COMPLIMENTS OF THE AUTHOR. 
Traumatisms of the 
Urinary Tract 
BY 
JOHN B. MURPHY, A. M., M. D., 
of Chicago. 
Professor of Surgery and Clinical Surgery, College of 
Physicians and Surgeons, Chicago; Professor of 
Surgery, Post-graduate Medical School and 
Hospital; Attending Surgeon to Cook 
County Hospital; Attending 
Surgeon to Alexian 
Brothers' Hospital; 
President National Association 
reprinte! from 
I 
THE SURGEON 
m 
CHICAGO. COMPLIMENTS OP THE AUTHOR. 
Traumatisms of the 
Urinary Tract 
JOHN B. MURPHY, A. M., M. D., 
of Chicago. 
Professor of Surgery and Clinical Surgery, College of 
Physicians and Surgeons, Chicago; Professor of 
Surgery, Post-graduate Medical School and 
Hospital; Attending Surgeon to Cook 
County Hospital; Attending 
Surgeon to Alexian 
Brothers' Hospital; 
President National Association Railway Surgeons, etc. < 
REPRINTED FROM 
THE RAILWAY SURGEON 
Monadnock Block, 
CHICAGO. TRAUMATISMS OF THE URINARY 
TRACT. 
By John B. Murphy, A. M.,M. D., of Chicago. 
Professor of Surgery and Clinical Surgery, College of Physicians and 
Surgeons, Chicago: Professor of Surgery, Post-graduate Medical 
School and Hospital: Attending Surgeon to Cook County Hospital; 
Attending Surgeon to Alexian Brothers’ Hospital; President Na- 
tional Association Railway Surgeons, etc. 
The first systematic treatment of trauma- 
tisms of. the kidney was given by Rayer in 
1840. The subject was not advanced by the 
writers of the next thirty years. The great 
Simon took it up in 1876 and advanced it to 
a higher stage than that of a collateral sub- 
ject. He was followed by Maas in 1878. 
From the time of the writings of the last two 
authors the subject has received careful con- 
sideration at the hands of many writers. Ex- 
periments and close clinical observations have 
given results upon which scientific treatment 
may be based. The most striking work that 
has appeared in this period is that of Edler, 
(Traumatische Verletzungen der Parenchy- 
matoesen-Unterleibs Organe: Archiv fur 
Klin. Chirurgie, B. 34, 1882). This work con- 
tains a large number of valuable statistics, 
although there is little advancement made in 4 
the symtomatology and pathology of the 
authors first mentioned. Other able works are 
those of Grawitz and Schlange. 
Injuries of the kidneys may be classified as: 
First, contusions, those without laceration 
of the external tissues. Second, penetrat- 
ing wounds, involving laceration of the tissues 
as well as of the kidney. Third, ruptures 
into the peritoneal cavity, whether from pene- 
trating wounds or contusions. 
CONTUSIONS OF THE KIDNEY, WITHOUT EXTER- 
NAL WOUNDS. 
In considering this group we must be mind- 
ful of the fact that these injuries vary greatly 
in degree. The simple contusions, in which 
there is a slight hematuria, without tumefac- 
tion or phlegmon in the region of the kidney 
are of common occurrence, and require 
but little immediate attention from the sur- 
geon. Rest in bed for three or four days, 
abstention from work or violent exercise for 
ten or twelve days longer is all that is neces- 
sary in the treatment of sucli cases; though 
they should be carefully watched for second- 
ary lesion. 
The more serious cases of contusions (that 
is, contusions accompanied by severe hemor- 
rhage, both within and around the kidney, 
with tumerfaction and phlegmon) are not 
of rare occurrence, and tax the surgeon’s 5 
judgment and skill to conduct them to a suc- 
cessful termination. Of this class Edler col- 
lected ninety cases, to which Grawitz added 
eighteen, making a total of 108 cases collected 
up to January, 1889. Since that time I find in 
the literature a rapidly increasing number of 
cases. 
Examples of this class of cases are the fol- 
lowing: 
Case I. R. D., aged 11 years, came under 
my observation the 10th of May, 1885. He 
was returning from school and was run over 
by a horse car, one wheel passing directly 
over his abdomen. Patient was taken home 
in a collapsed condition and remained so for 
several hours; he was paralyzed in the right 
lower extremity, and was unable to urinate. 
An examination was made and it was found 
that he was very tender in the area over the 
left kidney, and that the spinous process of 
the first lumbar vertebra was fractured; also 
the nth and 12th ribs on the left side. 
There was very slight external evidence of 
an injury to the abdomen. 
Restoratives were administered, and eight 
hours after the injury the patient micturated, 
the urine containing a large quantity of blood. 
The following day the tenderness in the region 
of the left kidney increased. There was a 
sense of fullness and pressure there, as ex- 
pressed by the patient. The blood continued in large proportions in the urine. This condi- 
tion remained unchanged until the fifth day, 
when the tumor became quite marked, and the 
patient developed a temperature of 101 (prob- 
ably the absorption fever of Bergmann and 
Angerer). The fever continued to increase, 
until at the end of three weeks it had reached 
in the evening. The patient was emaciat- 
ing rapidly. The tumor now filled up a 
greater portion of the left side and extended 
as far as the umbilicus. The blood had dis- 
appeared from the urine. It still contained 
some albumen and debris. A Lumbar incision 
was made, and about a quart of bloody pus 
and urine evacuated. An opening about an 
inch long was found extending from the pelvis 
of the kidney upward and outward. Urine 
flowed from the fistula for seven months. The 
paralysis of the limb (produced, undoubtedly, 
by the fractured spinous process) entirely dis- 
appeared, and the patient made an excellent 
recovery, having no evil effects from the in- 
jury. 
Cases II and 111 occurred in the prac- 
tice of my colleague, Dr. E. W. Lee. 
Case 11. C. J., aged 10 years, run over by 
a street car. He was caught under the car in 
such a manner as to “double him up.” Dr. 
Lee found him in a condition of extreme col- 
lapse and reaction was not fully established 
for nearly 36 hours. The urine was bloody. 7 
An area of dullness could be outlined on the 
fourth or fifth day on the right side over the 
kidney; it was quite extensive. There was 
general abdominal tenderness. The case pro- 
gressed without any marked symptoms for 
about three weeks, when a well-defined tumor 
could be outlined. A temperature developed, 
showing absorption. A lumbar incision was 
made, evacuating a quantity of pus and urine. 
It took about four months for the fistula to 
close. 
Case 111. Wm. L., aged 24 years, while 
crossing a railroad track October 28, 1882, fell 
forward, the right hypochondrium coming in 
contact with the rail. He felt faint and sick 
immediately, and was removed to his home. 
Dr. Lee found him somewhat collapsed, pulse 
rapid and weak, and the urine bloody. Next 
morning a distinct area of dullness could be 
outlined over the right kidney in front; temper- 
ature normal; pulse slower, and fuller. The 
urine was occasionally bloody for the next 
week. He developed an evening temperature 
of 102 degrees, and November 13 had a chill, 
followed by a temperature of 103 degrees. 
