RUPTURE AND INJURIES OF THE BLADDER.
Rupture or bursting of the bladder may be caused by violence ap plied directly over it when it is in a more or less distended condition; by penetration from within, as by the sharp ends of fractured bones, or from without, by bullets and other missiles. It has been known to give way under artificial distention for surgical purposes, and it is also believed to have been ruptured by muscular contraction.' - It has been occasionally opened accidentally in the course of surgical opera tions involving parts in its immediate contiguity.
There are certain general considerations to which reference may first be made before proceeding to notice the varieties the injury pre sents in view of their treatment. In many cases of rupture of the bladder there can be no doubt that a weakened state of its walls, due to long standing disease, has contributed in no small measure to this result. This circumstance is important to remember where we have to employ distention of the bladder for surgical purposes, as, for in stance, in supra-pubic cystotomy, where the resistance of the coats of the viscus is occasionally submitted to a somewhat severe test. In relation to contributing causes of rupture of the bladder, Mr. W. H. Bennett'has reported a case where the puncture made by an aspirator needle preceded this event. In the next place stress may be laid upon the importance of making an early diagnosis in all instances of this kind, for, if the rupture is to be closed with any chance of success, no time should be lost. Hence, it is a good rule in cases of pelvic in jury, or even of suspicion that such may have occurred, to make care ful investigations as to the state of the bladder, and if necessary to take the precaution of using the catheter. If a direction of this kind can be regarded as applying to conscious patients, it does so with still greater force to those who, for some reason or other, are not in possession of their faculties. In more than one instance that has come to my knowledge it was discovered after death that the insensibility of alcohol or poison led to a lesion of this kind having been over looked. Though in none of the cases I can now recall was the rup tured bladder the immediate cause of death, the fact that it compli cated other still more serious conditions must not be forgotten. Further, as cases of this kind not 'infrequently occur in connection with matters requiring medico-legal investigation, such as in fighting, sparring, wrestling, and in modern football, difficulties sometimes arise in getting at the facts, for which allowance should be made. In
hospital practice it has happened that this lesion has not been recog nized, because not suspected, and thus complaints have arisen in con sequence of patients having been allowed to go to their homes and to remain there until symptoms developed. Subsequent autopsy, in some of the cases, has shown the difficulties connected with diagnosis to have been well-nigh insuperable.
Ruptures of the bladder are of two kinds—intra-peritoneal and ex tra-peritoneal. In the former the area of the abdomen, as defined by the peritoneum, is opened into, and urine usually enters it; while in the latter, if urine escapes, it is in the form of an infiltration around the parts constituting what is called the neck of the bladder, where it produces effects such as are observed' in more superficial parts in connection with extravasation of urine.
In the case of an injury applied over the region of the bladder, how are we to ascertain that this organ is ruptured, and if so, whether the rupture involves the cavity of the abdomen? Having de termined these two points, what are the lines of treatment? These three aspects will now be considered: In addition to the history of the injury and its locality, such a lesion is usually attended with con siderable shock. If the urine has suddenly escaped into the perito neal space, this collapse may be spoken of as profound, and perito nitis generally follows with much acuteness. Then we have the fact that the catheter usually draws off only a small quantity of blood stained urine, and possibly it may at the same time be noted that the instrument passes quite easily up to the hilt, giving the impression that it must have entered the abdominal cavity, which is often the case. Upon the latter point there is, however, sonae variation. Though there may be a rent directly communicating with the perito neal cavity, the end of the catheter may not happen to pass through it, and then a sensation of contraction is experienced such as almost to lead the surgeon to believe that the instrument has not taken the natural course. Examination, however, by the finger in the rectum generally serves to indicate that the instrument is in its right posi tion, but is firmly grasped by the contracted viscus.