When it is desirable to open the bladder by a transverse incision, the opening should be made immediately above, and parallel with, the line of the pubis, which involves the division of some portion of the tendons of the recti muscles. Trendelenburg recommends that the mucous membrane of the bladder should be connected with the skin by means of temporary sutures. This incision affords a greater area of surface for doing what is necessary, and is recommended in some cases of tubercular ulceration of the bladder requiring local treatment, for plastic operations, for removing extensive growths, and for the direct inspection and manipulation of the orifice of the ure ters. I have never had occasion to adopt it, except to a limited ex tent in conjunction with the ordinary median incision, as first de scribed. It is stated that the transverse incision is more liable to be followed by a ventral hernia than the other.
The bladder having been opened, I will now notice the variations necessary in accordance with the different requirements and the sub sequent management of the wound. If there is a stone it is usually at once felt with the finger, when it can be withdrawn with a pair of straight or curved forceps. Care should be taken not to damage the sides of the wound. Should there be a growth or prostatic enlarge ment encroaching on the interior of the bladder, it can generally be felt by the finger. It can also be inspected by opaque glass or vul canite specula of different sizes introduced through the wound as de scribed by Mr. Hurry Fenwick "° in conjunction with the reflection from the electric light. The latter plan is an excellent one, not only so far as seeing the growth is concerned, but also in assisting mate rially toward its removal. For keeping the bladder open to inspec tion, and at the same time occupying very little room, if the viscus is of fair capacity, Watson's spring wire speculum will be found useful. Various kinds of forceps for twisting off pieces of growth should be at hand. This, I believe, is the best method of removing masses of hypertrophied prostate or other growths. Some scoops and an elm cleator hook should also be in readiness. In this way, and by other modifications which will occur to the practical surgeon, intra vesical growths may be removed with a preciseness which previous to the introduction of supra-pubic cystotomy, the use of specula, and proper forceps and light, was generally unattainable. Where there is bleeding the vessels may readily be touched with some styptic, such as iron, turpentine, or the wires of a galvanic cau tery ; whereas if the oozing is general the surface may be exposed to the action of hot water and hazeline injected through the wound.
When drainage alone is required, supra-pubic cystotomy has been re sorted to with much advantage.
Mr. Lawson Tait "' has recently described a method of operating by a process of drawing up the bladder, which he describes as simple and safe. From some experience of supra-pubic cystotomy under almost all conditions for which it is applicable, I think the less we alter the relations of the bladder in removing anything from its inte rior the better. There is no necessity for either pushing it up from the pelvic outlet or disconnecting it from its peritoneal attachments, and I have never found the least difficulty in opening it either for stone or tumor in the way mentioned.
The object of cystotomy having been accomplished, the question arises as to what is best to be done to secure the rapid healing of the wound, should this be required. Cases have been recorded where the suturing of the bladder and superficial wound has been followed by primary union, but they are rare; on the other hand, instances are narrated where not only have these attempts failed but inflamma tion had followed by the confinement of urine in the prevesical space. My belief is, as matters stand at present, that a medium course is best. With this object I leave the bladder opening alone and close the superficial wound to some extent, but allow space for the use of what is generally known as Guyon's double drainage-tube. This is really two rubber catheters connected together, which give access either way either to antiseptic lotion or urine, the latter being received in a bottle by the patient's side. The dressing is then completed by gauze, wood-wool pads, and an abdominal many-tailed bandage. If for any reason I were disposed to attempt to obtain primary union by complete suture of the bladder and superficial wound, I should put into the bladder a perineal drainage-tube. One word in connection with the use of bladder sutures in these and similar operations : if they are put in, care should be taken that they are completely removed. I have known two instances where these bodies gave much trouble subsequently in causing cystitis and the deposit of a phosphatic stone. Mr. Jordan Lloyd records an instance where a calculus formed upon a nucleus of this nature was expelled per urethron.'" If an attempt is made to close the bladder wound by suture with the ob ject of obtaining primary union, the accuracy of approximation should be tested by the injection of water into the viscus.