November 14 a lumbar incision was made; 
evacuated about a pint of pus and bloody de- 
bris. Urine drained through the opening, 
which closed on December 17. 
Case IV occurred in my service at the 8 
Alexian Brothers’ Hospital, in July, 1892. 
Frank F—, aged 22 years. He was thrown 
against the. edge of a coal bin in a rail- 
road accident. Immediately following the in- 
jury he was severely shocked, although he did 
not lose consciousness. When brought to the 
hospital he was suffering from severe pain in 
the abdomen; tenderness of the right kidney; 
no laceration of the external parts; urine con- 
tained a considerable quantity of blood. On 
the third day a distinct tumor could be felt at 
the position of the right kidney. There was 
no infiltration of the tissue, and no phlegmon. 
The patient’s temperature did not exceed 
These symptoms continued for about ten days, 
and then began to subside; the tumor dimin- 
ished in size; the blood gradually disappeared 
from the urine; and at the end of five weeks 
the patient left the hospital with a slight en- 
largement of the right kidney; .urine normal. 
These suffice as examples of injuries of this 
class. We will now take up their cause, and 
the method of their production. 
The most frequent causes of injuries to the 
kidneys are blows or kicks (particularly from 
horses), and falls in which the region of the 
kidney is brought in contact with a sharp point 
or edge. The kidney suffers more frequently 
when the force comes from the front or side, 
not so often when it comes from behind, ex- 
cept as in railroad injuries, where the entire 9 
body is thrown with great force upon a flat 
surface; here the kidneys may be considerably 
lacerated. 
Indirectly, the kidney may be lacerated by 
suddenly doubling the body together, as il- 
lustrated in one of Dr. Lee’s cases. All of these 
injuries have but slight manifestations upon the 
surface of the body of their severity, because 
at this point the surface of the body is yield- 
ing and readily gives under force. Not infre- 
quently the ribs, or the spinous processes of 
the vertebrae are fractured, which shows the 
severity of the force. The anatomical condi- 
tion following injuries of this class is as fol- 
lows: Where the force is from in front we 
have the kidney protected by the intestine and 
the soft wall of the abdomen anteriorly; but 
posteriously we have the hard resistance of the 
rib, and to the inner side the spinal column. 
When the rib is fractured in conjunction with 
an injury to the kidney we may have the lat- 
ter punctured, as in the case of injuries of the 
pleura or lung, or we may have it lacerated 
in the line of the rib from pressure. The kid- 
ney is found torn in a more or less transverse 
or radiating direction from the hilus to the 
periphery, frequently dividing the kidney 
through and through, into an upper and lower 
portion; one of these may be entirely separated 
from its connection with the remaining por- 
tion of the kidney or pelvis. The following 10 
explanation has been given as to the cause 
governing the direction of the laceration: 
The kidney is known to be made up in fetal 
life of from twelve to fifteen small bodies, the 
so-called “renculi,” which, in the first years of 
life, adhere and unite, leaving greater or lesser 
depressions at the line of union; and in many 
cases a deep fissure continues through life. 
There is also a depression in the capsule at the 
position of union of these bodies, and the blood 
vessels and connective tissue loop and separate 
to a considerable extent along, these lines; 
that is, their communication and interlacing 
is less at this point than any other portion 
of the parenchyma. This creates a congeni- 
tal locus minoris resistentise, and accounts 
for the direction of the line of laceration. The 
tendency to lacerations in this direction Gra- 
witz could not establish by experimental con- 
tusions in the dead subject. Still, he believed 
this was due to the absence of turgor in the 
cadaver. Aside from the lacerations we fre- 
quently have contusions of the parenchyma, 
accompanied by bloody and urinary infiltra- 
tion of the tissue. Extensive parenchyma- 
tous hemorrhages accompany almost every 
contusion of the kidney. Severe hemorrhages 
do not take place except where the larger 
branches at the pelvis are punctured. The 
injuries to the cortex rarely bleed severely, but 
transverse lacerations of the hilus close to the 11 
attachment of the ureter, not infrequently rup- 
ture large blood vessels that run parallel to 
the long axis of the kidney, from which ex- 
tensive hemorrhage takes place. It is not un- 
common to have a vessel of one-eighth of an 
inch in diameter running parallel to the longer 
axis of the kidney. This I have frequently 
observed on the injected cadaver and in my 
experiments on dogs, and the surgeon should 
always be guarded against incisions in this po- 
sition. Another condition that favors severe hem- 
orrhage from laceration of the kidney is the 
large renal artery, and the high pressure that 
must exist in its branches. 
In order to have a urinary infiltration 
of the parenchyma of the kidney, it is 
necessary that the pelvis be lacerated 
When the pelvis and capsule are not 
lacerated a large blood accumulation may 
form in the parenchyma of the kidney, and 
but little appear in the urine, and none escape 
into the surrounding cellular tissue. But 
when the capsule is lacerated the blood will 
pour into the retro-peritoneal cellular tissue, 
and form a large tumor that may extend from 
the diaphragm to the pelvis. It is not uncom- 
mon to have both the capsule and pelvis lacer- 
ated. In these cases the blood finds a natural 
outlet through the ureter, and though a con- 
siderable tumor may form shortly after the in- 
jury, with a free communication with the cel- lular tissue, it is not uncommon to have this 
entirely disappear by drainage through the 
ureter. In rupture of the ureter in connection 
with laceration of the kidney no such drainage 
takes place, and the tumor remains and in- 
creases rapidly in size; finally a phlegmon is 
formed, involving a greater portion of the 
side. 
The condition is entirely changed when 
the peritoneum is lacerated as well as the kid- 
ney. Here you have a most dangerous com- 
plication. This occurs most frequently in 
children, as the peritoneum is more friable and 
its tension is greater in early life. 
The pronounced symptom immediately after 
injury is shock, and this shock has no specific 
characteristics to indicate a lesion of the kid- 
ney. It is the shock of severe abdominal in- 
jury, and would be present in impalement, con- 
tusion or laceration of any of the viscera of 
the abdominal cavity. It is not prolonged, 
however, beyond a few hours, except when 
accompanied by severe internal hemorrhage. 
Almost immediately after the injury, and be- 
fore the symptoms of shock have subsided, the 
patient complains of severe pain in the neigh- 
borhood of the injured kidney. This pain is 
increased very much on pressure or manipu- 
lation. The physical signs produced by the 
hemorrhage will depend: first, on the quantity; 
SYMPTOMS. and second, whether it is retained in the cellu- 
lar tissue or admitted into the peritoneal cav- 
ity. If it be retained in the capsule or cellu- 
FIG. I. DIAGRAMMATIC SKETCH SHOWING RELATION OF 
PERITONEUM TO KIDNEY, URETER AND BLADDER, AND 
DISTANCE BETWEEN PERITONEAL CAVITY, AND SYM- 
PPIYSIS PUBIS WITH BLADDER DISTENDED. 
tent depending upon the quantity of blood. 
