to using it, or when serious difficulties are offered by prostatic enlargement.
=Treatment.=--Diagnosis or even serious suspicion of such injuries to the bladder as above described require either perineal or abdominal section, the choice of the procedure being based upon circumstances. If there be reason to suspect intraperitoneal extravasation, then the abdomen should be opened, carefully cleaned, the bladder rent sought and sutured, the mucosa being first closed with hardened gut, while the peritoneal aspect may be sutured with silk or thread. The bladder should be drained, at least by retention of a catheter, passed if necessary by perineal section, and the abdomen drained. In the female drainage may be made through the cul-de-sac. If there be urinary extravasation behind the perineum, then perineal section should be made, and the bladder, thus freely opened, should be drained with a sufficiently large tube; while in the female it will probably be sufficient to dilate the urethra and insert a tube of sufficient size. It is not always easy to discover an opening placed posteriorly in the bladder wall, and after a wide exposure, with emptying and cleansing of the pelvis, it may be of great assistance to place the patient in the Trendelenburg position. Under rare circumstances the rent may be so placed as to justify a suprapubic drainage of the bladder.
FOREIGN BODIES IN THE BLADDER.
Foreign bodies other than calculi occur in the bladder in consequence of both accident and of design. The former are, _e. g._, represented by pieces of broken catheter, while the latter are materials introduced from without in consequence of sexual perversion, during intoxication, or from some other vicious tendency. The latter occur more often in girls and women, the former more often in men. In such a collection of cases as was made by Poulet (_Foreign Bodies in Surgery_) almost every imaginable object that could be introduced into the bladder is mentioned. Some of these have slipped in accidentally after external manipulation, as in masturbation, and some have been deliberately introduced. Perhaps as common an object as any is the ordinary hairpin. It is the short urethra of women which is made the much more frequent resort for such practices than the long urethra of men, in which latter foreign bodies are often entangled or arrested before they reach the bladder.
Any object allowed to remain in the bladder will serve as a nidus for the formation of a calculus, which will form in time, and it may result that not until the removal of the calculus and examination of its interior structure will the original foreign body be found.
All objects of this kind should be removed as early as possible after their introduction. Such removal may be easy and accomplished by dilatation of the female urethra, with or without the use of the cystoscope; or the bladder may require to be opened, either above the pubis, through the perineum, or through the vagina, in order that the object in question may be extracted.
INCONTINENCE, RETENTION, AND SUPPRESSION OF URINE.
Students often confuse not only terms but conditions, and it is necessary to be accurate in teaching regarding these subjects. _Suppression of urine_ is purely a matter of cessation of renal function, and _has nothing to do with the bladder_. _Retention of urine_, on the other hand, has nothing to do with the kidneys, but is purely a bladder affair. It may be due to spasm of the bladder outlet, or to its obstruction by calculi, other foreign body, or by prostatic enlargement, or it may be a consequence of paralysis of bladder muscle. Such retention is the inevitable consequence of fracture of the spine, since paraplegia is to be expected in such cases, and the condition is to be atoned for by careful and _regular catheterization_. Retention, again, is occasionally seen in hysterical patients. It furnishes the distressing and sometimes permanent or even fatal consequences of prostatic enlargement in old men. _No matter how produced, it must be relieved_, for urine tends to accumulate and to distend the bladder, which will finally burst unless the difficulty be sufficiently overcome so that urine may in some way escape. Distention of the bladder under these circumstances is recognized by the formation of a rapidly increasing tumor, which finally rises to the level of the umbilicus, fluctuates, and is accompanied or not by pain according to the nature of the cause of retention. In paralytic cases there will be little or no pain. In obstructive cases it will be agonizing.
By natural efforts final rupture of the bladder is usually prevented, as after a certain degree of distention has been attained urine begins to escape drop by drop. This is simply an _expression of an overflow_, and is not to be confused with incontinence in the proper sense of the term. It may be spoken of as _stillicidium_, due to retention. The young and indifferent practitioner may mistake this escape of urine for incontinence, which would be a most serious error. Under any circumstances, when such a condition may possibly occur, the lower abdomen should be palpated, when the presence of a distended bladder should be instantly recognized. The first indication is for its prompt relief by the use of the catheter, while the necessary catheterization should be done with the usual precautions. When the passage of an ordinary instrument is made difficult or impossible the cause of the retention is usually thereby revealed, and may be shown to be so serious as to necessitate further operative procedures.
