needle. This thread is passed through the upper end of the ureter (Fig. 286). The needles are made to enter the lower end of the tube through the door made by the sur

FIG. 286.--Van Hook's method of ureteral anastomosis.

geon. They are pushed through the wall of the ureter onehalf an inch below the window (Fig. 286). Traction upon the strings causes invagination and the ligature-ends are tied. If the operation is intraperitoneal, the ureter is wrapped about with peritoneum.

DISEASES AND INJURIES OF THE BLADDER.

Retention of Urine.-By this term is meant an inability to empty the bladder. The retention may be complete, not a drop emerging, or it may have been complete, a dribbling setting in after a time, due to paralysis of the bladder, which cannot contain more fluid, expulsion of the overflow from the ureters being produced by atmospheric pressure. This condition is known as the engorgement, the overflow, or the incontinence of retention. There may be a partial retention from enlarged prostate, a portion only of the urine being voided. Retention may be caused by-(1) obstruction, resulting from urethral stricture, hypertrophied prostate, inflamed prostate, occluded meatus, impacted calculus, urethral tumors, complete phimosis, fecal impaction, and pressure from large tumors, or by (2) defective expulsion, resulting from paralysis,

disease or injury, atony, reflex inhibition, shock, muscular weakness of fevers, and the action of such drugs as belladonna, opium, or cantharides.

Symptoms. In acute retention there is an agony of desire to urinate, the patient making acutely painful straining-efforts, during which feces are often passed. There are severe pain and aching in the abdomen, thighs, perineum, and penis. All the symptoms rapidly increase, a typhoid state is inaugurated, and death closes the scene unless relief be given. If retention is from time to time alleviated by the passage of a little water, the symptoms are slower in evolution and are less intense, and the case is said to be chronic. Some cases of gradual onset, due to atony, are very insidious, the patient feeling no particular pain and complaining only of the dribbling, which is really the overflow of retention, and is not a sign that the bladder is successfully emptying itself. In any case of retention the bladder rises above the pubes, and there is found a pyriform, elastic, fluctuating tumor (dull on percussion) in the hypogastrium, which tumor gradually enlarges until the bladder is evacuated or incontinence sets in. The flanks give a clear percussion-note, and the tumor is

FIG. 287.-Gouley's tunnelled catheter, threaded over a filiform bougie.

more prominent when the patient is erect than when recumbent. Long continuation of obstructive disease, producing partial retention with or without attacks of complete retention, disorganizes the kidneys. Acute and complete retention may induce rupture of the urethra or urinary suppression.

Treatment.-Place the patient upon his back, keep him warm, and if instrumentation does not rapidly succeed, give an anesthetic. Be sure that every instrument is aseptic. In organic stricture try to pass a soft catheter; if this fails, endeavor to insert a hard catheter. Try a large size first, and gradually go to smaller sizes if the larger instrument will not pass the obstruction. When the instrument enters the bladder draw off but half of the urine, withdraw the instrument, wait a few hours, insert it again and then empty the bladder and wash out the viscus with hot boric

acid solution. To draw off all of the urine at once is dangerous, because the sudden relief of pressure from distended veins leads to bleeding from the mucous membrane and hemorrhage into the bladder-walls. Fig. 289 shows several varieties of rubber catheters, and Fig. 291 shows a silk catheter. Fig. 290 shows the proper curve and the improper curve for a metal instrument. After the bladder has been emptied the patient is wrapped in blankets, a bag of hot sand is placed against the perineum, and a hot-water bag over the hypogastric region; when he recovers from the effect of the anesthetic he is given suppositories of opium and belladonna, and tablets of salol and boric acid are administered for several days. If it is found impossible to insert a rubber instrument or a metal catheter, make an attempt to carry a filiform bougie into the bladder. Fig. 288 shows filiform bougies. If the stricture is known to be organic from previous history, at once insert a filiform. bougie. On this bougie Gouley's tunnelled catheter can be threaded (Fig. 287) and carried into the bladder, the viscus being half emptied. Instead of carrying in the catheter, we can leave the filiform in place, and fasten it. The filiform bougie will act as a capillary drain, and in a few hours will empty the bladder. Then insert another bougie beside the first, and so on for several days, using also opium, ordering rest in bed, and making no attempt to dilate the stricture forcibly until retention has ceased and inflammation has subsided. If no bougie can be passed, aspirate or perform cystotomy (suprapubic or perineal). In spasmodic stricture hold a good-sized metal catheter firmly against the face of the spasmed area: relaxation will occur and the instrument will eventually pass. An individual who has an organic stricture which has given but little trouble may develop attacks of retention because of inflammatory edema of the mucous membrane and spasm of the urethral muscles. These attacks are temporary, and an instrument can usually be inserted when employed as above directed. In inflammations give a hot hip-bath and suppositories of opium and belladonna, and then use a hot sand-bag to the perineum and a hot-water bag over the hypogastrium. If these fail or if the symptoms are urgent, pass a soft catheter. In the occluded meatus of the newborn incise with a tenotome. In a congenital cyst of the sinus pocularis pass a steel bougie, which will rupture