When the peritoneum is lacerated the blood 
lar tissue, palpation and percussion will elicit 
the signs of tumor around the kidney, the ex- 14 
escapes into the /peritoneal cavity, and the 
evidences of tumor are absent both in the 
neighborhood of the kidney, and in the great 
majority of cases in the peritoneum, unless the 
quantity of blood is very large, in the latter 
case you will have the symptoms of acute 
anemia. When the peritoneum is ruptured 
the manifestations of collapse are also more 
profound and of longer duration. (See Fig. I). 
An almost invariable symptom, and one of 
great importance, is that of hematuria. It is 
often excessive, but in rare cases it is entirety 
absent. The quantity of blood in the urine 
bears some relation to the extent and position 
of the laceration; and when it is great the prob- 
ability is that one of the large vessels of the 
pelvis is involved. 
Hematuria without tumefaction indicates 
that the capsule is not lacerated. The urine 
may be simply colored with blood, or it 
may be almost pure blood and coagulate 
when voided. Intermittent hematuria after a 
laceration of the kidney is not uncommon. 
The intermission is produced usually by a co- 
agulum forming in the ureter. During the 
intermission there is severe pain in the renal 
plexus, which may extend down into the tes- 
ticle, as in renal colic of calculus. Three or 
four days after the laceration the tissues at the 
side commence to show urinary infiltration. 
If the urine be aseptic it does not produce sup- 15 
puration, but an infiltration of the tissues, ac- 
companied by excessive exudation in the cel- 
lular tissue, muscles and lymph spaces. This 
infiltration increases the density of the tissue, 
so that it often has a ligneous feeling, which 
prevents the detection of fluids by fluctuation, 
notwithstanding there may be a large quantity 
present. Percussion enables us to determine 
the outline and extent of the infiltration and 
accumulation. Gradually the tumor increases 
in size; its outlines become more marked, and 
after a week or ten days, or possibly two 
weeks, the patient commences to have a tem- 
perature that exceeds 100, fibrin intoxica- 
tion or resorption fever. 
From the quantity and character of the blood, 
except where it is very minute, it is impossible 
to say whether it comes from the kidney or 
bladder. Occasionally we have an angle- 
worm clot, or a bloody cast of the ureter. 
When present it is pathogomonic of renal 
hemorrhage. We have besides these symp- 
toms, those of vesical tenesmus or bladder colic. 
This was noticed most frequently by Simon, and 
is due to a coagulum forming in the neck of 
the bladder, preventing the- escape of urine. 
The renal and bladder colics both subside as 
soon as the clots break down and the free pas- 
sage is re-established. The hematuria lasts 
from one week to three; rarely longer. 
The above is the train of symptoms commonly present, except in the complicated cases; that 
is, where you have along with the laceration 
of the kidney a rupture of the intestines, 
stomach, gall-tracts, etc. The symptoms will 
vary in accordance with the particular organ 
injured, and would have in addition symptoms 
peculiar to that organ. One of the most diffi- 
cult complications, and indeed, one in which 
it is impossible to make a diagnosis without 
exploratory incision, is the laceration of the 
spleen, as is shown in the folowing case. 
J. P—, admitted to Cook County Hospital 
in May, 1879. Patient was in a buggy at- 
tached to a run-away horse, and was thrown 
from the vehicle and doubled up around a 
lamp-post, the force being centered below the 
margin of the ribs, and a little to the right side. 
When admitted to the hospital two hours later 
he was very much collapsed; in a cold, clammy 
perspiration, and complained of great pain in 
the abdomen; pulse feeble and frequent; lips 
pale and exsanguinated. The urine contained 
a large quantity of blood. Percussion showed 
dullness on the right side, and there was a frac- 
ture of the eleventh and twelfth ribs. The 
patient continued to fail, and died four hours 
after admission. 
Post-mortem: Peritoneal cavity full of blood. 
The spleen was macerated to a pulp. The left 
kidney was torn transversely in many places, 
and hung by shreds to the pelvis. The peri- 17 
toneum over the kidney was also torn. The 
ribs did not penetrate the kidney. There was 
no injury to the intestines nor other internal 
organs. Cause of death, hemorrhage and 
shock. 
Fractures of the spine, rupture of the 
diaphragm, and rupture of the bladder occa- 
sionally accompany lacerations of the kidney. 
Prognosis: Of the 108 cases reported by 
Edler, 58 terminated in recovery. 
PATHOLOGY. 
We have in the nephritis traumatica primary 
healing and secondary healing. Primary 
healing takes place in the greater percentage 
of the cases; that is, the repair without a local- 
ized abscess or external opening. Of the 58 
cases above reported as recoveries, 46 were of 
this class, and the average time was about 
three weeks. With secondary infection we 
have suppuration and a large abscess; or a 
large accumulation of blood, which requires 
considerable time for absorption and cicatri- 
zation. In these cases it is not exceptional to 
have bloody urine for weeks during the pro- 
cess of repair. Cicatrization takes place first 
outside of the kidney, and gradually approxi- 
mates the kidney substances itself. A loose 
connective tissue is developed at the point of 
laceration, Tuffier and Paoli believed that 
they observed in their experiments the repro- 18 
duction of glomeruli in the cicatricial mass; 
but Barth in his more elaborate and extensive 
experiments and observations has come to 
the conclusion that the glomeruli are not re- 
produced. Maas is of the same opinion, and 
has found that after primary healing the scar 
continues to contract until a deep fissue is pro- 
duced at the position of the wound. If the 
lacerations have been extensive, when the pro- 
cess of repair is complete and the contraction 
has taken place, a great portion of the secret- 
ing surface may be destroyed; but this is rap- 
idly compensated for by the hypertrophy in 
the healthy tissue. In the complicated cases 
of rupture of the kidney, or the cases of 
secondary union with suppuration, the mor- 
tality is greater. Grawitz found in 17 cases of 
secondary union 10 recoveries. 
The cause of the suppuration has not been 
satisfactorily explained. Healthy urine does 
not produce suppuration, as has been shown 
many times by experiments, and as I have also 
demonstrated experimentally; but it does pre- 
pare the tissues for suppuration, necrosis and 
gangrene, that is, tissues infiltrated with urine 
if they become infected, rapidly break down 
and slough. This should be kept in view in 
treating all traumatisms involving the urinary 
tract. We have before the injury presumably 
a healthy condition of the bladder and kidneys. 
We should be careful to perform no operation 19 
nor procedure that would be liable to infect the 
tissues; for if infected the suppuration would 
be great. It was for a time believed that alka- 
line urine would produce suppuration; but that 
is not true, unless the alkalinity is produced by 
(decomposition. Urine will produce an in- 
flammation, or an excessive regenerative re- 
action, or cell proliferation; but without the 
admission of microphytes from without there 
will be no suppuration. Experiments have 
shown that lacerations and incisions of the 
kidney, where there is no loss in substance, re- 
pair themselves in from ten to twelve days. 