When the bladder is distended and no catheter can be introduced it is advisable to _aspirate_, the aspirating needle being introduced through the sterilized skin just above the pubis, its point directed toward the centre of the mass formed by the distended bladder. Repeated aspiration may be necessary, and it has been suggested to make more or less permanent use of such a tube or hollow needle. At present no surgeon would continue this as a permanent measure, but simply as a temporary relief, even if repetition be necessary, until more radical procedure can be carried out. Whether this be the removal of a foreign body or calculus, or of an enlarged prostate, it is indicated just the same, the only exception to this statement being those cases already too seriously involved to justify more than perineal section (cystotomy for drainage). _Retention of urine, then, is always a preventable condition, and its continuance is inexcusable._
_Incontinence_ implies a paralytic condition, usually of the expulsive muscles, but sometimes of the sphincter apparatus in either sex, by which urinary control is lost and urine escapes involuntarily. It may be a temporary and occasional phenomenon, occurring under the influence of strong excitement or during sleep, especially in children, or it may be due to spinal disease or traumatisms, with paralysis of the lower segments of the cord and nerves given off from them. When originating in the latter way it is usually a hopeless condition, but _nocturnal incontinence_ of children, or even of adults, or that due to hysterical or other neurotic conditions, may usually be benefited. For this purpose the surgeon should search for the cause from which the reflex proceeds. This may be extreme acidity of urine, the irritation of a tight prepuce in either sex, the presence of worms, intestinal disturbances, or any one of a great number of possible causes of disturbance of nerve control. Some of them permit of surgical relief; others require simpler measures. Children thus suffering should be given no fluid late in the evening, but should be made to empty the bladder before retiring, and perhaps be aroused once or twice through the night for the same purpose. In all cases the urine should be examined and hyperacidity overcome. All forms of genital excitement should be obviated. In the adolescent and in adults thus annoyed, and in the insane, it has been shown to be of great benefit to make a few intraspinal injections of sterile salt solution, as for local anesthetic purposes, a little cerebrospinal fluid being first withdrawn, and then from 2 to 10 or 15 Cc. of the solution being introduced. This seems to have been empirically suggested by a French surgeon, but has been found of value by Valentine and others, including the writer.
The above forms of incontinence are to be distinguished from intense irritability of the bladder, with frequent calls to empty it, which accompany many such conditions as cystitis, tuberculosis, tumors, calculi, and the like. This is the extreme irritability of local disease rather than true incontinence. But there is also a form, in women, characterized by falling away of the urethra and neck of the bladder from the pubis, due usually to injuries received during parturition, with consequent sacculation or dilatation of the urethra and formation of a cystocele. (Dudley.) This may also be associated with other results of perineal laceration. Here loss of urine is not constant, but occasional or frequent. For its treatment the following methods have been suggested: the injection of paraffin; partial torsion of the urethra (Gersuny), _i. e._, a partial dissection of the urethra and revolution upon its own axis, with subsequent suture, by which incontinence may be overcome, but at the possible risk of sloughing. Finally, Dudley has proposed the method of advancement of the urethra. He makes a horseshoe denudation, between the meatus and the clitoris, down on either side of the urethra, and nearly its entire length. Its anterior end is then loosened sufficiently so that the meatus can be drawn forward and secured below the clitoris by two sutures. The balance of the wound is then closed, the effect of the operation being to replace and retain the urethra and prevent its sagging. Other surgical treatment, as for cystocele, laceration, etc., may be added as needed.
CYSTITIS.
The condition of true _cystitis_ arises invariably either from the _irritation of a foreign body_ or the _presence of bacteria_; the former need not necessarily be large, and minute and irritating crystals are often sufficient to produce at least some of its features. Sooner or later, however, the germ element enters, and from that time on cystitis is a bacterial infection. Furthermore this infection is usually secondary, rarely if ever primary, and may come from without or within. Thus it may be the consequence of the introduction of unclean instruments; is a very frequent consequence of gonorrhea, including all forms of urethritis; or may be the result of local tuberculous processes or those travelling downward from the kidneys; or, again, of more general toxic or septic conditions, such as typhoid and other infectious fevers. Certain conditions predispose, such as the presence of calculi or the occurrence of traumatism. Again, a bladder weakened by overdistention or paralysis, as in cases of spinal injury, loses its natural resisting power and succumbs to infection abnormally easily. It should be emphasized that the absolutely healthy bladder wall is resistant to all germ activity, but this resistance is easily lost or modified in the presence of disease, either close by or distant. A bladder whose normal shape has been greatly changed by enlargement of the prostate is again rendered not only unhealthy, but incapable of
## acting normally. It becomes, therefore, easily infected, and _cystitis
is a frequent accompaniment of prostatic hypertrophy_.
[Illustration: FIG. 651
Internal appearance of bladder in some cases of inveterate cystitis; mucosa sacculated by columns of hypertrophied tissue. (Launois.)]
=Symptoms.=--The _cardinal symptoms of cystitis_ are three in number, _i. e._, _pain_, _frequency of micturition_, and _pyuria_, the latter being the consequence of changes in the urine, as well as in the bladder wall, while the pain and the thamuria are expressions of irritation, especially of the base of the bladder and the posterior urethra. In fact, all the more violent expressions of cystitis are found at the lower part of the bladder rather than in its upper portion. Obviously, then, irritation of adjoining organs is more easily accounted for, _e. g._, of the urethra, the seminal vesicles, the prostate, and the lower ends of the ureters.
