the injury, an abdominal incision should be made and the bladderwall examined. If an intraperitoneal rupture has occurred, it should be sewed up with catgut. The peritoneum should also be united with fine catgut or silk, the latter being used in preference to the catgut when there is fear that the former may be too rapidly absorbed before the opening has united. An ununited opening may give rise to peritonitis. The serous and muscular surfaces. only should be sutured. The opening should then be closed, and a perineal section made for drainage purposes or a retention catheter should be put in place. If an extraperitoneal rupture exists, a suprapubic incision may be made, the condition of the walls of the bladder examined, and such after-treatment prescribed as the needs of the case may seem to indicate. If infiltration has taken place, this is manifested by the swelling about the gluteal region, thighs, perineum, and lower part of the abdomen. In such infiltrations incisions should be made through the skin and cellular tissue, and as many drainage-tubes, running in various directions, introduced as the character and number of such infiltrations require, in order that the skin and cellular tissue be drained as well as possible, otherwise troublesome sloughing will result; some is, nevertheless, bound to occur in any case.

There is one point to which attention must again be drawn, and that is as to the urgent need of performing early catheterization in persons found in an unconscious state from injury, drunkenness, or apoplexy. In a large series of these cases studied by the writers, overdistention was found to be the principal predisposing cause of cystitis. This series included some cases of unrecognized rupture of the bladder. Early catheterization, then, if sometimes performed on the unconscious, would reduce the number of cases of cystitis due to overdistention, and would occasionally permit an earlier diagnosis of rupture of the bladder to be made, thereby increasing the prospects of a favorable afterresult.

TOTAL EXTIRPATION OF THE BLADDER

This operation is occasionally performed for extrophy of the bladder, as previously mentioned, or for the relief of patients suffering from malignant diseases of the bladder. It necessitates

the performance of a double nephrotomy, or that the ureters be transplanted into the intestine or the loin. In transplanting the ureters care must be used to see that the course of the ureter is not interfered with, and that no kinking results. The method of transplanting or making an anastomosis with the intestine has already been referred to. The operation of excision consists in making a long incision in the median line from the pubes to the umbilicus; at right angles to this incision, just above the pubes, an incision is made across each side as far as the external border of the recti muscle, so that the general shape of the incision is that of the letter T. The skin, muscles, and peritoneum are incised; then the bladder should be freed from the deep layer of the peritoneum on each side, in the following manner; the intestine having previously been pushed upward, a pair of forceps is put on the top of the bladder to pull it above the pubes; the peritoneum is then cut along the sides of the bladder, as far as the base of the bladder; a transverse incision then divides the peritoneum, just back of the posterior superior border of the prostate; the peritoneum is then stripped off the bottom of Douglas' cul-de-sac and the posterior aspect of the prostate. With the peritoneum are detached the seminal vesicles and the extremities of the vas. The bladder is now pulled forward on to the pubes, and the pelvic peritoneum is brought together by a vertical suture from the bottom of Douglas' cul-de-sac to the upper border of the abdominal incision; the remainder of the operation is extraperitoneal. The various ligaments are tied off, and the ureters are cut through. If the bladder be lifted up with considerable tension, the incision of the ligaments is rendered easier. The urethra is then incised in front of the neck of the bladder, the organ being pulled toward the umbilicus for this purpose. The bladder is then removed as a complete sac, the cavity is then drained and, if necessary, packed.

HERNIA OF THE BLADDER

Vesical hernia is generally associated with inguinal hernia, and manifests itself, as does the latter, by swelling in the groin. Very rarely it happens that a hernia of the bladder descends with intestinal hernia into the scrotum. The condition often remains

unrecognized until operation for the relief of hernia is performed. Occasionally it is very manifest, as is shown in the illustrations taken from Frisch and Zuckerkandl. If marked diminution in the size of the tumor is found to take place on urination, a diagnosis of bladder hernia can be made.

In operating for the relief of inguinal hernia, if protrusion of the bladder is also encountered, it should be freed from adhesions and returned to its place and the wound sutured. An attempt should be made to restore it to its former position even if all the adhesions cannot be freed. If a vesical hernia becomes strangulated, it may be necessary to open and drain. If the bladder hernia has formed a pouch so that urine that collects in it cannot be released from the bladder, it may be necessary to also open the pouch and drain. If the bladder is wounded during the operation for hernia, the incision should be sutured, the hernia of the

bladder replaced, and drainage instituted through the suprapubic incision by the perineal route or by a retention catheter.

The treatment of the case will depend to a great extent on the individual circumstances surrounding each case; it may, however, be summed up as follows: the return of the hernial pouch; when possible, the opening and draining of the bladder pouch, which will hasten the expulsion of retained secretions that cannot otherwise be voided, together with drainage of the bladder, when

necessary, by suprapubic or perineal incision. Resection of the bladder for hernia followed by suture of the organ has not as yet been demonstrated to be a successful operation.

DIVERTICULA OF THE BLADDER

These may not in themselves give rise to any characteristic symptoms, whether they are of the congenital or the acquired variety. The use of the cystoscope and instrumentation will generally render their diagnosis comparatively simple. Concerning their treatment, if there is no cystitis present, they can be allowed to remain as they are. If the bladder becomes infected, the effect of irrigations should be observed; if such irrigations are not sufficient to restore the bladder to a normal condition, it may become necessary to operate on the diverticula. The form of operation required will be indicated by the nature of the diverticula. A simple wall existing between the diverticula and the bladder can be removed by incision, and the whole cavity thrown into one. Other forms of diverticula will require complete removal and suturing of the bladder-wall.

Patent Urachus.-A patent urachus may be the seat of abscess and sometimes the point of origin of tumors and cysts. The cysts are generally retention in origin, according to Vaughan,' who has made a careful study of the matter. The different forms of patent urachus are discussed under the four headings:

(1) The complete, in which the duct is open all the way, forming a continuous communication between the bladder and the outside of the body at the navel.

(2) The blind internal, in which the navel remains closed, but the duct communicates with the bladder.

(3) The blind external, in which the communication with the bladder is closed, but the navel end of the duct remains open.

(4) The blind, in which both ends are closed, but the duct remains open in the middle.

Thirty-two out of fifty congenital cases were in men, the lesion appearing at birth or soon after the stump of the cord separated. The acquired cases, that is, those in which patent urachus subse

"Patent Urachus," "Transactions of the American Surgical Assoc.," 1905, vol. xxiii.

quently develops, may be of any age, the oldest reported, according to Vaughan, being seventy-nine. Symptoms vary according to the condition present; they may consist in having urine appear at the umbilicus, or pus, or the indication of formation of cysts. Patent urachus can be diagnosed with comparative ease if there is an exudation of dus or blood from the umbilicus; if a cystic

Fig. 147. Patent urachus: N, Navel; U, urachus (dilated); B, bladder (after Vaughan). formation exists, it may be mistaken for cysts due to other causes. If the umbilicus opening is closed, it may be diagnosed from cysts due to other causes by instrumental or cystoscopic examination of the bladder. Treatment, when possible, consists of extirpation, closure of the bladder opening with sutures and drainage, or in some cases the slitting up of the cavity and packing it.