starts into view. The knife should here be laid aside and the bladder exposed by tearing with finger nail and forceps, to avoid injury to the large vesical veins which ramify hereabout. Sir Henry Thompson has devised a special instrument of ivory for this "scratching work," and it is of the greatest possible use. The bladder must be thoroughly bared before it is opened. Its walls are unmistakeable to those who have once appreciated their peculiar appearance. The pale irregularly arranged cords. of bladder muscle cannot easily be overlooked. Any large vein which is likely to be injured during the next stage of the operation is tied with two catgut ligatures, and divided between. The bladder is now caught at its highest part with a tenaculum, which is to be passed into the tissues until a trickle of fluid by its side proves its entrance into the cavity. With the bladder held up firmly by the hook, a half-inch vertical incision is made downwards through its most presenting part; there is at once an escape of fluid. Each edge of this small wound is secured immediately by a silk thread, introduced from within outwards with an ordinary curved needle. These threads are looped, tied, and given into the hands of an assistant, and the tenaculum is now withdrawn. The loops serve the double purpose of holding the bladder wound open for further manipulation and of preventing the organ retracting out of sight behind the pubes when its fluid contents have escaped. The tip of an index finger is introduced through the wound, and the size and locality of the stone determined. The opening is best enlarged by dilatation; the other index finger is introduced, and the stone, caught between the fingers held palm to palm, and withdrawn. A tighter hold may be taken by locking the fingers which are outside the bladder into each other. This is Thompson's suggestion, and it certainly answers better than either forceps or scoop. The objection that it necessitates a slightly larger opening has no real foundation. Care must be taken during extraction that no further disturbance of the cellular tissue in front of the bladder is made than is absolutely necessary.

When the stone is removed, and all bleeding arrested, the

questions we have to consider are two in number; one relating to the treatment of the bladder wound, and the other with reference to bladder drainage. With regard to the former several courses are open for our adoption: we may merely pass a tube through the wound into the bladder, and leave the parts to adapt themselves together as they will, and heal by granulation. This is the easiest, simplest, and probably the safest plan, and is the method recommended by Sir Henry Thompson. We may, if we chose, pass a large tube through the wound down to, but not into, the bladder, and suture the belly walls closely round it, allowing the vesical wound to close in its own way. Instead of leaving the bladder wound open to heal by granulation, we may endeavour to close it at once. Opinions are divided on this question, and on the best ways of securing it. Several plans have been practised, with the result that failure has occurred in the majority of cases submitted to trial. One point is already made certain, that if immediate union of the bladder wall is to be attained the stitching must be such as will hermetically seal the opening. The slightest leakage immediately after operation negatives rapid healing. In four of my cases I have striven to secure closure of the vesical wound, but in one only has primary union followed, and here ten silk sutures were inserted so that none of them perforated the mucous lining. During this patient's recovery he had an attack of pain low down in the right side of the pelvis, which led me to think that a little leakage was occurring in the deep parts of the wound, and gave me some anxiety for several days. The whole thing cleared off, however, in about a week, and he made, with this exception, a rapid recovery. Dr. Brenner, of Vienna, has recently described a method of closing the bladder, by means of buried sutures, which are made to encircle the opening like the string round the neck of a bag. I have tried the plan in small fœcal fistula without success, although Mr. Tait has succeeded in curing biliary fistula by the same method. I have used the suture known as Lembert's, but I do not think it has any real advantage in extra peritoneal wounds. I believe that

interrupted sutures of fine antiseptic silk put in close together are best of all. A curved needle should be inserted one-third of an inch from the edge of the wound, and passed through the muscular layer into the submucous tissue, emerging on the wound's surface without entering the vesical cavity. It should enter the opposite side in the submucous tissue, pass through the muscular layer and escape at a point corresponding to the puncture of entrance. The sutures should be not more than one-tenth of an inch apart, and should all be inserted before any are tied. I would here point out how easy it is to suture connective tissue, thickened and stiffened with effused blood, in mistake for bladder wall; but if two silk loops, which I have already spoken of, are used, they are unmistakeable guides to the vesical tissues. After suture the bladder may be injected for the purpose of seeing whether the joint is watertight, and if leakage is discovered additional stitches must be introduced. With regard to this matter of immediate bladder suture, I think the condition of the bladder's interior should chiefly guide us. If the bladder lining is healthy, and the urine at the time of the operation is practically of normal constitution, I think we should certainly endeavour to secure immediate closure; but if, on the contrary, the mucous membrane is inflamed and thickened, and the urine ammoniacal, purulent, or "ropy," no attempt should be made to shut up the diseased organ, for in lengthened drainage we have an almost infallible means of cure for these unhealthy conditions.