The _pain_ may be severe, and is especially complained of with each act of urination. It is referred not only to the region of the bladder proper, but along the urethra to the end of the penis in the male, and down the thighs in both sexes. With frequency of urination there is also distressing urgency, so that once the necessity be felt nothing can restrain the promptness of the act. In fact so powerful is the expulsive tendency that the tenesmus affects not only the bladder but often the rectum, while the feeling or desire to urinate continues after the bladder has been emptied of its last drop, even for several minutes, and may cause the patient to sit in agony for some time. The distress produced in acute cases of cystitis is excessive, and sedatives and anodynes constitute no small part of the treatment.
The amount of _pus_ contained in the urine will vary with the degree of acuteness and the stage of the disease. At first it is but slight, but rapidly increases, until the urine may contain thick mucus and pus up to one-third or more of its volume. Finally _blood_ may appear, by whose appearance a serious degree of inflammation is betokened.
Later, at a variable date, the putrefactive element is introduced; and when the urine begins to smell of ammonia--_i. e._, when _ammoniacal decomposition_ has once begun--the bladder is thereby the more irritated and the case made still worse.
No vesical mucosa left suffering from such acute inflammation will remain unaffected in its tissue elements, but will rapidly become more or less thickened. In fact the entire bladder wall undergoes a process of thickening, from hypertrophy of its inner and its muscular or middle coats, the latter due to extra activity in consequence of the constant tenesmus. There results in time a marked _eccentric hypertrophy_, whose result is really a contraction of the bladder cavity and a distortion of its lining. Under these circumstances, also, the mucosa becomes _sacculated_, and numerous little pockets, which may contain decomposing urine, serve to complicate the situation; while, finally, more or less _incrustation_ or _calculous degeneration_ and implantation modify the character of the mucous coat. For all these changes to occur requires time, but their combined effect is such thickening and contraction of the bladder as to permanently alter it and lead to a final _concentric_ hypertrophy.
=Tuberculous Cystitis.=--The picture presented by tuberculous disease of the vesical mucosa is, in the beginning, one of miliary or disseminated involvement; but later, when ulcerative changes have taken place, the end results are scarcely different from those rehearsed above, save that the ulcerative element is more predominant, and there is great probability of involvement of the ureters or of any of the adjoining organs. As conditions do not essentially vary, neither do symptoms, and a diagnosis of tuberculous cystitis often must, in the early stages, be reached by a process of exclusion, corroborated perhaps by the cystoscope.
=Postoperative Cystitis.=--A different clinical type of irritation, or mildly infective cystitis, is known to be a sequel of certain operations, not alone those upon the pelvis. In the majority of cases it occurs when catheterization has been required, the first event being urinary retention, by which the bladder mucosa must be more or less disturbed. It may be perhaps accounted for by the fact that the urethra is practically never free from germs, which, in that canal, seem to be innocent, but which, carried upward into an irritated bladder may excite serious inflammation. These cases are perhaps more frequent after pelvic operations for cancer. There seems, however, no doubt but that repeated catheterization for several days lowers bladder resistance.
=Treatment.=--When the occurrence of cystitis is imminent prophylactic or preventive treatment is recommended. This should consist in administration of large quantities of fluid, with urinary antiseptics, in lavage of the bladder itself, and in reliable antiseptic precautions in catheterization. Thus to operate upon a bladder which has long held seriously infected or decomposed urine, without previously cleansing it as much as possible, is simply to invite further trouble.
The medicinal treatment of cystitis, on which we mainly rely, consists in dilution of the urine by large amounts of fluid ingested, in overcoming hyperacidity by the administration of alkalies, and in combating putrefactive conditions, so far as possible, by antiseptics which are eliminated through the kidneys. Balsams have been long held in great repute; but remedies like urotropin and other synthetic compounds have taken their place. Of them all, and especially in the presence of ammoniacal urine, urotropin and the alkaline salts of benzoic acid seem most reliable. Excessive irritability may be overcome by local measures, such as frequent hot rectal douches, hot sitz baths; by quieting irritation of the genitospinal centres by administration, _e. g._, of cannabis indica, in doses pushed to the physiological limit; by local anodynes, as by opium suppositories, or in extreme cases by general anodynes like morphine.
Theoretically a seriously infected bladder should be washed out and cleansed as any other pus cavity, but when so inflamed the bladder becomes so intolerant and exquisitely irritable that the mere act of washing can only with difficulty be borne by the patient. Retention of a catheter, which might be advisable under most circumstances, may also be impossible for the same reason. The condition of a patient under extremes of this kind is pitiable, and resort to general anodynes unavoidable. Still it is possible with patience and the use of selected drugs to gradually allay even a most acute cystitis. Confinement in bed and an almost fluid diet are also necessary features of treatment.
