POST MORTEM EXAMINATION - RUPTURE OF THE BLADDER. Examination. —On opening the peritoneal cavity, about four pints of clear fluid welled up through the incision. The bladder was found contracted and a laceration of its posterior surface to the length of two inches was detected extending in an oblique di rection. In other respects the organs presented no morbid changes.
This case presents the following points of interest: First, the power of locomotion after so serious an accident, the patient hav ing walked to his home, a distance of two miles, immediately after the occurrence. Secondly, the length of time he survived—sixteen clear days—the average duration of life in these cases being from three to seven days. Thirdly, the absence of all signs of peritonitis. Fourthly, could the death of the patient be attributed to peritoneal absorption? In view of what has been effected by laparotomy and suture in cases of intra-peritoneal rupture of the bladder, no other treatment can be recommended, unless for some reason or other it is found im possible to give effect to it.
The diagnosis of extra-peritoneal rupture of the bladder is some what facilitated by excluding, in the way referred to, the likelihood of the other variety. If the use of the catheter, in conjunction with the history of the case, and examination by the rectum are insufficient to indicate this, in the presence of a lesion evidently involving the mechanism of micturition, a perineal puncture into the membranous urethra for the digital exploration of the neck of the bladder should be proceeded with. Many patients in cases of this kind have un doubtedly been lost for the want of that knowledge which can only be thus obtained. the suspicion is grave, the possibility of not finding such a lesion by exploring should not be allowed to weigh against making the attempt. If a pelvic fracture, with rupture of the viscus, or rupture alone, is discovered, a drainage-tube should be in serted in the bladder. If the prevesical space is also opened, an ditional aperture above the pubes will be required, in order that through drainage may be provided. Procedures of this kind are safe and slight compared with the risk connected with extravasation of urine imperceptibly going on in a part where otherwise drainage is impossible and subsequent absorption certain. This point is illus trated in the following case which I saw, with Dr. C. G. Walker, at the Bootle Hospital in 1882 : patient, aged 40, a fireman on board a steamer, was brought into hospital with the history that on the preceding day the surgeon of the ship was summoned to him in consequence of his ina bility to pass urine and of pain above the pubes. It was thought that
he had been drinking, and might have hurt himself when stoking coals. The catheter was passed, and about two pints of blood-stained urine drawn off. On admission the abdomen was distended, with an area of dulness on percussion and tenderness above the pubes; the per ineum was ecchymosed, and he was collapsed. Alter the diagnosis of rupture of the bladder had been made, the treatment consisted in the retention of a rubber catheter and irrigation of the bladder with a weak carbolic lotion. An erythematous rash, suggestive of extravasation, began to appear over the right iliac region, extending half-way down the thigh. Vomiting and prostration set in, and the patient died on the fourth day after the presumed injury. At the autopsy a cavity about the size of an orange, filled with blood-clots, was found behind the pubes. There was a rupture two inches in length in the anterior wall of the bladder where it is uncovered by peritoneum, the urethra being normal. Though there was no history of injury, there could be no doubt that the lesion was due to a blow above the pubes over a full bladder.
The following case, recorded by Dr. Weir,' illustrates the practice that is to be recommended in cases of this description: CASE.—" It was one of injury to the pelvis and left hip of a man, Case.—" It was one of injury to the pelvis and left hip of a man, aged 28, by a fall of earth. A catheter was passed on his admission to the New York Hospital on November 20th, 1883, a short time after the accident, which gave exit to a moderate amount of bloody urine. The injury was regarded as a slight urethral laceration, but the marked increase in the supra-pubic dulness, which now extended four inches above the pubes and across into each groin, with tenderness, led to a closer examination of the patient. The catheter passed read ily into the bladder and only occasionally gave exit to blood-stained urine. The urine itself was passed at times voluntarily, and was not apparently diminished in amount. The temperature was but 99°. Abdomen not distended, though its walls above the dulness were somewhat rigid. Condition still good. No signs of fracture elicited, but the finger in the rectum detected a softer spot on the left side of the prostate, which was decidedly painful. The ecchymosis of the scrotum and perineum was now very pronounced.