ing it in situ. When the bladder is greatly distended all the urine should not be drawn off at once, lest syncope be induced. A catheter failing, the retention may be relieved by: 1. puncture above the pubes; 2, puncture through the rectum; and 3, forcing a catheter through the prostate (tunneling). The first method is decidedly the best. The second is seldom applicable, as the enlargement, as a rule, leaves no room between the prostate and the pouch of peritoneum for puncture, which, if attempted, will probably wound the peritoneum. The third method is attended with extreme danger, and is seldom practiced at the present day.

4. Retention from Organic Stricture.-The symptoms and diagnosis of stricture have already been described. Here only need be mentioned the treatment to be adopted in cases of retention from this cause. An endeavor should first be made to pass a catheter, if necessary, under an anesthetic. If this fails, and the symptoms are not urgent, a hot bath and a full dose of tincture of opium may be given, and another trial made in a few hours. Where, however, there are signs of grave kidney mischief, opium must be withheld or given with great caution. Should these means not succeed, or if from the first the symptoms are urgent, one of the following methods may be resorted to, viz.: 1. Aspiration, or puncture of the bladder above the pubes; 2. Puncture of the bladder through the rectum; 3. Cock's operation of opening the urethra behind the stricture through an incision in the perineum; and 4. Forcing a catheter into the bladder. The last method is highly objectionable, and should on no account be practiced. Of the other methods, aspiration above the pubes, repeated, if necessary, should the stricture not quickly yield after the spasm has been removed by emptying the bladder and thus reducing the tension, is in my opinion the best. Puncture through the rectum is strongly recommended by some surgeons; but it is open to the objection that suppuration between the bladder and rectum, extravasation of urine, and a permanent recto-vesical fistula, are liable to follow, to say nothing of the annoyance to the patient from the presence of the cannula in the rectum, and the excoriation of the parts by the urine, which, notwithstanding care, is apt to occur. The vas deferens, moreover, may be injured, and atrophy of the testicle ensue. Cock's operation is difficult to perform, and does not appear to possess any advantage over aspiration or puncture above the pubes. Should the passage of a catheter not be effected after the bladder has been aspirated on several occasions, Wheelhouse's operation, or one of the other operations described under impermeable stricture, may be undertaken. Aspiration, though as a rule

attended with excellent results, is not absolutely free from danger. Thus it should not be practiced when the urine is unhealthy, lest a drop or two escape through the puncture and set up septic inflammation and suppuration, which may be followed by extravasation of urine.

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5. Retention from hysteria should be combated by such moral and physical treatment as is applicable to that disease. eter should not be passed if it can be possibly avoided.

6. Retention from paralysis or atony of the bladder, from abscess or tumor of the urethra or bladder, from impacted calculus, and from ligature of the penis, is discussed under the heads of Paralysis of the Bladder, Impacted Calculus, etc.

PUNCTURE OF THE BLADDER ABOVE THE PUBES.-Make a small incision through the skin immediately above the pubes, having first ascertained by percussion that the bladder has risen well out of the pelvis ; and thrust Cock's curved trocar and cannula downward and backward into the bladder. Withdraw the trocar and secure the cannula in situ. In a few days, when the parts are consolidated, the cannula should be changed. When the bladder is distended, a good inch rises above the pubes uncovered by peritoneum, but when contracted and hypertrophied may rise but little, if at all. Under these latter circumstances the trocar and cannula must be passed close to the pubes for fear of wounding the peritoneum.

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Aspiration is performed in a similar way, except that the aspirating needle or trocar is thrust in without any preliminary incision of the skin. If a small aspirating needle or cannula is used there is no danger of extravasation, as on its withdrawal the puncture in the bladder is closed by the contraction of the muscular fibres; and even should a drop or two of urine escape, no harm will ensue provided the urine is healthy. It is a most useful emergency operation, and, if necessary, may be repeated on several successive occasions.

PUNCTURE OF THE BLADDER THROUGH THE RECTUM.-Place the patient in the lithotomy position. Pass the left forefinger into the rectum, and place its tip just beyond the back of the prostate; take Cock's long curved trocar and cannula, with the point of the trocar slightly withdrawn within the cannula. Introduce it through the anus, and guide it by the finger in the rectum to a spot immediately behind the prostate exactly in the middle line. Press the cannula firmly on the fluctuating trigone of the bladder, and plunge the trocar boldly into the bladder, in a direction upward and forward toward the umbilicus. Withdraw the trocar, and secure the cannula in situ with suitable tapes. Do not plug the cannula, but fix an India-rubber tube on its end and convey this to a vessel beneath the bed.

DISEASES OF THE GENITAL ORGANS.

DISEASES OF THE PENIS.