If the introduction of an instrument can be borne it may be possible to leave in the bladder some soothing solution after it has been washed, such as a mild cocaine solution containing a little morphine, or olive oil containing orthoform, or a mild preparation of ichthyol. Even if these be retained but for a short time they will usually afford relief.
Finally in severe forms of cystitis the _bladder may be opened_ for the purpose of giving it physiological rest, selecting either the suprapubic or the median perineal route. The relief thus afforded is usually gratifying, while drainage may be maintained until the local treatment has been sufficiently effective to permit either spontaneous closure of the drainage opening or its repair by suture. This measure is known as _cystostomy for the relief of cystitis_.
Obviously if cystitis be due to the presence of any foreign body its treatment becomes necessarily surgical, the same being true of those forms due to or connected with hypertrophy of the prostate. It is impossible to accomplish a cure here until the mechanical difficulty is first overcome.
VESICAL CALCULUS.
In the urinary bladder as well as in the gall-bladder mineral elements held in solution by the contained fluids are precipitated, the consequence being the formation of _calculi_ or _stones in the bladder_, which vary in size from the smallest concretions to those weighing many ounces, and in number from one to scores, a large proportion of these representing original concretions passed down from the kidneys, _i. e._, minute renal calculi. Every calculus has a nucleus, and in many instances this may be a clot, or clump of cells encrusted with salts, which have formed within the bladder and not come down from above. Such foreign bodies will become the nidus for a calculus, while in vesical calculi are frequently found pieces of catheter, of straw, chewing-gum, hairpins, and the like, which have been introduced from without. These stones are constituted mainly of the ordinary urinary salts, _i. e._, _phosphates_, _urates_, or _oxalates_, deposited as described above. Much more rarely _cystin_ and _xanthin_ are found. Instead of urates crystallized _uric acid_ will be occasionally seen. The oxalates are mostly those of calcium, while the phosphates are those of calcium, magnesium, or ammonium, more or less combined. The first requisite for a calculus is a nidus, the second the deposition of one or more of these salts. Calculi are sometimes _composite_ in structure, some having a uric or urate nucleus becoming later encrusted with phosphates. The oxalic calculi are exceedingly hard and usually rough, being often spoken of as _mulberry_. They rarely attain large size. The rapidly forming phosphatic calculi are often so small as to disintegrate or break in the process of removal. Thus there may be great differences in density of these stones. Their formation is particularly favored by retention of alkaline urine, as in many cases of prostatic enlargement.
=Symptoms.=--Discomforts and symptoms produced by bladder stone depend upon their size, number, roughness, movability, and location. The larger and rougher stones, which are more or less easily moved inside a tender and irritable bladder, will cause a large amount of discomfort and actual pain, while a small calculus, which may be formed within a pocket or become encysted at some distance from the urethral opening may remain unnoticed. The indications of calculi are essentially those of cystitis, _pain_, _frequency of urination_, and _pyuria_, sometimes with hematuria. The pain is local and referred, especially along the urethra, to the glans in the male, and is often aggravated by the final expulsive movements of the bladder at the termination of urination. Local discomfort is aggravated by active exercise. Reflex pains have been known in distant parts of the body. The frequency of urination is increased by exposure to cold or by activity. Pyuria and hematuria do not differ from those of non-calculous cystitis. A most significant feature is sudden _stoppage of the urinary stream_, with more or less pain. Statements to this effect, especially if accompanied by a history of renal calculi in time past, are most suggestive.
Unless, however, particles of calcareous material have been passed the positive diagnosis of calculus rests upon its detection by examination, either with a _stone searcher_ or with the _cystoscope_. The former is essentially a short-beaked, light sound, which may be more easily manipulated after introduction within the bladder. In using it the same precautions are taken as for catheterization or sounding, while the deep urethra may be made less sensitive by a cocaine solution. The instrument is introduced exactly as is a sound, and its beak is carried completely into the bladder. Sometimes even before this has been accomplished will be noted the rough, grating sensation which indicates contact with a stone. At other times it is only after considerable search that a small stone is “touched.” A stone easily found is within the possibilities of unskilled manipulation, but to accurately examine a bladder, especially behind a large prostate, is a fine art. For this purpose the bladder should be partially distended with fluid, the patient should be in the horizontal position, and the stone searcher so manipulated that its beak may be made to traverse every portion of the lower part of the bladder and to come into contact with its wall, for only in this way can an encysted calculus be discovered. The beak must, moreover, be rotated so as to be carried down into the pocket behind an enlarged prostate, as in such pockets many calculi nestle. Some stones are felt even in introducing a soft catheter; others are discovered only after such manipulation as the above. Nothing but necrosed bone or a foreign body can convey to the metal instrument, and through it to the finger, the peculiar sensation produced by contact with a stone. By 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.
