spoon, or a finger-nail. If bleeding is severe, check it by pressure, by iced water, or even by the actual cautery.

Median Cystotomy.-The same incision is made in the perineal raphe in median cystotomy as for median lithotomy. A grooved staff is introduced and is hooked up under the pubes; an incision is made into the membranous urethra and is extended backward for three-quarters of an inch, and a finger is carried into the bladder. If searching

Š TIEMANN &ND.

ZIEMANN & CO.

GTIEMANN & CO

FIG. 298.-Thompson's vesical forceps for removing growths in the bladder: for growths close to the neck of the bladder, with separation of the blades, to avoid nipping the neck of the bladder.

for a growth, find it with the finger, catch it with Thompson's forceps, and twist it off. Soft growths can be scraped away. Stop bleeding by digital pressure or by injections of iced water. If median cystotomy does not allow access to the tumor, perform suprapubic cystotomy.

Growths in the Female Bladder.-Dilate the urethra as in a case of stone, and scrape, twist, pull, or ligate the growth away. If the growth is large or if there are multiple growths, perform suprapubic cystotomy.

DISEASES AND INJURIES OF THE URETHRA, PENIS, TESTICLES, PROSTATE, SEMINAL VESICLES, SPERMATIC CORD, AND TUNICA VAGINALIS.

Injuries may arise from traumatism to the perineum or the penis, from cuts and twists of the penis, from the popular "breaking" of a chordee, from tying strings around the organ, from forcing rings over it, from the passage of instruments, or from the impaction of calculi. Violence inflicted upon an erect penis may fracture the corpora cavernosa. The writer saw one man with a glass rod broken off in the canal, he having been in the habit of introducing it at the dictate of morbid sexual excitement. A patient in the Insane Department of the Philadelphia Hospital had a ring around his penis, which organ was lacerated into the urethra. These injuries are treated on general principles.

Perineal Bruises.-If the perineum be bruised without rupture of the urethra, the perineum and scrotum swell and become discolored; water is passed with difficulty because the extravasated mass of blood in the peri-urethral tissues occludes more or less the canal; the water is not bloody; and there are pain and profound shock. Some authors designate as rupture those cases in which laceration of the spongy tissue occurs, without involvement of the mucous membrane or of the fibrous coat, but they are properly contusions.

Treatment. Place the patient in bed and establish reaction, and when reaction is complete employ opiates for the relief of pain. Place lint, wet and kept wet with lead-water and laudanum, upon the perineum, alternating every two hours with a fifteen-minute application of the ice-bag. If, notwithstanding these measures, swelling continues, introduce a silver catheter (No. 12 E.), tie it in, and make firm pressure upon the perineum by a firmly-applied T-bandage or by a crutch braced against the thighs or the foot-board of the bed. Even when swelling is slight retention may occur from projection of a submucous blood-clot into the canal of the urethra. Punctured wounds of the urethra require ordinary dressings. Incised wounds of the urethra, when longitudinal, are closed by suture. Healing is rapid, and ill consequences are not to be feared. Stricture does not follow. When the wound is transverse, introduce a catheter, suture the wound over the instrument, and remove the catheter at the end of the third day. If a catheter cannot be introduced, employ sutures, but at the first evidence of extravasation open the

wound, and if drainage is not free perform an external perineal urethrotomy.

Rupture of the Urethra.-By this term is meant a lacerated or a contused wound of the urethra, destroying partially or entirely the integrity of the canal. A lacerated wound may be induced by fracture of the cavernous bodies during erection, the symptoms being severe hemorrhage, intense pain, retention of urine, and inability to pass an instrument; infiltration of urine occurs, and gangrene is a common result. The writer has seen one case of rupture of the penile urethra due to a man's slipping while shaving, the penis being caught in a partially open drawer, the drawer being shut by his body coming against it. Rupture, however, is almost invariably located in the perineum, and it arises when the urethra is suddenly and forcibly pressed against the arch of the pubes by a blow, by a kick, or by falling astride a beam or a fence-rail. The lesion of urethral rupture consists in some cases of laceration of the spongy tissue and the mucous membrane, a cavity being formed which communicates. with the canal, and which fills with urine during micturition. In other cases not only the spongy tissue and the urethral mucous membrane are rent asunder, but the fibrous coat is also torn, the canal opening directly into the perineal tissues, among which a huge cavity forms, that fills with blood and later with clot, urine, and pus. The urethra may be torn entirely across, but in most cases a small portion at least of its circumference is uninjured. Rupture never occurs primarily and alone in the prostatic urethra; it is extremely rare in the membranous urethra unless due to pelvic fracture; and it is very unusual in the penile urethra. The seat of rupture in the great majority of cases is in the region of the bulb. Very rarely is the skin broken.

