If the bladder communicate with fcetal sac or dermoid cyst, it will depend partly upon the size of the vesical concrements, bones or calculi, and partly upon the size of the tumor and its liability to rupture whether urethral dilatation, extraction of the foreign body and cauterization of the cavity will be sufficient, or whether it will be necessary to divide the abdominal and the vesical walls and perhaps remove the ovarian tumor. In the case which Pincus has published, where Czerny operated, the der moid cyst was removed by laparotomy, and the ensuing vesical deficiency closed with silk sutures. Three drainage tubes were placed in the lower border of the wound. The patient made a good recovery, although there occurred a large abscess of the abdominal wall.
In any case it is well to irrigate the bladder as frequ.ently as possible with a lukewarm solution of salycilic acid (1 to 1000) using llegar's funnel. Mild diuretics are indicated. If the contents of the intestine pass into the bladder it will be proper to use opiates in moderation with a view of lessening peristalsis, as also to exhibit astringents such as decoct. quinife, decoct. colombo, rhatany, etc. Suture of the gut has latterly made so good a record that laparotomy with separation and closure of intestine and bladder may well be as feasible as the operation of Czerny above described; though the operation for ileo-vesical fistula will in any case be more difficult and more dangerous than is ovariotomy with suture of a vesical wound.
Rupture of Female Bladder.
Etiology.—This can as a rule only occur when the viscus is subjected to direct violence when in a more or less filled condition. The greater the violence, the leas fluid need the bladder contain to cause rupture. A blow, a push, a fall upon the abdomen, a fall from a considerable height upon the feet, may, as Wernher has proved, cause even the empty blad der to rupture. The common causes of the accident, such as scuffling, occur much more rarely in the female. In 86 cases Graw found only 11 in women. In a woman who had received a blow upon the abdomen. Hawkins found two ruptures, one .6 inches long opening into the abdominal cavity, and another opening into the pelvic connective tissue. Possibly also the greater motility of the female bladder and the non-resistance of the pelvic outlet, protects the female, whilst the male organ is more exposed to injury. On the other hand rupture vesiem has occurred in consequence of hyper-distension in connection with that diseased state of the bladder wall so often found in cases of retroversia and retroflexio uteri. The most important cases of this class which have been subjected to post-mortem verification are those of Guslth. van Doeveren (1765) and Lynn (1767). In other cases, like those of Reinick, William Hunter, and Wall, usually cited in this connection, there was really marked retention of urine with faulty position of a pregnant uterus. In a case that I pub lished myself (1.c. p. 76), when a dying pregnant woman was admitted into the Dresden maternity hospital, the bladder had been dilated until it equalled the size of a child's head; its walls were in some parts thin, in others thickened, and it was filled with muddy, sour-smelling urine. Its
vessels were markedly injected, and at the fundus was a space the size of a hand, showing several larger and smaller losses of substance, which were covered with a thick, gelatinous substance of an ammoniacal odor. And all this was after the bladder had been emptied with the catheter shortly before death. It is easy to understand how, with this over-distended blad der, any pressure caused by an a,ccess of bearing-down pains, or by an attempt to empty the rectum, these thinned-out places might give way, and rupture of the bladder occur. Krukenberg has demonstrated that with long-continued urinary retention, the termination in rupture is the commoner. In addition to the above-mentioned cases of van Doeveren and Lynn, he has collected one of Hunter (1771), Naumburg (1796), Sax torph (1803), Moreau (1838), and Southey (1871), of actual vesical rupture. Since the publication of the first edition of this work, we note in addi tion a case by E. Schwartz,' and one by Brukenberg (1882).
Vesical rupture during labor has been mentioned, but I know of no case of the kind. They may possibly occur, but a3 a rule they are con tusions and tears rather than ruptures.
Anatomy.—In Doeveren's ca,se the urinary bladder was found ruptured and the entire abdominal cavity filled with urine. Lynn found 9 to 10 pints of urine in the abdomen; the bladder, torn at the fundus, hung re laxed in the belly; the edges of the wound were gangrenous. Naumburg found an abscess nith a fistulous internal opening in the anterior bladder wall, and a small ronnd perforation in the posterior wall. Saxtorpli found the posterior vesical wall torn. In Moreau's case the bladder was attached to the omentum, and showed a gangrenous spot and perforation. Southey found two gangrenous holes in the bladder, the lower one open ing into the vagina, near the vesical neck, while the upper one led to a cavity between bladder and uterus, which was formed by extensive adhe sions between uterus, C83CUM, small intestine, and sigmoid flexure. E. Schwartz's patient had 10 pints of brownish-red fluid in the abdominal cavity; there was a rupture 1.2 inch long in the posterior bladder wall. A similar condition of things was found in Hunter's ease. Finally Kru kenberg saw the space between the abdominal wall and the anterior surface of the bladder filled with a tissue infiltrated with pus. The pel vic entrance was occupied by the lower coils of the jejunum and the upper ones of the ilium; and two of these coils were adherent, with mesentery, to the edges of a defect in the bladder wall as large as the palm of one's band, which they closed. In this case it is to be remarked that 11 days after the reposition of the displaced pregnant uterus, a gangrenous mem bmne 1 line thick and weighing 1771 grains was cast off, which distinctly showed an inner and a peritoneal surface. On the mucous surface were amorphous masses of urates and ammonio-magnesic phosphates.