Where infection takes place the healing is very 
much retarded, and if the circulation is defec- 
tive in portions, it is likely to become necro- 
tic, as in the case recently reported in the 
New York Medical Record. The modus 
operand! of infection of the kidney is first and 
most frequently along the urinary tract, and 
second through the blood; third through the 
intestinal canal. 
First Source.—The most frequent source 
of infection is through the urinary tract 
from below, as from gonorrhea, cystitis, 
or more frequently in connection with 
injuries to the kidney, faulty catheteriza- 
tion. The latter procedure is so fre- 
quently 'performed in a careless; indeed, I 
might say, dirty manner, that many of the 
-cases receive their infection from this source. Second Source.—The kidney is recognized 
as an eliminator of many kinds of bacteria; it 
is also recognized as the position in which 
emboli in pyemia, erysipelas, pneumonia, scar- 
let fever and diphtheria are most frequently 
arrested, and produce suppurating foci; and as 
in injuries of the kidney, we have a locus 
minoris resistentise it would therefore be ex- 
pected that the microphytes would here be ar- 
rested, and that they would find a favorable 
nutrient material for their development. The 
experiments of Rhine on the lower animals, 
however, do not justify this theory. 
20 
Third Source.—The third channel for infec- 
tion is through the injury of a portion of the 
intestinal tract in close proximity to the lacer- 
ated kidney. It is not necessary that there 
should be a perforation of the bowel, but a 
traumatic ulcer of the bowel may infect the 
lymphatics, and by its contiguity to the in- 
jured kidney produce a suppuration of the 
latter. 
CAUSES OF DEATH. 
Of the 108 cases quoted above 50 terminated 
fatally—46.3 per cent. Of the 50, 18 were 
complicated, giving us a mortality in 90 un- 
complicated cases of 35.5 per cent. It is my 
belief that this mortality is too high, as many 
of the milder cases were not reported. The 
causes of death may be divided into: First, 
shock; or better, shock accompanied by hem- 21 
orrhage. Fourteen of the 108 cases died from 
this cause on an average of from fifteen to 
twenty hours after the injury. The quantity 
of blood found in the abdomen was very much 
less than would have been necessary to pro- 
duce death from injuries to the extremities or 
blood vessels without the element of shock. 
We know that death from hemorrhage is due 
not alone to the quantity of blood lost, but that 
the rapidity with which the blood pressure is 
lowered is an important cause of sudden 
death from hemorrhage. When the perito- 
neum is opened the shock is greater. Not- 
withstanding that the urine does not produce 
suppuration, it does produce peripheral nerve 
irritation, and in that way adds greatly to the 
element of shock. Second, continuous hem- 
orrhage for a long time produced death in 
eight cases. Third, suppuration of the kidney 
or peri-renal tissue, produced death in seven 
cases. Fourth, from uremia three deaths. 
TREATMENT. 
The treatment of injuries of the kidneys 
should be such as would overcome the causes 
of death in such accident. We find in the 
analysis of the causes of death primary hem- 
orrhage and shock in 15.5 per cent of the cases. 
The first indication, therefore, to be met is the 
hamastasis; can we, by external pressure, by 
position, by manipulation, in any way lessen the hemorrhage? No. Where we have the 
symptoms of exsanguination following trau- 
matism, with bloody urine and local tender- 
ness, there is but one means of suppressing 
that hemorrhage, and that is by operation, 
effecting compression or ligation of the renal 
vessels, or extirpation of the kidney. 
Is such an operation justifiable? 
In cases of laceration of the kidney with 
severe symptoms it certainly is. Not only can 
we extend some hope to the 15 per cent who 
die fromprimary hemorrhageand shock,butwe 
can also lessen the danger from the 9 per cent 
that die from secondary hemorrhage, making 
a total of 24 per cent of the cases whose chances 
would be increased by an immediate operation. 
In addition to this we can certainly lessen the 
mortality of the 16 per cent that die from com- 
plications, such as rupture of the gall-bladder, 
intestines, stomach, etc., by immediate action. 
The indication, therefore, in lacerations of 
the kidney with severe symptoms is immediate 
exposure of the kidney: (a) by laparotomy; 
(b) by lumbar incision; the former is always 
to be given the preference. 
In modern surgery is there any other field 
where hemorrhage (primary and secondary), 
or lacerations of the viscera are allowed to 
continue with a mortality of 24 per cent with- 
out the surgeon making an effort to reduce 
it? It is my firm conviction that we are swerv- 23 
ing in our our patient when we 
stand idly by and allow a condition that neces- 
sitates a mortality of 46.40 per cent to continue 
without making an effort to save the life of the 
patient. 
The indication in the milder cases is the 
opposite. We should wait. If a suppuration 
or a large accumulation forms, it can readily 
be drained; this should always be done by the 
lumbar incision; and indeed, a portion of (or 
even the entire) kidney may be removed, two, 
three or more weeks after the injury, if it be in- 
dicated. The septic symptoms are usually very 
mild, showing but a low degree of intoxica- 
tion, making but slight inroads upon the 
strength of the patient, and allowing the sur- 
geon ample time to consider all the bearings 
of the case before he is compelled to operate. 
When drainage is established the opening 
should be large and kept patulous. It is pre- 
ferable in these cases not to operate until the 
third or fourth week, as the injured tissues 
have by this time regenerated, and are in bet- 
ter condition to withstand the secondary in- 
fection, which frequently takes place after the 
operation, than they would be at an earlier 
time. Where the ureter is permeable the fis- 
tula will finally close, though it may continue 
to discharge for months. 
The cases of traumatic nephritis in which 
the symptoms of uremia occur must be treated from a medical standpoint, with water, diure- 
tics and proper diet. 
Penetrating wounds are rare accidents in 
railway surgery, and for that reason will not 
be considered in extenso here. I would merely 
say that the symptoms and indications are 
practically the same as for those of the sub- 
cutaneous variety, the greatest precaution be- 
ing taken to keep the wound aseptic, and if 
the peritoneum be invaded as a complication, 
suture it immediately and shut it off from the 
renal lesion and drain in front. 
Injuries of this class are produced more 
frequently by railroad accidents than any other 
form of traumatism of the urinary tract. 
We will divide them into three classes. First, 
ruptures into the peritoneal cavity. Second, 
sub-peritoneal ruptures. Third, ruptures of 
the neck into the pelvic cellular tissue above 
the triangular ligament. 
TRAUMATIC RUPTURES OF THE BLADDER. 
All of these may, or may not, be accompa- 
nied by external openings. More frequently 
they are not. Ruptures of the bladder have 
been recognized, treated and feared for cen- 
turies. Heinrich von Ruhnheisen wrote the 
first classical description of this class of in 
juries in 1663. 
