Five cases of primary nephrectomy with one death, a mortality of 20 per cent.; and thirteen cases of secondary nephrectomy with five deaths, a mor tality of 3S.5 per cent., showing that secondary ncphrectomy is nearly twice as fatal as primary.
As to the route of the operation; of three cases of abdominal nephrectomy, one died, a mortality of 33.3 per cent.; and fourteen of lumbar nephrectomy, of which four died, a mortality of 28.6 per cent. W. W. Keen (Annals of Surg., Aug., '96).
Bladder. — When a patient presents the history of a severe abdominal con tusion or crushing, followed by inability to micturate, the catheter should at once be used.
Most important signs of vesical rupt ure: a peculiar pain felt at the time of the injury; chilling of the surface of the body, which persists for some time: an urgent desire to micturate, which the patient cannot satisfy; the absence of any vesical swelling above and behind the pubes, and also the absence or the presence, but in very small quantity, of urine in the bladder. Catheterizing, though valuable, ought not to be prac ticed except with very great caution. Sieur (Arch. G6n. de MM., Feb., Mar., '94).
The presence of hmmaturia will indi cate a lesion in the urinary tract, kidney, or bladder. If the urine withdrawn is observed to be well mixed with blood and, instead of red, it appear brown and smoky, the lesion is probably one of the kidney. If, on the contrary, the urine be bright red, the probability is that the bladder has been torn. In the latter condition the diagnosis may also be as sisted by the quantity of fluid passed at a given time. If, when the catheter is introduced and after a history marked with shock, no urine is obtained, the chances are that not only the bladder has been ruptured, but that the laceration is extensive, the opening having allowed the vesical fluids to escape into the ab dominal cavity. A free flow, on the con trary, would tend to show that the tear, if any exist, is small. Of course, the imagination of the intestines into the vesical opening, or a valve-shaped lacer ation, may cause the same favorable signs to exist, thus misleading the diag nostician. small lesions may be
present, sufficient to allow the urine to escape, drop by drop, into the surround ing parts. Detection of them is very difficult, the subsequent complications. alone showing the presence of extrava sated fluids.
The presence of any tear, except very small ones, may also be ascertained by injecting a weak boric-acid solution into the organ, through the catheter. If a rupture be present, the bladder will not fill and rise above the pubis. Filtered air may be used for the same purpose, but it is less satisfactory, owing to the danger of secondary collapse.
Case in which diagnosis was estab lished by inflating the bladder with air forced in by two or three compressions of the rubber ball of an ether-freezing microtome. The amount of air to be introduced need only be very small, and only moderate pressure is required for the inflation.
The introduction of air through the rent into the abdominal cavity, even in small quantity, was attended by a pro found disturbance in the patient's gen eral condition, which passed off on open ing the abdomen and allowing the free air to escape. The method should not be applied till the patient is on the operat ing-table, so that, should the collapse. threaten life, the abdomen could be opened at once. W. J. Walsham (Univ. Med. Jour., July, '95).
The urine may have passed into the prevesical connective tissue outside the peritoneum, or the vesico-rectal or yes ico-uterine space, owing to a rupture in these locations. This constitutes the extraperitoneal lesion. Cellulitis and sloughing rapidly ensue without subse quent involvement of any organ in the neighborhood of the lesion, the vagina, the rectum. etc., the patient dying from septim>mia.
Two cases of uncomplicated intraperi toneal rupture of the bladder. Death probably due to the absorption of the urine by the peritoneum and to its con tinuous accumulation in the blood. In both cases the rupture was situated on the posterior wall. There were no signs of acute peritonitis in either case. The patients lived probably five and three days, respectively, after the accident. Joseph Coats (Brit. Med. Jour., July 21, '94).