Symptoms.-The symptoms of rupture of the urethra are considerable pain, aggravated by motion, pressure, and attempts to pass water; great shock; in some cases micturition is still possible, blood preceding and discoloring the stream, for some blood usually runs into the bladder; retention soon comes on; in a vast majority of the cases retention is absolute from the very first, and it is due to the interruption in the integrity of the canal and to the occlusion of the channel by blood-clots. Bleeding, which is usually free, lasts for several hours, some little blood generally appearing externally and much being retained in the perineum, inducing progressive swelling. The presence of a large swelling is regarded as evidence of urethral rupture. The blood which is effused in

the perineum may extend under the fascia to the penis and scrotum; the swelling soon becomes reddish, purple, or even black, and pressure upon it is apt to cause blood to run from the meatus. This swelling enlarges when attempts are made to urinate. After a time, if the surgeon does not act, the urine fills the perineal cavity and widely infiltrates, and there ensue gangrene, sloughing, and sepsis, life being endangered or fistula being left as legacies. In rupture of the urethra the course of the extravasated urine will often enable one to locate the seat of injury. In rupture of the membranous urethra, if uncomplicated, the urine remains between the two layers of the triangular ligament until a channel is opened for it by sloughing or by the knife. When extravasation occurs behind the posterior layer of the ligament the urine finds its way to the perineum in the neighborhood of the anus. When the rupture is in front of the anterior layer the urine, directed by the deep layer of the superficial fascia, finds its way into the scrotum and up on the belly, but does not pass into the thighs. A contusion is distinguished from a rupture by the facts that in the former the perineal swelling is not very extensive and does not enlarge on attempting micturition, while in the latter it is extensive and does enlarge on attempting to pass water. Furthermore, contusion does not cause urethral hemorrhage, while rupture does. A contusion sometimes, but not often, prevents the passage of a catheter; a rupture almost always, but not invariably, does so. The mortality from severe rupture with extravasation is about 14 per cent. (Kaufman).

Treatment. In some cases it is possible to suture the urethra, and this procedure should be carried out when possible. In order to suture perform suprapubic cystotomy and make a perineal section. Find the posterior end of the ruptured urethra by passing a catheter from the bladder into the urethra. Suture with silk. The sutures pass through all of the coats of the urethra. The roof of the canal is sutured first, then a steel sound is introduced from the meatus, and the urethra is sutured around the instrument. The sound is withdrawn and the bladder is drained by Cathcart's siphon as modified by Keen. In recent cases of ruptured urethra the usual treatment is as follows: immediate perineal section with turning out of the clot; trimming off of lacerated edges; finding the prox imal end of the urethra, passing a catheter from the meatus into the bladder, and leaving it in situ until healing has begun around it. In cases of stricture it is a good plan to excise the 1 See Weir's report in Med. Record, May 9, 1896.

cicatricial tissue. In cases with extravasation lay open freely all pockets of urine and proceed as above. If the proximal end of the urethra cannot be found, either open the bladder by Cock's method of perineal section without a guide, cutting toward the apex of the prostate gland and carrying the incision forward into the rent, or perform a suprapubic cystotomy with retrograde catheterization; that is, push an instrument from the bladder into the wound, and use it to guide a catheter passed from the meatus into the bladder. The wound is packed with iodoform gauze, and the bowels are tied up with opium for a few days. Many surgeons strongly disapprove of the custom of retaining the catheter, believing that the instrument does no real good, as urine is certain to get between the catheter and the walls of the urethra. In fact, it is quite enough to stuff the wound with gauze, the patient urinating through the wound for the first few days, after which time a catheter is used. Whatever method is employed, healing will require from six to eight weeks, and the patient must during the rest of his life, from time to time, introduce large-sized bougies.

Foreign Bodies in the Urethra.-These bodies may be calculi, bodies introduced by injury, as shot, bone, etc., bodies entering from a fistulous opening into the rectum, or bodies introduced from the meatus, as broken bits of catheters, straws, pins, etc. The symptoms vary with the size and the nature of the body. Sometimes there are almost no symptoms; at other times there are found great pain, retention of urine, and hemorrhage. Examination is made by feeling carefully with a finger in the rectum and by searching. very gently with a sound, taking care not to push the body back. If the bladder is well filled with water when the body becomes impacted, inject a little oil into the meatus, close the lips with the fingers, and direct the patient to forcibly attempt urination, the surgeon opening the meatus when the urethra is widely distended, the foreign body being often forced out. If this maneuver fails, and the foreign body is impacted in the pendulous urethra, prevent its backward passage by at once tying a rubber tube around the penis. Try to squeeze the body out, and, if unsuccessful, endeavor to catch it with a wire loop, with a scoop, or with the long urethral forceps. If these methods fail, cut down upon the body and remove it, dividing any existing stricture. hairpin is in the canal, the feet of the pin are almost always pointing to the meatus; to prevent them catching on attempted withdrawal, the penis must be squeezed to approxi

If a