abdominal wall left by the removal of the bladder; if necessary, side flaps can be made to help cover in this latter.

We have very recently received from Dr. John T. Bottomley, of Boston, Mass., the report of a case of exstrophy of the bladder treated by what seems to us a very practical method, and that is

Fig. 144. Segond's operation for exstrophy of the bladder. The borders of the penal gutter and of the adjacent skin are freshened, the dissected portion of the bladder-wall is brought down upon the penal gutter, and the two first sutures (1) are put in each side. The adherent border of the prepuce is then punctured transversely and turned inside out, and is spread apart by the retractor to show the extent of the raw surface which is to be brought up over the portion of bladder-wall.

the removal of the bladder which is preceded by the transplantation a few days earlier of the ureters to the skin of the loins. He has recently operated on a patient by this method, the report of the operation, as kindly furnished us by him, is as follows:

"Through an incision on either side of the abdomen about

parallel with the crest of the ilium go to the peritoneum; the latter structure is pushed forward, the ureter on either side is found, freed, cut across at the point where it crosses the iliac vessels, and through a small stab wound in the loin the end is

Fig. 145.-Segond's operation for exstrophy of the bladder. The dissected portion of the bladder has been folded down and fastened on each side with the sutures (1, 1), and the preputial hood has been raised over the penis and the raw surface of the dissected portion of the bladder. The sutures (2, 2) fix the shape of the meatus. The sutures (1, 1) have been passed through the prepuce so as to be removed afterward. The prepuce is lifted aside to show the course of the suture (1) on the right side. The suture (3) reunites the skin of the penis, the freshened border of the penal gutter, the dissected portion of the bladder, and the preputial hood. The suture (4) closes carefully the vesical fold near the ureter. The suture (5) will lift up the prepuce and fasten it to the skin of the abdomen.

carried out on to the skin of the loin and held there by sutures to the skin, about one-eighth inch of the ureter being allowed to project. Ten days after the preliminary operation the ectopic bladder is removed; the denuded area is covered in by grafting

and by skin flaps. The patient wears an apparatus for collecting the urine, is really very comfortable, there is no urinous odor, and the apparatus keeps the patient dry." Mr. Reginald Harrison,1 in 1896, treated a case by removing one kidney and then transplanting the ureter of the remaining kidney to the skin of the corresponding loin. Dr. Bottomley in performing his operation attached the ureter of each kidney to the loin on the corresponding side.

INJURIES OF THE BLADDER

Injuries of the urinary bladder occur in the form of wounds, contusions, and rupture of the organ. In dealing with an injury of the bladder it is important to determine whether the lesion is an extraperitoneal or an intraperitoneal one. Now that such great advances are being made in general surgery and exploratory incisions for the purpose of ascertaining the extent of an injury have become so common, together with the fact that skilful operators are becoming so numerous, it hardly seems necessary to divide injuries and rupture of the bladder into many different classes, each to be considered under a separate head. The most exhaustive work that has been done on this subject, according to the writers' knowledge, is recorded by Duplay and Reclus, "Traite de Chirurgie,” vol. vii.

The bladder is rarely wounded in its anterior aspect, unless the organ is very much distended, for the reason that, when empty or only partially full, it is protected in front by the pubic bone. It is more often wounded as the result of a penetrating injury through the perineum, as from falling on a sharp substance; through the rectum or through the back, following the infliction. of a stab wound, and occasionally from the toss of a bull. It is also not infrequently wounded during the performance of some abdominal operation, particularly during hysterectomy. Quite a large portion of the bladder-wall may be torn off either from the inside or as the result of injury outside of the bladder, the organ continuing to functionate and repair of the wound following.

Wounds of the bladder are very seldom uncomplicated, being almost always associated with wounds of some other organ. Experiments and observations on both experimental animals and on

1 Harrison, Reginald: "Lancet," 1897.

man tend to show that nature very quickly attempts the repair of an injury to the bladder.

If the wound is situated intraperitoneally, adhesions from the peritoneum form very rapidly and tend to close it in. If extraperitoneally, it closes almost as rapidly. A considerable portion of the bladder substance may be removed and cicatrization and repair still go on. The folds of the wounded bladder tend to shut down on themselves and keep the urine from escaping through the wound.

Painful micturition, bloody urine, and shock are more or less constant symptoms of bladder injuries. Later, if the wound has been an intraperitoneal one, these symptoms may be followed by peritonitis or by symptoms of purulent cystitis. A fistula may subsequently be established. If the bladder is wounded during an operation and the wound is immediately sutured, ordinarily but little trouble follows. Infiltration of urine into the surrounding tissues may, however, follow infliction of the wound, and can generally be diagnosed by the swelling caused by such infiltration if the wound has been an extraperitoneal one.

The treatment of wounds of the bladder is as follows:

The hemorrhage should be checked, foreign bodies removed, and proper care observed, by the use of antiseptic measures and drainage, to prevent the after-formation of fistula. This can be accomplished by the introduction of a retention catheter or by making a perineal or suprapubic incision. In all doubtful cases of penetrating wounds of the lower portion of the abdomen an exploratory laparotomy is indicated.

RUPTURE OF THE BLADDER

Rupture of the bladder is probably somewhat more common than are wounds of the bladder. It may be the result of injury or of overdistention of a diseased bladder. Rupture has been known to follow overdistention due to the employment of too large a quantity of an irrigating fluid by the surgeon. It would be interesting to observe how many cases of rupture of the bladder occur in drunkards either from overdistention or from injury. Rupture of the bladder may occur either extraperitoneally or intraperitoneally, the latter being by far the most common. The

site of the rupture is generally at the back or at the bottom of the bladder. The rupture that occurs in fractures of the pelvis is more likely to be extraperitoneal. The rent is generally a vertical or an oblique one.

The symptoms of rupture of the bladder, like those of wounds of the bladder, consist of shock, which is particularly marked in those cases in which the rupture is due to some abdominal injury. In other cases the shock is not so marked. Tenesmus and hemorrhage are generally associated. If sought for carefully shortly after rupture a prevesical swelling will generally be detected-symmetric if it is intraperitoneal, asymmetric if it is extraperitoneal. A searcher introduced into the bladder may locate the rupture, as evidenced by the pressure made by the searcher against the hand on the abdomen. In intraperitoneal rupture very little urine can be obtained, the jet is diminished in volume, with feeble pressure under the movements of inspiration and expiration. Rupture of the bladder, particularly of the intraperitoneal type, if allowed to go untreated, is likely to be followed in four or five days by symptoms of general peritonitis. One - hundred and seven cases of intraperitoneal rupture have been reported, of whom 82 died during the first five days. In those cases in which the rupture takes place extraperitoneally the symptoms of urinary infiltration are more numerous, and its increase is manifested by the extension of the prevesical swelling and the tendency of the infiltration to extend in other directions. More or less pain in the region of the buttocks is generally present. Rectal examination may be an aid in diagnosing urinary infiltration. It is necessary to differentiate this condition from injury of the kidney, as the latter may also give rise to tenesmus and bloody urine. The searcher, associated with the rectal and abdominal touch, should be of considerable aid in making the differentiation. The prognosis will depend upon many different factors-the nature of the injury to other organs, the age of the patient, and many accompanying circumstances. As a rule, the prognosis is grave.

Treatment. The treatment must necessarily be modified to suit the individual case. When doubt exists concerning rupture or injury of the bladder within twenty-four hours of the time of