[Illustration: FIG. 652
Method of seizing the stone behind the prostate.]
[Illustration: FIG. 653
Ordinary position in seizing the stone.]
[Illustration: 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.
[Illustration: 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).
[Illustration: FIG. 656
Villous tumor (papilloma) of bladder. (Musée Dupuytren.)]
[Illustration: FIG. 657
Tumor of bladder as seen 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.
[Illustration: 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).
[Illustration: 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 Young, that the element of _cancer_ is present in a proportion of cases hitherto quite unsuspected. It may begin as a small indurated nodule, in one or both lobes, and while developing remains confined for a relatively long period by the strong prostatic capsule. When it extends, its line of invasion is upward toward the vesicles rather than into the bladder. When the latter has become involved, if a radical operation is to be practised, extirpation must include not only the entire prostate, with its capsule, the urethra, the vesicles, but the adjacent portion of the base of the bladder. Early diagnosis in these cases is difficult, since it may occur at any age after fifty years, and, being connected with hypertrophy, produces symptoms masked by it, only the element of pain being more prominent. As the condition develops pain becomes rather disproportionate, spreads to the suprapubic region, and is intensified as the bladder fills. When pain is referred also to the rectum and lower extremities it is a suspicious symptom. The condition does not necessarily, at least at first, cause enormous enlargement. Therefore the obstructive features vary. If the portions involved can be left they will be found more dense and hard than the surrounding tissue. One peculiarity of prostatic cancer is that metastases occur more often in the bones than in the lymphatics. Consequently the pelvic nodes are not so often affected. Ulceration and intravesical tumor are rare.
=Diagnosis.=--Early diagnosis is based on rapidity of growth, disproportionate pain, indurated contraction of the prostatic urethra near its apex, and absence of intravesical enlargement, as shown by the cystoscope. When there is much residual urine, without enlargement of intravesical lobes, suspicion is strengthened. If after removal of such prostate it should be shown to be more or loss dotted with “seed calculi,” as is possible, instead of with cancer, the benefit and relief to the patient would be none the less marked, while the prognosis would be all the better.
Prostatic hypertrophy leads to a collection of phenomena spoken of as _prostatism_. These include mechanical impediment to urination, with consequent obstruction, sometimes with complete retention, and to the consequences of the same in the direction of infection and cystitis, with added features of pain, tenesmus, and pyuria. _Prostatism is a matter of gradual development._ Its earliest symptoms are frequent urination with occasionally some difficulty or slowness in the act. From this as a beginning cases become gradually aggravated, until death finally ensues from retention, rupture of the bladder, pyelonephritis, or exhaustion in consequence of the pain and suffering entailed.
Prostatism may be imitated in persons whose prostates are not perceptibly enlarged, in whom the difficulty and obstruction are due to sclerosis and contracture of the vesical neck. This condition is especially common in elderly men, subjects of arterial sclerosis. This will account for instances of prostates which, on removal, are found hard and sclerosed, and yet not enlarged enough to be obstructive. If such a prostate could be divided by the cautery, benefit, even permanent relief, might ensue. Therefore, such a condition might be well attacked when diagnosticated (either by suprapubic operation or by perineal section), with the use of the Bottini galvanocaustic instrument, especially through a perineal opening.
Prostatic enlargement produces distortion of the prostatic urethra, which becomes longer, smaller, and sometimes deviated, with elevation of the level of the vesico-urethral orifice, and causes, by pressure on veins, more or less disturbance of the return circulation. Enlargement with impediment produces dilatation of the bladder, with possible involvement of the ureters or the kidneys, and thickening of the vesical walls, often with sacculation of its mucosa between its disturbed muscle fibers.
Finally come the consequences of septic infection with ammoniacal putrefaction of urine, pyuria, and perhaps pyelonephritis with uremia, which will be terminal. While the condition is generally regarded as belonging to the late years of life it may begin by natural processes at the forty-fifth year, although uncommon before the fifty-fifth.
[Illustration: FIG. 660
Enormous prostatic hypertrophy, necessitating suprapubic cystotomy because of impossibility of catheterization from below. (Socin and Burckhardt.)]