The ruptures may be produced by severe 
blows in the pelvic region; by the body being 25 
thrown with great force against solid objects; 
by crushing injuries, as between bumpers, 
by being run over with heavy weights or 
wagons; they are frequently accompanied by 
fractures of the pelvis, the fragments of bone 
producing the laceration. 
Bartels, in 1878, found in 504 injuries to the 
bladder 169 ruptures. Rivington, in 1882, re- 
ports 322 cases of bladder rupture, of 
these 183 were intra-peritoneal, and 119 
extra-peritoneal. Of the 183 intra-peritoneal 
only one recovered. Of the 119 extra- 
peritoneal twenty-six recovered. A suc- 
cessful case of intra-peritoneal rupture oc- 
curred in the practice of Dr. Walter of Pitts- 
burg, where he performed an immediate lapa- 
rotomy and suture of the bladder. To Walter, 
therefore, belongs the honor of being the first 
to outline a rational treatment for ruptures of 
the bladder. The procedure previous to that, 
(and indeed, by many since) has been the per- 
manent catheter. From the time of Simon it 
has been established that healthy urine in the 
peritoneal cavity does not produce septic per- 
itonitis. 
Why, then, should the mortality be so great? 
While urine in the peritoneum does not pro- 
duce suppuration, it does produce an abrasion, 
that is, an exfoliation on the endothelium ot 
the peritoneum, and thus prepares the surface 
for infection and rapid absorption. Schlange, in 1892, collected 33 cases operated; 22 for 
intra-peritoneal rupture, with 10 recoveries 
and 12 deaths; 10 for extra-peritoneal rup- 
ture, with seven recoveries and three deaths. 
At first sight this would seem to be a great 
advance; but I doubt if the statistic justify the 
conclusion that 40 per cent of these cases have 
been saved, as many unfavorable ones are not 
reported. Still, it does justify beyond question 
laparotomy for intra-peritoneal laceration. Let 
us take some examples. 
In September, 1890, I saw with Dr. J. W. 
O’Connor, chief surgeon of the Denver & Rio 
Grande, a case at his Salida hospital. The 
patient had been injured in a wreck two days 
before. He was suffering from a fracture in 
the pelvis; had great pain in the abdomen; 
tender; tympanitic, and in no place could a 
distinct outline of dullness be determined. His 
pulse at the time we saw him was about 140; 
his temperature 101. Several hours after the 
injury he was catheterized and a small quan- 
tity of bloody urine obtained. A few hours 
later the catheter was again passed, and only 
a few drops of blood. The next morning 
catheterization was repeated, and by pushing 
the instrument in as far as possible, a large 
quantity of bloody urine (something like a 
quart) flowed out. Subsequently the catheter 
gave but a little clear urine. At the time we 
saw him his expression was bad; he was col- lapsed, and his condition such that he would 
not tolerate any operative interference. 
Diagnosis: Rupture of the bladder. Post- 
mortem the following day. The abdominal wall 
slightly infiltrated with serous exudate. Peri- 
toneum excoriated, inflamed, and the pelvis 
contained a considerable quantity of sero- 
purulent urine and blood. Bladder contracted. 
There was an extensive laceration of the blad- 
der on the posterior surface, extending through 
the peritoneum. A multiple fracture of the 
pelvis. Cause of death, peritonitis from rup- 
ture of the bladder. It is evident from the 
post-mortem that the small quantity of bloody 
urine, and the clear urine withdrawn with the 
catheter, were taken from the bladder. The 
large quantity withdrawn on the second morn- 
ing was taken from the peritoneal cavity by 
the passage of the catheter through the open- 
ing in the bladder into the peritoneal cavity. 
Dr. Fernand Henrotin kindly furnished me 
with the history of the following case; 
Male., aged 15 years. Admitted to the hos- 
pital April 6, 1895. A few hours before, while 
leaning over a banister, he lost his balance: 
fell three stories, landing on his hip and right 
side. Collapsed after the injury, but was not 
unconscious. No bones broken. Com- 
plained of very severe pain in the abdomen, 
the latter was tense and tympanitic. In- 
ability to produce bowel movement. Fre- 28 
quent vomiting and constant nausea. No 
urine was passed in the first twenty-four hours. 
A little blood was discharged after efforts at 
urination. No hemorrhage from the urethra. 
After catheterization a small quantity of clear 
urine was obtained. .Laparotomy; large 
quantity of blood and urine in peritoneal 
cavity; laceration of bladder not found, as 
patient’s condition was too extreme to per- 
mit prolonged search; abdominal drain; urine 
discharged through incision for three days 
and patient succumbed. Post-mortem not per- 
mitted. 
In arriving at a definite diagnosis in lacera- 
tion of the bladder the history of the case must 
be taken into consideration, and a careful ex- 
amination made of the boney framework of 
the pelvis. In the absence of fracture of the 
pelvis, with the remaining symptoms of rup- 
ture of the bladder, the chances are that the 
rupture is of intra-peritoneal variety, and not a 
rupture into the cellular tissue of the pelvis. 
On the other hand, when it is accompanied by 
a fracture of the pelvis, the bladder is very 
likely to be lacerated at the neck, and extra- 
peritoneally, careful palpation and percussion 
should be made of the abdomen and pelvis. 
The area of dullness may be found either lo- 
cated centrally or to one side. Palpation 
through the rectum and vagina may assist us 
DIAGNOSIS. 29 
in outlining the tumor. If the resistance to the 
wall of the abdomen be too great, it will be 
necessary to place the patient under an anaes- 
thetic, and to prepare for a laparotomy. The 
diagnosis must be made at the first examina- 
tion; that is, we are not justified in allowing 
the patient to go for hours and hours with an 
indefinite idea of the condition. 
It will be noted so far that I have refrained 
from mentioning the catheter. The catheter 
should not be used as an aid to diagnosis if 
the patient is able to urinate, but if he is not 
able to urinate it must be passed, and all the 
aseptic precautions taken in inserting the cath- 
eter that would be taken by a man with an 
aseptic conscience if he intended to insert that 
catheter into the peritoneal cavity; for if the 
patient has a rupture of the bladder it is pos- 
sible that the catheter will be passed directly 
into the peritoneal cavity, and even though 
it be not passed through the peritoneum and 
the rupture exists the catheter will set up a 
decomposition of the urine and blood in the 
bladder, and this will rapidly spread through 
the opening into the peritoneal cavity. It is 
my belief (and it is based on the observa- 
tions of a long hospital service), that there are 
more lives sacrificed and more subsequent 
trouble and pain produced by uncleanly cathe- 
terization than by any other operative proce- 
dure indulged in by physicians to-day. True, the majority of physicians to-day do not spit 
ron the catheter for the purpose of lubricating 
it; but many do slip their hands into their 
pockets, draw out the catheter, and insert it 
without disinfecting the catheter, their hands 
or the genitals. In this connection I do not 
allude to the permanent catheter. That will 
be considered under the subject of treatment. 