After any of the above procedures the bladder may be drained through a catheter per urethram, or through a specially made perineal incision. I have tied in a catheter in most of my cases, but I am inclined to think that it does more harm than good. I have no experience of drainage through a perineal incision but it seems to me an altogether unnecessary addition to the operation.

When we decide to leave the wound to granulate, it should be lightly covered with clean absorbent wool, and the patient directed to lie alternately on each side to allow of perfect

drainage of the bladder cavity. When I attempt to close the wound at once, I dress it with the same dry boracic-acid dressings I am in the habit of applying to all primary wounds. At the close of the operation the rectal bag is to be removed after being emptied.

The chief points to attend to in the performance of the operation I would summarise thus:-The rectal bag should always be used, and the bladder moderately distended. Care should be taken not to wander away from the middle line in deep dissections. Do not forget to divide the fascia transversalis. Avoid the use of the knife when the perivesical fat is reached. Take a firm hold of the bladder before its contents are allowed to escape, and do not relinquish it until the operation is completed. Enlarge your bladder opening by stretching and careful tearing. Do not poke about in the connective tissue behind the pubes. Extract the stone with your fingers. Suture only wounds in healthy bladders, and suture them closely. If the bladder is to be drained at all, drain it through the wound you have already made.

I have not succeeded in ascertaining the mortality after Peterssen's operation, but judging from what I have learned from my own cases, and from an acquaintance with the work of other surgeons, I should expect to find it less than that of lateral lithotomy.

It is worth while briefly to consider the possible causes of death after this procedure.

Shock in a well executed operation-unless a patient is previously exhausted by his malady-ought scarcely ever to be severe. None of my operations have been followed by even moderate collapse.

Hæmorrhage either primary or secondary-can only occur from vesical veins, and will not constitute a danger if the operation is carried out as I have described. I have had no trouble whatever with the bleeding. I have rarely tied a single vessel during operation, and only once have I seen hæmorrhage subsequently. On the following day my last patient passed per

urethram about 11⁄2 ounces of dark clots in blood-stained urine, but I am inclined to think they had been left in the bladder when the lithotomy was done.

Cellulitis in the connective tissue about the bladder constitutes a real danger, but may almost certainly be avoided by cleanliness and gentleness at the time of operation. I have not yet seen it in my own cases, but I was consulted recently by an elderly man whose general condition was anything but satisfactory, by reason of deep-seated suppuration in the left loin, which had followed a suprapubic lithotomy performed two or three months previously. Cellulitis is most likely to result when attempts are made to close wounds in unhealthy bladders.

Peritonitis may occur here, as in all other operations in the neighbourhood of the belly cavity. It is extremely unlikely to arise however, if we avoid injury to the membrane during our manipulations.

Exhaustion, urinary suppression, pyæmia, and septicemia are less likely in this than in operations through the perineum.

Up to the present, I have seen in my own practise only one condition which may militate against suprapubic incision, viz., that of intractable urinary fistula. Case No. 4 has a small, occasionally discharging opening now, seven months after operation. I have tried two or three times to close it, but without success. I intend making a perineal incision soon, so as to drain the bladder from below, and thus give the fistula the best possible chance of healing.*

I would thus sum up the advantages of Peterssen's operation. It is an operation in the middle line of the body. There are no important anatomical structures, except the peritoneum, in the neighbourhood. It enables the operator to see every detail of his handiwork. It gives plenty of room for the removal of the largest stones. It is followed by more rapid convalescence. It does not endanger a man's virility. It is attended by little blood loss, and lastly, it is a procedure which demands less

* Since reading this paper I have made a perineal incision, and the suprapubic fistula has soundly healed.