=Symptoms.=--When a man past the middle years of life, previously free from urinary difficulties, is aroused to urinate more frequently than usual, especially at night, while the desire to urinate and the natural feeling of relief at the conclusion of the act are more or less perverted, the beginning of prostatism may be suspected. If in addition to these features the urine shows fermentative changes, or the presence of mucus or pus, the more or less disastrous consequences of obstruction have begun. Symptoms similar to these may be caused by the presence of calculus. It is therefore necessary to differentiate between this and prostatic enlargement. This is first done by a careful digital examination of the empty rectum, the index finger being gently introduced and made to so completely palpate the prostate, through the anterior wall of the rectum, that an accurate estimate of its relative size, as well as of any marked irregularity, may be made. If the prostate be enlarged the explanation is at once afforded. If there be but little apparent change noted by this method the surgeon should introduce a stone searcher. Manipulation with this, in a bladder distended with fluid, should reveal the presence of a calculus, or should indicate a lengthening of the prostatic urethra, with such distortion, as might make the introduction of the instrument difficult, while by further manipulation, its beak being gently revolved, he learns whether behind the prostate there is a pocket in which residual urine may be retained. The question of calculus being settled the patient should now empty the bladder naturally and as usual, after which a catheter should be introduced, in order to withdraw such residual urine as may be retained, whose amount should then be noted. This is a measure of the size of the postprostatic pocket which the patient fails to empty, and in which decomposition and pathological changes are especially likely to occur. Should such a pocket be found in a case without noticeable other enlargement (as detected through the rectum) it will indicate _intravesical growth_ and the formation of the so-called “third lobe” or “median bar,” as it was formerly called (_i. e._, an outgrowth at the posterior end of the prostatic urethra, projecting upward into the bladder, impeding alike the exit of urine and the introduction of an ordinary instrument). Those expert with its use may gain still further information of value by use of the cystoscope.
=Treatment.=--The diagnosis thus established, the question of treatment is raised. Views concerning what is best have been largely modified by the operative methods recently introduced, and the advice given a few years ago is now frequently modified. So long as surgical treatment was unsatisfactory and incomplete it was to be postponed as long as possible. Under those circumstances patients were taught to use the catheter and established the “catheter habit.” Almost invariably they became careless, and the catheter habit led invariably to cystitis. Nevertheless circumstances may arise which make this good advice even today, as in the presence of other and serious disease, or of anything which makes radical operation inexpedient. Under such circumstances the patient must be impressed as profoundly as possible with the necessity for care and caution. If such a case has progressed to the stage of almost complete retention then the catheter should be used at regular intervals. If it be simply necessary to draw off residual urine once a day, then it may be used at night, at which time it would be well also to gently and carefully wash the bladder. It is possible in this way to temporize for a variable length of time, and until more serious conditions supervene.
When, however, the prostate has enlarged so conspicuously as to be not only a constant impediment but a constant menace to the comfort and even life of the patient, one is brought to seriously consider which of the various mechanical methods for relief should be instituted. The choice must now be governed by the physical condition and the surroundings of the patient, as age, degree and character of the obstruction, and the extent of septic infection. One has again to choose between the most radical and usually the most satisfactory method of _extirpation_ (_prostatectomy_), or one of the less radical and palliative operations, such as the _Bottini operation with the galvanocautery_.
A few years ago White and others laid great stress on the fact that after removal of the testicles there was notable atrophy of the prostate, and suggested the expedient of _double castration_ or _orchidectomy_ for this purpose. The method proved disappointing, although doubtless more or less effective in some cases, and so objectionable to many patients, for obvious reasons, that it has been practically abandoned. The less mutilating substitute of division and exsection of a portion of each vas deferens (_vasectomy_) has for the same reason been discarded.
When radical measures become necessary the choice should be made between the _galvanocautery_ (_i. e._, canalization of the base of the prostate and its median bar by means of the instrument devised by Bottini) and the bolder and more radical method of _extirpation_ (prostatectomy). This _prostatectomy_ is done by either the _suprapubic_ or the _perineal_ route. As between them there is often room for choice, for reasons mentioned below. Each method has its advocates and its opponents.[71]
[71] The question of credit and priority for these operations has been of late much discussed. To McGill, of Leeds, and Goodfellow, of San Francisco, should be given most of the credit for the earliest perineal operations, while Fuller, of New York, who first performed the suprapubic operation in 1894, should probably be given credit for the latter, although it has been evidently unjustly claimed for Freyer, of London. Belfield, of Chicago, was also one of the earliest advocates of extirpation of the enlarged prostate.