FIG. 288.-Points of Gouley's whalebone guides.

In

the cyst. In complete phimosis split up the prepuce. impacted stone try to pull it out with urethral forceps; if this fails, push it in or cut. In fecal impaction scrape out with a spoon. In enlarged prostate insert a coudé catheter (Fig. 289, b) strengthened by the insertion of a filiform

b

a

с

GTIEMANN &CO

FIG. 289.-a, French olivary gum catheter; b, Mercier's elbowed catheter (coudé); c, Mercier's double-elbowed catheter; d, curved gum catheter.

bougie nearly to the beak (Brinton), or pass a silver instrument with a large curve. In retention from expulsive defect use a soft catheter. Cases of retention require warmth, confinement to bed, the administration of laxatives, free action of the skin, and the use of such drugs as salol, boric acid, and quinin to asepticize the urine. In some few cases no instrument can be inserted in the bladder. In most of such cases aspirate-which may be done several times if necessary -and in a day or two, when swelling and congestion abate, an instrument can be passed. A small trocar or an aspiratorneedle is pushed into the bladder, the trocar or needle being inserted in the median line, just above the pubes, and taking a course downward and backward. The parts are first prepared antiseptically, and the puncture is dressed with iodoform and collodion. Only half of the urine is withdrawn at a first aspiration. Rectal puncture is now obsolete. The perineal incision is not advocated for retention unless rupture of the urethra has taken place. When a catheter is used for retention the patient must be recumbent to minimize shock.

Injuries of the Bladder.—This viscus is so deeply situated, and the abdominal walls are so elastic, that it is rarely injured when empty. If the bladder be full and the abdomen be tense-which is common in alcoholic intoxication-force applied upon the abdomen may injure the bladder.

Contusion of the Bladder.-In this condition there are noted, vesical hematuria, tenesmus, severe cystitis, and an impediment to the flow of water because of clots. Hemor

rhage may be very severe and sepsis may arise, even causing death. When contusion exists retention is relieved by a clean soft catheter; if this fails because of occlusion of the eye of the catheter with blood-clot, there must, from time to time, be forced through the catheter by an irrigator a solution of sodium bicarbonate in cooled boiled water. Gross's blood-catheter can be used, or the evacuator of Bigelow may be employed. The patient is put to bed, a hot-water bag is applied to the hypogastrium, morphin is administered in moderate doses, the bladder is washed out several times

1% IN.

D

B

FIG. 290.-A B E shows the proper curve (reduced in size) for unyielding male urethral instruments; CBD shows an improper curve.

a day with boric-acid solution to disintegrate and remove blood-clots, and the urine is diluted and rendered aseptic by the stomach administration of salol, boric acid, and liquor potassii citratis. Hemorrhage usually ceases on relieving distention; if it does not, some more radical measure must be employed (see Hematuria).

Besides contusions, the bladder may be injured by bullets; by stabs or punctures through the abdomen, the vagina, or the uterus; or by penetration by a fragment of a fractured pelvic bone. The symptoms of such conditions are those of rupture of the bladder (q. v.). In any intraperitoneal wound at once open the abdomen, suture the wound in the bladder-wall, irrigate the peritoneal cavity, and drain the bladder by means of a retained catheter, a perineal section, or a suprapubic cystotomy. In an extraperitoneal wound drain the wound by a tube, and drain the bladder by a retained catheter, a perineal section, or a suprapubic opening.

Rupture of the bladder occurs in three forms: (1) intraperitoneal-a rupture involving the peritoneal coat; (2) extraperitoneal—a rupture of a portion of the bladder not covered by peritoneum; and (3) subperitoneal—a rupture of the mucous and muscular coats, the urine diffusing under