Abdominal surgery . of the bladder over the foldedperitoneum without elevation of that membrane is also well shownin Fig. 8i. The structure of the bladder-wall is well known, and neednot be dwelt upon. In operating, it must not be forgotten thatthe fibres of the external muscular coat arise in front from theposterior surface of the body of the pubes, and may easily be torn from theirinsertion byrough manipula-tion. Two largeveins, continua-tions of the dorsalveins of the penis,pass through thisinsertion, one ateach side of thesymphysis, aboutthree-quarters ofan inch apart; ifthe knife is notke
Abdominal surgery . of the bladder over the foldedperitoneum without elevation of that membrane is also well shownin Fig. 8i. The structure of the bladder-wall is well known, and neednot be dwelt upon. In operating, it must not be forgotten thatthe fibres of the external muscular coat arise in front from theposterior surface of the body of the pubes, and may easily be torn from theirinsertion byrough manipula-tion. Two largeveins, continua-tions of the dorsalveins of the penis,pass through thisinsertion, one ateach side of thesymphysis, aboutthree-quarters ofan inch apart; ifthe knife is notkept carefully inthe middle line,one of these maybe wounded. Thethree muscularlayers — externallongitudin al,middle circular,and internal lon-gitudinal — formthe bulk of the bladder-wall. The submucosa is intimatelyunited to the mucous coat; the mucous coat is, by comparisonwith that of the intestines, thin and anaemic. In some casesof old-standing calculus, however, it becomes greatly thickenedwith the Fig. 8i. (Garson.) Sagittal Median Section of Male Pelvis, with Distentionof Bladder and Rectum. MORTALITY. 671 MORTALITY AND APPRECIATION, The early mortality of the operation in the hands of thosewho studied its methods was under 15 per cent, for all cases,and some of these cases were ver}/ bad indeed. Dulles,* up to1875, h^<i collected records of 478 cases. An analysis of thesecases showed that the results of supra-pubic lithotomy wereas good as the lateral operation for calculi weighing betweenone and two ounces, and better for calculi weighing abovetwo ounces. In 1881 his collection of cases amounted to 636,and the results continued unchanged. Denniss collection of127 cases operated on since 1879 gives a mortality of 9 per must not be forgotten that these cases include the very worstexamples of stone. Dr. Ussendelft of Nijni-Novgorod f who,since 1883, has performed exclusively the high operation, hashad 102 operations with two deaths, one being left
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