=Suprapubic Prostatectomy.=--It is of assistance in this method to have the empty rectum somewhat distended, and held up by the introduction of a rubber bag, which may be later distended with water or with air. By this means the prostate and floor of the bladder are pushed upward toward the operator’s finger. This is, however, by no means necessary, but simply advantageous. The first part of the operation is essentially that described as suprapubic cystotomy. The bladder being thus opened and the prostate carried upward by a sound, which should have been inserted in the urethra, the finger first accurately notes its dimensions and the direction of its enlargement. Blunt scissors are now used, or the sharp finger-nail, for making an opening through the mucosa and prostatic covering, _through the capsule_ of the latter, down upon that body. This opening is preferably made near the urethral entrance. The balance of the operation consists in blunt dissection by the end of the finger, _i. e._, _enucleation_ of the prostate from within its enclosing capsule and surrounding tissues (Fig. 661). More or less disturbance of the basal structures is necessitated, but as the surgeon becomes expert the amount of this disturbance becomes relatively surprisingly small. In most instances it is possible also to practically strip off the prostatic tissue from the urethra, so that it is rarely necessary to tear or to cut across it in order to lift the prostate out of its bed. In the average case it is possible in this way to enucleate the prostate in a single piece, and to remove it as an _entire organ_. If, however, it should prove too large for the bladder opening which has permitted the procedure it would be better to morcellate it, or so far divide it with scissors as to permit its extraction piecemeal. Its removal leaves a bleeding cavity at the base of the bladder, with torn and separated tissues, and a pocket where the prostate used to lie, into which urine will be poured from above, while it cannot ordinarily be at first easily emptied from the more or less injured urethra connected with it. From this surface there will be at first considerable oozing, mostly venous. Should this be serious and prolonged a quantity of gauze may be packed into it through the opening, and pressure thus made. Such packing should only be retained for a few hours. Ordinarily it is sufficient to provide at once for _drainage_. My own preference is to make double provision for this by the passage of a catheter through the urethra, and by the insertion of a drainage tube from above, whose lower end rests within the pocket. It is a great desideratum to drain the urine as fast as it accumulates, and, at the same time, to keep the patient dry. This is best effected by a method described later, of complete _bladder siphonage_, which can be resorted to in either form of operation. It is again advisable to get the patient into the sitting posture, which should be done within a day or two, or as soon as his strength will permit, in order that gravity may assist in drainage. (See p. 1003.)
[Illustration: FIG. 661
Suprapubic prostatectomy. Process of enucleation by finger-tip of one hand in the bladder, the other hand making pressure in the perineum. (Hartmann.)]
When difficulty is met in enucleation assistance is derived by the introduction of one or two fingers of the disengaged hand into the rectum, by which certain manipulation can be effected from below that will be of material help. Pressure in the perineum or manipulation of a sound may also be of assistance.
So soon as satisfactory drainage through the urethra can be effected the suprapubic tube should be removed, and the wound thus encouraged to close.
=Perineal Prostatectomy.=--Perineal prostatectomy constitutes a similar attempt at enucleation, effected from a different direction. The patient now being in the lithotomy position, with the rectum not only emptied but sterilized, the perineum is widely opened. While the removal may be accomplished through a median incision it is better to have ample room, therefore by a semilunar flap a sort of trap-door should be raised, its apex downward, through which easy access to the deep perineum is afforded. It is only necessary to divide the central tendon of the recto-urethral muscles before the operator arrives at the apex of the prostate and the membranous urethra. The latter, being exposed at this point, is usually divided upon a grooved staff. Here, at its junction, the capsule is usually divided by a free opening, through which the finger-tip is insinuated and made to strip the capsule from the prostate itself. By different operators instruments have been devised which facilitate much of the subsequent work. Perhaps the best of these is the double-blade retractor of Young, which, shaped like a sound, can be opened after introduction, and made to serve excellent purpose by traction upon its handles. If, now, the perineal route have been large enough, and retracted sufficiently, the prostate can be so pulled down into the wound as to be exposed to sight as well as to touch. The effort is sometimes made to enucleate the prostate entire and withdraw it whole, but usually to separate each lateral mass by itself. It is advisable to seize with strong tenaculum forceps and pull down the loosened portions of the organ, in order that it may be more easily separated at its upper part; but it has now been found unnecessary to either open the bladder above the pubis, or even to expose it by an opening through the skin so that it may be pressed down, traction from below taking the place of suprapubic pressure, whatever is needed in the latter direction being effected through the uninjured abdominal wall (Figs. 662, 663 and 664).
[Illustration: FIG. 662
First exposure of prostate after introduction of sound through opening just in front of it. (Proust.)]
[Illustration: FIG. 663
Enucleation of a portion or all of the prostate by use of the index finger. (Proust.)]
[Illustration: FIG. 664
Hemisection of prostate, each half being secured within the bite of vulsellum forceps. (Proust.)]
The balance of the procedure must depend on the size and character of the growth. To strip off a naturally adherent capsule is quite easy, but to detach one which has become firmly adherent through old inflammation or cancerous infiltration is sometimes extremely difficult. Thus enucleation may sometimes be effected in two or three minutes. The stripping and enucleating process should be carried around the prostatic enlargement and into the bladder, and the effort should be to make the smallest possible rent in the vesical mucosa, as well as to separate prostatic tissue from around the urethra rather than to tear or mutilate the latter. Experience and patience will permit the accomplishment of this to a surprising degree. Morcellation may be an aid in removing large masses, and no hesitation should be felt in dividing a mass of tissue which does not come out easily through the wound (Fig. 665).
[Illustration: FIG. 665
Prostate removed by the perineal route: _A_, lateral lobes; _B_, intravesical growth particularly obstructing urethral entrance. (Proust.)]