The information that we can derive from 
catheterization, is the quantity and character 
of the contents of the bladder. If it be small 
and bloody and the patient has not urinated 
for a considerable time previous to the injury, 
it signifies rupture. We must be careful to 
note that the eye of the catheter is not closed 
with a blood clot, as a very distended bladder 
under such circumstances could not be evac- 
uated. If no urine is withdrawn from the 
bladder it may be filled with a colored salt so- 
lution by means of a siphon attached to the 
catheter, the quantity being first measured ex- 
actly, using on the average a quart of water. 
This should then be made to siphon off and 
again measured. If there be a noticeable dif- 
ference in the quantity, and the catheter is not 
closed by a blood clot, the chances are alto- 
gether in favor of a rupture of the bladder. 
The increase in the area of dullness in the ab- 
domen should be noted before filling, while 
full and after emptying the bladder. When 
this procedure is undertaken every prepara- tion must have been made to do an imme- 
diate laparotomy. 
31 
Now if the fluid does not return, and we are 
convinced that it is a rupture of the bladder, 
the question arises; is it intra-peritoneal, sub- 
peritoneal, or intercellular? If of the intra- 
peritoneal variety, the fluid passes in with less 
force, and the dullness will become more dif- 
fuse. In the sub-peritoneal variety, as shown 
by the following history, the tumor will be 
circumscribed, and will be highest in the cen- 
ter. 
DR. ALEX. C. WIENER’S CASE. 
F. D—, a healthy, strong man, aged 28 
years. While unloading railroad iron fell back- 
ward, with a rail crossing his abdomen. Be- 
came unconscious immediately, but soon re- 
acted, was taken to his home, and went to bed. 
Was unable to urinate; had severe vesical 
tenesmus. In the evening he became tym- 
panitic and complained of great pain in the 
abdomen. The following morning the patient 
collapsed; pulse 130; temperature sub-normal. 
Abdomen very tympanitic; dullness over lower 
portion of abdomen, having the outline of a 
very much distended bladder, or an ovarian 
tumor. Catheterization produced only a few 
drops of bloody urine. 
Diagnosis: Extra-peritoneal rupture of the 
bladder; sectio alta. Removed to the Stadt- 
krankenhaus. As soon as the deep fascia and 32 
the pre-vesical space was opened there was a 
gush of bloody urine, as if under considerable 
pressure. Deep down in the sub-peritoneal 
space was found a contracted bladder, in the 
apex of which was an opening three quarters 
of an inch in diameter. The peritoneum was 
pushed up into the abdomen, and a large quan- 
tity of fluid had accumulated in a sac, sur- 
rounded by peritoneum above. As the fluid 
escaped the peritoneum fell back in the direc- 
tion of the bladder. The opening in the blad- 
der was sewed with silk, and a drainage tube 
inserted in the sub-peritoneal cavity between 
the bladder and the peritoneum. This was re- 
moved on the third day. There was no frac- 
ture of the pelvis. The patient made an un- 
eventful recovery, and was discharged from the 
hospital in four weeks. 
This case illustrates beautifully the method 
in which the peritoneum is separated from the 
bladder, and the large quantity of urine that 
may be accommodated, without rupture into 
the peritoneal cavity. It also illustrates the 
indication for treatment in those cases where 
there is laceration; that of immediate suture 
of the bladder and thorough drainage be- 
tween it and the peritoneal cavity. 
In this class of cases it can be readily seen 
why the peritoneum is pushed in advance of 
the urine, and forms a second urinary sac 
(extra-peritoneal), between the peritoneum and the wall of the contracted bladder. It can also 
be seen that an exploration of the bladder from 
the perineum, and through the perineal sec- 
tion with the finger is not possible, particu- 
larly if the patient be at all obese, and even if 
you find a laceration in the bladder you can- 
not (determine whether 'the laceration con- 
tinues through the peritoneal coat, or whether 
the peritoneum be pushed forward ahead of 
the fluid and separated from the other coats 
of the bladder. The proper operation for 
such cases, both with a positive diagnosis of 
intra-peritoneal rupture, or with a doubtful 
diagnosis of intra-peritoneal rupture, or with 
a diagnosis of rupture into the cellular tissue, 
is a supra-pubic section. The bladder can be 
opened through this incision and explored 
without opening the peritoneal cavity, and if 
the urine be sub-peritoneal, it can be drained 
through this opening. If the opening in the 
bladder be sub-peritoneal it can be sewed 
through this incision. If the rupture is intra- 
peritoneal, the peritoneum can be opened by 
increasing the incision an inch upward, and 
the cavity can be irrigated and drained through 
the same opening. A permanent drainage of 
the bladder can also be made through the lat- 
ter, thus placing it in a most favorable condi- 
tion to keep the escaping urine aseptic. With 
a glass speculum the surface of the bladder 
can be thoroughly examined with the eye as well as digitally. The ureter can be examined 
and re-united if ruptured, and hemorrhage can 
be suppressed, all through the same incision. 
In other words, every indication (immediate 
and remote) in connection with intra-perito- 
neal rupture of the bladder can be made by 
this method of operating, and that without 
jeopardizing the patient by the operation itself, 
or the function of the neck of the bladder dur- 
ing subsequent years. It was first suggested 
by Gutesbock, and performed by Mikulicz 
After the bladder is open a careful examina- 
tion of the surface should be made, not alone 
for one opening, but for many, as the rupture 
is frequently multiple. The usual incision for 
supra-pubic section should be made. The 
tissues will be found infiltrated with blood and 
urine; the bladder will be found deep in the 
pelvis and contracted. It cannot be elevated 
with a rectal bag in these cases. When the 
bladder is opened and the anchor stitches are 
placed in position a digital exploration may 
be made, and then an examination with a 
speculum. If it is found that the bladder is 
ruptured into the peritoneal cavity, the in- 
cision should be enlarged upward, and the peri- 
toneal cavity opened. The bladder closed with 
a Czerny-Lembert suture. The peritoneum 
should then be thoroughly 'cleansed, thor- 
oughly irrigated with a salt solution, the 
ureters examined, and a large glass drain in- 35 
serted. The bladder should be sutured to the 
abdominal wall, and a speculum or a drain an 
inch in diameter retained in the opening in the 
bladder. It can in this way be frequently 
irrigated. 
What are the dangers? First, there is dan- 
ger of peritonitis from the effect produced to 
the peritoneum by the urine. In these cases 
death occurs as a rule from the third to the 
fifth day. Second, there is danger of absorp- 
tion of the infiltrated urine in the pelvic cellu- 
lar tissue. Third, there is danger from necro- 
sis of the cellular tissue, and extensive slough- 
ing produced by the decomposed urine. 
