Stone in the Kidney.—Operations for stone located in the kid neys are straightforward if the stone be small in size and when only one kidney is affected. It is not uncommon for more than one stone to be present, and there is considerable variety in their form and nature, which affect the liability to recurrence. A stone may be passed from the kidney down the ureter into the bladder, and if it is sufficiently small, may even be evacuated naturally. The prolonged presence of a stone in the kidney, especially if it leads to a partial obstruction in the outlet, results in inflammation of the kidney substance, and for this reason early recognition of a stone by X-rays and its radical removal are important.
Tuberculous Kidney and Bladder.—Tuberculosis of the kidney may appear as the main focus of tuberculous infection in the body. In such cases the organism must, however, have been con veyed by the blood system from some previously established focus elsewhere. A tuberculous infection of the kidney may be part of a diffused tuberculous infection or one involving the whole urinary system. In the case of limited and early disease of one kidney, the symptoms may be slight, and the recognition of the presence of the infection will depend upon finding of B. tuberculosis in the urine. In such cases, or in those in which the disease is more ad vanced but has remained localized, the excision of one kidney is practiced with satisfactory results.
Tuberculosis of the bladder is usually secondary to the presence of this infection in some other part of the genitourinary tract. It leads to great irritability of the bladder and corresponding dis comfort to the patient. Treatment of the condition by direct sur gical means is clearly difficult, and is seldom attempted.
Enlargement of the Prostate.—This condition affects males above middle life. The enlarged gland, situated as it is, at the neck of the bladder, tends gradually to interfere with the proper evacu ation of this organ. This may produce attacks of complete reten tion of urine or result in the development of cystitis. The con tinued existence of the condition produces in time by the effect of back pressure or infection, secondary damage to the kidneys. This will materially sap the patient's resistance to infection or in deed in itself produce a condition inconsistent with life, if the sup pression of the function of the kidneys is carried far enough. The relief of prostatic obstruction may be temporarily effected by the passage of a catheter to empty the bladder at regular intervals, but as this process is not a convenient one and in itself is bound to lead to the establishment of chronic cystitis, radical removal of the enlarged prostate is usually carried out.
The operation is usually effected by opening the bladder through an abdominal incision and gaining access to the base of the blad der in this way. In some clinics approach to the enlarged gland is by the perineum. In view of the age of the patients affected by this condition, the operation must be considered a severe one. The mortality has been considerably reduced in the last ten years by modifications in technique and by the carrying out of the pro cedure in two stages in those instances in which chronic cystitis is present or where there is evidence of disturbed function of the kidneys from back pressure.
Cancer of the prostate occurs and may be associated with simi lar symptoms to those of simple enlargement of the organ. Oper ative removal of the cancerous gland is practised, but on account of its anatomical position the probabilities of recurrence are great.
New Growths of the Kidney and Bladder.—The kidney and bladder may be involved in new growths which may be either simple or cancerous. The symptoms are generally evidenced by the passing of blood and disturbance in the regular evacuation of the bladder. In the case of the kidney, complete removal of the growth, if recognized early, is a simple and satisfactory pro cedure. In the bladder complete removal of malignant growths is difficult, consistent with the maintenance of the normal function of the organ.
Stricture of the Urethra.—Stricture of the urethra is due to contraction of scarred tissue in and around the tube secondary to old-standing inflammation. The closing down of the urethra leads to a gradual difficulty in emptying the bladder and indeed to a group of symptoms similar to those observed in enlargement of the prostate ; the condition, however, usually develops much earlier in life and will be associated with a previous history of urethral infection. The condition in the early stages can be treated by reg ular dilation of the stricture with suitable bougies. If it is allowed to develop to the stage of complete obstruction associated with retention of urine, various operations for the relief of the condition may have to be brought into play.
Testicle.—This may be the seat of new growths which are gen erally cancerous or tuberculous. The statements made in regard to similar conditions affecting the kidney apply in general to this organ. On account of its accessibility early diagnosis and prompt treatment are relatively easy.
The condition of hydrocele (q.v.) is due to the secretion of fluid in the serous sac covering the testicle. The condition may arise apart from injury at almost any period of life. The largest forms are seen in those past middle-age. Radical treatment by excision of the sac is simple and straightforward.
Hernia (q.v.).—There are certain areas in the abdominal wall which are naturally weak and through these a protrusion or pouch of the peritoneum is liable to prolapse, producing a hernia. These regions are at the groins and umbilicus. Herniae are also likely to form in weak abdominal scars following operations. Apart from the discomfort caused by the prolapse of bowel into the hernia, there is always a danger of its contents becoming constricted or obstructed (see INTESTINAL OBSTRUCTION) by being nipped at the margin of the opening through which the protrusion has occurred. If such a complication arises it leads to strangulation which is an almost inevitably fatal condition unless relieved by prompt operation. The surgery of hernia should clearly be of a prophylactic nature and be undertaken as early as possible after the development of the swelling. Radical operations for herniae undertaken nowadays in good time on healthy individuals are fol lowed by a high proportion of permanent successes. (C. M. P.) See BONES, DISEASES AND INJURIES OF; FRACTURE; JOINTS AND LIGA MENTS ; ORTHOPAEDIC SURGERY ; GYNAECOLOGY ; DENTISTRY.