PARAPHIMOSIS is the strangulation of the glans penis by a tight prepuce which has been drawn back over it, and cannot be replaced. Thus, it is not infrequently met with in boys, from the accidental uncovering of the glans and neglect to draw the prepuce forward again. In adults it is generally due to swelling, caused by gonorrhoea or venereal sores, but it may occasionally occur during coitus. It is attended with great oedema of the glans and prepuce, and if not soon reduced, may lead to ulceration at the line of constriction, or even to sloughing of the penis. Treatment.-Seize the penis between the first and second fingers of each hand, press the blood and oedema out of the glans with the thumbs, and at the same time push the glans backward and

Method of dividing the stricture in paraphimosis.-(From Bryant's Surgery.)

try to draw the prepuce forward over it. If this fails, divide with a knife (Fig. 221) the constricting band, which lies just behind the fold of oedematous prepuce at the bottom of the furrow on the dorsum of the penis.

PHIMOSIS is a condition in which the prepuce is elongated, and its orifice contracted, so that it cannot be drawn back over the glans. It may occur as a congenital affection; or it may be acquired, and is then usually due to the cicatricial contraction of the orifice following syphilitic ulceration or repeated attacks of gonorrhoea. The orifice when very small may cause difficulty of micturition or even retention of urine; while the straining to pass water may induce prolapse of the rectum, hernia, irritation of the bladder, and symptoms of stone, and if not relieved may

produce the harmful effects on the urinary organs described under stricture; or the deposit of the urinary salts beneath the

FIG. 222.

prepuce may lead to the formation of preputial calculi. The inability to uncover the glans may cause pain and difficulty in coitus, and by preserving a mucous membrane-like character to the glans predispose to venereal disease; while the secretion which collects beneath the prepuce may, in consequence of the irritation it is apt to set up, induce priapism,

Seizing the prepuce preparatory to the operation of habits of masturbation, circumcision. (From Bryant's Surgery.)

inflammation sometimes

simulating gonorrhoea, adhesion of the glans to the prepuce, or even, as age advances, the formation of an epithelioma. The treatment may be considered under the heads of circumcision, sitting the prepuce, and dilatation of the preputial orifice.

1. Circumcision.-Lay hold of the prepuce transversely with a pair of polypus forceps, on a level with the corona; let the glans slip back, close the forceps, and shave off all the prepuce in front of them with a clean sweep of the knife. Remove the forceps, slit up the mucous lining of the prepuce in the middle line quite back to the corona, break down any adhesion between the prepuce and glans, wash away the secretion, twist or tie any spurting vessels, and stitch the flaps of mucous membrane to the skin with interrupted horse-hair sutures. Dress with boracic lint or iodoform.

2. Slitting the prepuce may be done with scissors or with a curved bistoury, guided by a director introduced between the glans and prepuce. In either case the mucous membrane should be united to the skin flaps with fine sutures after twisting or tying any bleeding vessels. Care should be taken not to pass the director into the meatus, and to ensure that the mucous membrane is slit quite back to the corona.

3. Dilatation of the prepuce may be accomplished in slight cases by a daily endeavor to draw back the contracted prepuce over the glans. It may also be done by the preputial dilator, or by forcible separation of the blades of the dressing forceps, though such means are not always successful.

PRIMARY VENEREAL SORES OR CHANCRES.-Two chief varieties

of venereal sore or chancre occur, the spyhilitic or infecting, and the local contagious or non-infecting. Either of these may be accompanied by sloughing or phagedæna, and are then spoken of as sloughing or phagedænic sores or chancres.

1. The primary syphilitic chancre has already been described in the section on syphilis (p. 50).

2. The local contagious or non-infecting sore, the soft chancre or chancroid as it is sometimes called to distinguish it from the hard or syphilitic chancre, is a specific form of ulceration probably depending upon a distinct variety of micro-organism. Though the ulcer, like the syphilitic, may occur on any part of the body that is inoculated with the specific virus, it is so much more frequently met with on the genitals that it is described with diseases of these organs. It is not followed by constitutional symptoms.

Signs. Soft chancres are most frequent at the junction of the glans and prepuce, where they often take the form of a ring of small ulcers around the corona glandis. More rarely they are met with on the muco-cutaneous or cutaneous surface of the organ. They usually begin as a pustule or slight excoriation generally within a few days of inoculation, and when fully established, appear as small oval ulcers, with sharply-cut edges and a slightly-depressed base covered by a grayish slough, and surrounded by a red areola of inflammation. When irritated, as by the rubbing of the clothes, or the retention of the secretion beneath a long prepuce, they may become indurated; but the induration has not the sharply-defined character of the syphilitic sore. The inguinal glands become enlarged (bubo), and matted together into a single mass, often of considerable size, and have a marked tendency to suppurate. The pus taken from them apparently contains the same micro-organism as that of the sore, since, when inoculated on the same or another person, a similar sore is produced.

Diagnosis.-The main difference between a non-infecting or soft sore, and an infecting or hard, are the following: The soft sore is generally unattended with induration; in the hard the induration is well marked; the soft occurs within a few days of inoculation, the hard not till after three to five weeks; in the soft the secretion is abundant and purulent, in the hard scanty, and often consists of little more than epithelial débris; the soft can be reinoculated on the same patient, and hence is frequently multiple; the hard cannot be reinoculated on the same patient, and hence is single unless, as very rarely happens, the patient is inoculated in two places at the same time. The bubo following the soft sore is single, soft, and very liable to suppurate; that