The indications, therefore, are: prevent fur- 
ther contact of the urine with the peritoneum, 
and provide thorough external drainage 
for the urine from the bladder. This cannot 
be done with a small drainage tube, nor with 
a siphon, but must be done with a glass specu- 
lum an inch in diameter. Where the perito- 
neum is separated from the bladder wall and 
the wall of the abdomen, and the urine rests 
in the sub-peritoneal space, great care should 
be taken not to open the peritoneal cavity, but 
to drain by a supra-pubic incision, as in the 
case kindly furnished me by Dr. Alex. C. 
Wiener. 
Wherever there has been a urinary infiltra- 
tion in any tissue, the most careful provision 
must be made for drainage, as it rapidly de- 36 
composes when exposed; and when decom- 
posed its destructive effect is very great. 
The most common ruptures of the bladder 
are those of the neck; and they are usually 
associated with fracture of the pelvis. The 
symptoms are very similar to those above- 
mentioned, except that the area of dullness 
does not extend up in the direction of the 
peritoneal cavity; but there is infiltration, ten- 
derness, tumor in the supra-pubic space (or 
evidences of tumor), and an infiltration to be 
felt in the pelvic cellular tissue through the 
vagina or rectum. Where we are able to ex- 
pose the laceration in the bladder, and through 
that to explore the bladder for other lacera- 
tions, it is not necessary to make an incision 
into the bladder. But where we are unable 
to locate the opening in the bladder, it should 
be opened supra-pubically, the location of the 
wound determined, and the same sutured. 
With immediate suture of the incision in the 
bladder we should resort to drainage of the 
space between the bladder and peritoneum for 
three or four days, until we determine whether 
or not primary union will take place. Itls un- 
necessary in these cases to keep the bladder in 
the external wound. It is also unnecessary to 
keep it open, as we can drain the line of suture 
and incision thoroughly after they are approx- 
imated; and in case of leakage it will not escape 37 
into the cellular tissue and through the perito- 
neum, but along the line’ of free drainage. 
There should be free incision into the infil- 
trated area, and the most thorough antiseptic 
precautions taken. The tissues should be irri- 
gated and constantly saturated with a boric 
acid solution. 
LACERATIONS OF THE URETHRA BELOW THE 
TRIANGULAR LIGAMENT. 
These are by far the most common injuries 
to the urinary tract. A kick, a blow, a fall, 
striking on a hard body with the perineum 
very frequently lacerates the urethra, with or 
without a fracture of the pelvis. More fre- 
quently without. These lacerations may be 
divided into partial and complete, that is, first, 
in cases where the urethra is torn only for a 
portion of its circumference, where it is possi- 
ble for the patient voluntarily or with the aid of 
the catheter to evacuate the urine; and second, 
where there is complete laceration, and when 
the patient makes an effort to urinate he feels 
an intense burning and sense of pressure in 
the perineum. 
Method of production: The urethra is im- 
pinged between the foreign body and the sym- 
phesis and lacerated; the force of a sharp ob- 
ject pressing the urethra against the corpus 
cavernosum may produce the laceration; or 
the laceration may be produced by a fracture 38 
of the pelvis, or by penetrations of the peri- 
neum. (See Fig. II.) 
Symptoms: Hemorrhage from the meatus; 
pain and burning in the perineum; inability to 
urinate, and when an effort is made, pain, 
burning and pressure are experienced in the 
perineum. 
In these cases it is not uncommon to have 
FIG. 2. ILLUSTRATING RELATIONS OF TRIANGULAR LIGA 
MENT (DEEP PERINEAL FASCIA) TO URETLIRA, ETC. 
(FROM GRAY). 
an infiltration of urine in the cellular tissue of 
the thigh, and along up the cellular tissue of 
the abdomen in the direction of the umbilicus. 
But if a case receives proper treatment at the 
start, that is, early operation and drainage, 
this does not take place. 39 
Physical signs; Swelling and infiltration or 
the perineum; tenderness on pressure; inabil- 
ity to pass catheter; distended bladder. 
Pathology: When the urethra is lacerated 
partially, or completely, the patient is unable 
to urinate; or if he does, it is but little and very 
painful. The urine is forced out by the con- 
traction of the bladder, and through the lacera- 
tions into the cellular tissue of the perineum 
into the corpus spongiosum; and the quantity 
may be so great as to produce a distinct swell- 
ing of the perineum, the buttocks, or even 
pass up onto the side of the leg. Catheteri- 
zation, if attempted, is ineffectual in relieving 
the bladder. The urethra at the point of 
laceration is thereby infected, and we have* a 
rapid decomposition of the urine in the cellular 
tissue, and a further infiltration at each effort 
to urinate. The distress becomes so great that 
the patient must have relief. 
The indications are: First, to relieve the 
distended bladder. Second, to relieve the 
urine from its retention in the perineum. Third, 
to provide a permanent and free escape of 
the urine. Fourth, if the tissues are exten- 
sively infiltrated, to give free exit to the fluid 
producing the infiltration. Fifth, to re-unite 
the urethra. 
The distended bladder is relieved by (a) the 
passage of a soft rubber aseptic catheter, with 
the hands and genitals thoroughly disinfected. If this fails (and it should not be persisted in 
for too long a time), the next indication (b) is 
immediate perineal section for the relief of the 
distended bladder and infiltrated perineum, at 
the seat of the laceration. One of the great- 
est difficulties in this operation is finding the 
proximal end of the urethra, particularly 
after the case has existed for a number of days. 
The steel sound or silver catheter should be 
passed down into the opening of the urethra; 
a free incision should then be made and the 
end of the catheter and the tissues carefully 
inspected; and with a grooved director an en- 
deavor made to locate the proximal end of 
the urethra. The tissues may be found cut, 
torn, lacerated, in fact mutilated, without 
greatly jeopardizing the patient. The prosta- 
tic and membranous portion of the urethra 
may be proximately located by passing the 
finger into the rectum and following it down. 
The search for the urethra may be kept up for 
an hour. If success has not attended by that 
time, it is advisable to allow the patient to 
come from under the influence of the anaes- 
thetic, and have him endeavor to urinate. The 
urine will frequently flow out through the 
wound. You have then accomplished the first 
and second indications. With the uretha thus 
opened the urine may escape through the 
wound immediately on the patient’s efforts to 
■urinate. The proximal end of the urethra 
40 41 
can then be readily located, and should be 
joined by suture, where it is possible, to the 
distal; and an opening retained for permanent 
drainage. 
If it be impossible for the patient to urinate 
after this procedure, and the urethra has not 
been found, his bladder may be aspirated with 
a fine needle in the supra-pubic position; or a 
supra-pubic cystotomy may be performed, 
though this is rarely necessary. When the 
urine escapes freely through the perineal wound 
in the efforts at urination, it is not necessary 
to keep in the catheter. Indeed, it is highly 
desirable that it should not be used at all. 
