Even the anterior wall of the bladder may suffer rupture; and adhe sions to neighboring organs not infrequently encapsulate the effused urine. But the posterior median portion is the thinnest part of the vis cus, and hence is the most prone to give way. The direction of the rup ture may be oblique or transverse, and the opening in tho serosa is larger than in the muscularis and the mucosa. The peritoneal border is sharp, the muscular coat ecchymosed, the mucous layer contains a narrow red ridge from effusion into the submucosa.
In one case, when there was effusion of urine from rupture of the anterior wall, the tissues up to the navel were infiltrated, and only then did the fluid break through the omentum. In 61 cases of rupture of the bladder in both sexes, according to Smith, 50 times it was through the peritoneum, 9 times through the anterior non-peritoneum covered wall, and 2 times through the neck of the bladder. Peritonitis set in in 54 cases.
Symploms.—Rupture of the bladder with effusion of urine into sur rounding parts may cause almost immediately the very severest symptoms of collapse. There is intense pain in the hypogastric region, a tearing feel ing, incessant desire to urinate without success, terror, abdominal disten sion, nausea and vomiting. Whether the urine is effused or not into the peritoneal cavity, there may be peritonitis, clammy sweat, urinous odor of the skin, and a small and very frequent pulse. The urine may be evacu ated spontaneously or the catheter may be needed; it is usually bloody, but may be clear. If the rupture affects the anterior wall, there occurs infiltration of urine into the tissues of the abdominal wall. Smith found a fracture of the pelvis in a woman sixty years old who had been run over; her urine was bloody, and there was a painful tumor in the right iliac fossa, from which air, pus, and .urine issued on puncture. Infiltration of urine may lead to abscess formation and so to spontaneous cure in these cases, without there being any peritonitis at all. As a rule, however, the pains increase and death speedily occurs.
If peritonitis has been already present, or if other injuries have been caused at the time of the rupture of the bladder, the dia,gnosis of the lat ter condition may be very difficult. The excessive desire to urinate will of course lead us to introduce a catheter; and the bloody urine, if pres ent, will lead us to think of a vesical injury. An exact examination, es pecially of the internal genitals, will, however, guide us aright. An evil smelling urine points to disease of the bladder wall. If the urine were in
the abdominal cavity, we might get no flow through the catheter until its head had been passed through the rent; or it might come now in full stream, and • now in dribbling manner. The general picture will be that of a " perforation peritonitis"; and we will not always be able to tell before the necropsy which organ has ruptured.
It is a question whether it is better, when we suspect a rupture of the bladder in an acute case, uncomplicated by retro-flexion of the gravid uterus, to search for the rent with the catheter, or to dilate the urethra and use the touch. There are as many arguments for the one as for the other course. One or other proceeding is necessary to inaugurate a nitional treatment. It is objected that thereby the rupture is reopened, the peri tonitis increased by renewed effusion of urine, that without narcosis the patient may quickly sink into collapse during dilatation, and more quickly sink if chloroform is used, and finally that we cannot obtain a complete reflux of urine through the rent. On the other hand the greater part at all events of the hurtful fluid can be removed by the catheter. A drainage tube passed through the rent into the alxlominal cavity not only permits the escape of all fluids therefrom, but promotes the flow of urine out from the bladder; and all modern experience te,aches us how easily and well such drainage tubes are borne, either with or without washing of the abdominal cavity with solutions of salicylic acid. Puncture of the abdominal wall would enable us to empty the peritoneal cavity of the greater part of the urine then present; but it could not be completely done, and would give but poor facilities for drainage. My opinion is that in cases where in women we suspect rupture of the bladder, we should dilate the urethra without narcosis, and thoroughly palpate the internal surface of the bladder.
The prognosis, which is very bad, is the factor that determines me in giving the above advice. It is true that 6 cases of ruptured bladder out of 97 have recovered; but 50 per cent. of all cases died within 5 days, 30 per cent. in 5 to 10 days, and the rest in 10 to 20 days. In inffitration of urine the prospects are of course better. Happily these cases occur but rarely. We must endeavor to bring to their aid all the resources of abdominal surgery which ovariotomy has brought us. In the cases of rupture of the bladder in women mentioned above, death only occurred between the fourteenth and the fifty-first days.