The organ once enucleated, there results a bleeding cavity, at the base of the bladder, which, however, is now opened below and should drain itself easily. If the surgeon’s finger and his instruments have been kept, as they should have been constantly, within the prostatic capsule there is no possibility of harm to the rectum, which, however, may be utilized for assistance in the manipulation should it be required. There remain, therefore, after enucleation the checking of hemorrhage, provision for drainage, and suitable narrowing of the wound. The first and second of these are usually combined by the insertion of a tube, of sufficient rigidity to permit a gauze packing to be placed around it. This should be connected exteriorly with a suitable drainage tube, and bladder siphonage be provided. The wound around the tube is closed by two or three deep sutures, usually of silkworm-gut, since it tends naturally to close by pressure and requires but little further attention.
The greatest harm likely to be done in this operation is _injury to the seminal vesicles_, above the prostate, between which and the prostate itself the surgeon may not distinguish, with _unnecessary mutilation of the posterior urethra_. Occasionally, in spite of great care, the rectum will be slightly lacerated. Injury or destruction of the vesicles might lead to impotence, while mutilation of the urethra would be followed by delay in repair, with uncertainty of subsequent bladder
## action and control.
Subsequent treatment consists in removing both gauze and tube at the earliest possible date, which should not be later than the fourth day; after this irrigation may be given once or twice a day, with the least possible use of instruments.
In either of these methods of prostatectomy the greatest reliance is to be placed upon natural processes of repair. In some way, which seems almost inscrutable, torn bladder and more or less mutilated urethra come naturally together and connection is reëstablished.
After this brief description of operative methods there remains only to contrast them. The especial advantages of the suprapubic method are the total avoidance of perineal fistula, of disturbance of the deep urethra, of the perineal structures, of the seminal vesicles, and a minimum of disturbance of the entire basal portion of the bladder, with a greater theoretical possibility of speedy restoration of its function. It is the method of choice with certain operators of large experience. It seems especially indicated in cases of pronounced intravesical enlargement, but may be made difficult in obese individuals.
In behalf of the perineal route must be alleged the advantage of seeing much of what one is doing, of being really nearer to the field of activity, and of more perfect control of the mass which is to be removed, as well as the fact that the prostate is not an intravesical organ.
Whichever method be adopted the patient should be encouraged to be up and about as soon as possible. Subsequent bladder control comes with varying rapidity to different patients. Urinary fistulas are not likely to persist in patients who have not worn drainage tubes too long. After two or three weeks it is advisable to pass a sound occasionally, in order to maintain proper direction of the urethral canal and prevent formation of stricture. Bladders in which there has been a serious complication of cystitis should be irrigated through the openings so long as they are maintained.
The operation of itself is not a very serious nor difficult measure. It is too often performed on feeble or septic patients, as a last resort, when it is too late.
The _galvanocaustic operation_ is done with an instrument devised by Bottini, shaped like a lithotrite, with a movable platinum blade, which can be heated to the desired degree by the electric current. This instrument is introduced into the deep urethra until its beak enters the bladder, after which the latter is turned half around; then the electric current is turned on, the movable caustic blade gradually withdrawn by a screw mechanism in the handle, and made to traverse a distance of one inch to one inch and a half, previously measured, and in such a way as to burn a channel through the floor of the prostatic urethra, and through any median bar or obstruction which may exist. This is the principle of its use. At one time it was popular, although of late prostatectomy seems to have supplanted nearly every other method. Nevertheless in certain cases it will be found of advantage. I have preferred to combine it, in most cases, with a small perineal opening, introducing the instrument after opening the membranous urethra, and having it in this way much more completely under control. Through the opening thus made subsequent bladder drainage can be effected if desired. It permits also of more perfect exploration of the bladder with the finger.
CANCER OF THE PROSTATE.
Extensive _cancerous involvement of the prostate_ puts a case beyond the pale of operative surgery, except for palliative purposes, though either perineal or suprapubic drainage may be made for final and temporary relief, the case admitting of nothing else. As mentioned above many apparently ordinarily enlarged prostates prove to contain cancerous elements. It has been found that, when not too extensively involved, prostatectomy in these cases gives as good results as in the absolutely non-malignant.
[Illustration: FIG. 666
Siphon drainage of bladder, with Cathcart’s S-tube (its essential feature). May be applied equally well to perineal or urethral tubes, or to drainage of other cavities.]
BLADDER SIPHONAGE.
A matter of great importance and comfort for the patient is an effective _siphonage of the bladder_ after it has been opened. This has usually been accomplished by the use of a Y-shaped tube, one of the branches connecting with a suitable reservoir for water, hung above the level of the body, the other with a tube connecting with the bladder, while from the lower end another tube connects with a suitable reservoir on the floor. This is rarely effective, and can only be made so by inserting the S-shaped tube devised by Cathcart in the lower drainage tube. With this, and a suitable regulation of the flow, the water can be made to escape, drop by drop, and make an effective suction that completely fails without the use of Cathcart’s tube. The device is illustrated in Fig. 666.
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