If it is impossible to bring the ends of the 
urethra together, a catheter should be inserted 
into the urethra and passing down to the 
sphincter, and retained there to aid in the for- 
mation of a permanent canal. 
On what class of cases of laceration of the 
urethra should we perform perineal section? 
On every case of traumatism to the perineum 
in which the urethra is involved; where there 
is hemorrhage from the meatus; a material 
diminution in the size of the stream; and where 
it is impossible for the patient to urinate and 
the catheter does not readily pass into the 
bladder. By this I mean, in every traumatism 
where the urethra is lacerated sufficiently to 
allow of infiltration of urine into the peri- 
urethral tissues. Yes, I will even go further, 42 
and say in every traumatism to the perineum 
where there is hemorrhage from the meatus, 
and where the patient cannot urinate volun- 
tarily and freely. 
When should this operation be performed? 
At the time when the attending physician en- 
deavors to pass the catheter for the first time 
after the injury. There should be no attempt 
at catheterization unless everything is in readi- 
ness for an external urethrotomy. If the 
patient goes for hours without urinating after 
the injury, there is no material destruction in 
his perineum, as the urine is aseptic, and it in- 
filtrates the tissue slowly; but just as soon as 
the catheter is passed, just so soon is decom- 
position of the urine set up, and immediately 
the destructive effect of the decomposed urine 
on the tissues commences. 
The operation in the early stage is a very 
simple one, that is, within three or four, or 
even ten hours after the injury, as the tissues 
still retain their natural color; impart about a 
natural sensation to the touch; can be recog- 
nized by their appearance; and are still in their 
proper anatomical relations. Now this is all 
changed in twenty-four, thirty-six or forty- 
eight hours, particularly if the doctor has 
spent an hour or two trying to pass a metallic 
catheter through the urethra. In my opinion 
the metallic catheter in traumatisms of the 
urethra is a surgical abomination. Its only 43 
potentiality over the elastic is its power to do 
damage. A soft catheter will pass if the 
urethra be permeable. A hard catheter can- 
not be forced into the bladder after it has es- 
caped from the normal tract of the urethra 
without making a false passage. It is merely 
forced into the perineum, into the peri-vesical 
cellular tissue through the triangular ligament; 
yes, it has been recorded many a time that it 
was forced into the peritoneal cavity. It 
should never be used for the purpose of cath- 
eterization in the presence of laceration. Its 
only use should be as a guide to the position of 
laceration. 
What are the evil consequences of such a 
procedure? First, the perineum is severely 
lacerated around the urethra. Second, the 
triangular ligament may be perforated, and 
the pelvic cellular tissue then become infil- 
trated. Third, the opening in the urethra is 
made larger; the tissues in the perineum are so 
torn that the urine freely infiltrates the peri- 
neum; and worse than all this, the laceration 
in the urethra is infected, and decomposition 
of the urine is set up. As a consequence of 
the infiltration and decomposition we may have 
the perineum, the scrotum, the corpus 
spongiosa entirely destroyed, so that the 
testicles become uncovered and even the 
tissues of the abdomen may become necro- 
tic. It has been my painful experience to see 44 
three of these cases during the last two years. 
In all three the entire urethra, from the posi- 
tion of laceration to the meatus, was destroyed; 
the skin and cellular tissue of the penis de- 
stroyed, the testicles left without a particle of 
dartos to cover them; and though the patients 
succeeded in escaping with their lives, one of 
them lost both testicles, one lost one testicle, 
and in another the testicles were covered with 
a flap from the thigh; and in all three the pa- 
tients were compelled to urinate subsequently 
through a perineal fistula. These are three 
extreme cases, and true, are only met with in 
extensive hospital practice; but every surgeon, 
even with limited practice, has seen examples 
of lesser degrees of severity of perineal fistulse, 
destruction of two or three inches of urethra, 
sloughing of a portion of the scrotum, or peri- 
neum, two or three months of confinement to 
bed from infiltration, and not so wery infre- 
quently deaths from sapremia. 
We, as railroad surgeons, should consider 
ourselves as a body of organized men where 
each individual feels it his duty to cry down 
careless, meddlesome, pernicious, yes, even 
criminal catheterization after lacerations of the 
perineum. The pocket catheter must go, and 
its place in the perineum must be supplanted 
by the guide and scalpel. 
An incision into the urethra has little 
more danger than an incision of the 45 
same size and depth into the calf of the leg. 
When I speak of incisions of the perineum 
into the urethra, I imply always incision into 
the urethra below the triangular ligament. We 
are never justified in passing beyond that land- 
mark in any effort to enter the bladder. Fur- 
thermore, we are never justified in performing 
the so-called Coxe’s operation, that is, putting 
the finger into the rectum, and stabbing for 
the apex of the prostate. In my interneship 
in the county hospital I saw two cases of this 
class. In both of them the triangular liga- 
ment was opened into the cellular tissue, and 
both patients died from pelvic urinary infiltra- 
tion and sapremia. When we are unable to 
get a guide into the bladder or find the urethra 
below the ligament, we have always left that 
simple and safe operation, supra-pubic section. 
Laceration and traumatism of the ureter 
occur most frequently with fractures of the 
pelvis or severe contusions of the abdomen, 
and are produced by penetration into the pelvic 
cellular tissues, or they may occur in abdominal 
operations. They may be: (a) extra-peritoneal 
(b) intra-peritoneal. If they are extra-perito- 
neal, the urine will accumulate beneath the 
peritoneum, and there will be a bulging cystic 
tumor at the position of laceration. This may 
be either above or below the pelvis. The 
urine immediately after the laceration may 46 
have a small quantity of blood, or, if the ureter 
is still patulous, the blood may continue in 
the urine for some time after the accident. If 
the laceration is intra-peritoneal, we have all 
the symptoms of the escape of urine into the 
peritoneal cavity, inflammation, vomiting, 
shock, etc. It is not uncommon after the first 
bloody urine passes to have the urine remain 
clear throughout the course of the case. 
The indications are, if extra-peritoneal, 
that the operation should be performed extra- 
peritoneally. The operation on the ureter 
above the pelvis can readily be made in this 
manner by an elongation of the incision 
usually made for lumbar nephrectomy, one 
inch anterior to the ilium, and down to the 
middle of Poupart’s ligament. The peritoneum 
can then be pushed forward as in ligation 
of the iliac; and the ureter can then be ex- 
posed from the brim of the pelvis to the kid- 
ney. By this operation the danger of cellular 
infection is increased; but the danger of peri- 
tonitis, which is the graver, is avoided. When 
the ureter is exposed, if it be completely sev- 
ered, the method of ureterectomy originally 
suggested and performed by Dr. Weller Van 
Hook of this city, is the best method for re- 
uniting it. 
If the laceration be longitudinal, it can be 
sewed and united by extra-mucous sutures of 47 
silk or catgut. If the laceration be trans- 
verse, and the ureter only partially divided, 
the method of elongation and lateral suture of 
Dr. Christian Fenger should be adopted.