Therapy.—If a patient with the symptoms which we have above des cribed, has fluctuating tumors in her abdominal walls, we would at once, after catheterizing the bladder, incise the spots, and empty them of their contents. If these contents contained urinary salts it would fix the diag nosis.
If there occur a sudden peritonitis from pouring of urine into the ab dominal cavity, we should empty the bladder, use ice locally and opiates internally, and await developments. If the threatening symptoms are not much lessened in 1 to 2 days, the time has arrived when we must decide upon the question of exploration of the bladder. In cases where we suspect deep-seated disease of the vesical walls, as in those due to pressure of the pregnant uterus, it is not to be thought of. Brukenberg has demonstrated. that even the most cautious manipulations may cause rupture, especially if attempts at reposition be made immediately after the expulsion of mem branes clothed with peritoneum. So that vesical exploration from within is only indicated in the rare acute cases of direct rupture. If a perforation was found, and percussion showed the presence of a considerable body of fluid in the abdomen, we would imitate the procedure so successfully carried out in cases of rupture of the uterus, and pass an elastic catheter cautiously through the rent. If large quantities of fluid passed out, we wonld pass a drainage tube on a stylet through urethra, bladder, and rent into the peritoneal sac, and either leave it there until the symptoms got better, or, if they did not, gradually exchange it for a smaller and smaller tube. As soon as the opening was so small that a tube could only be passed with very great difficulty, it should be discontinued, and tho edges of the wound cauterized with the solid stick.
Puncture into Douglas's pouch would only be necessary when there was fluid encapsulated in it, which threatened to suppurate. Otherwise we can only attempt to disinfect it by means of injections made through the drainage tube.
It is needless to say that free movement of the bowels should be attained and the position of the uterus be attended to. As long as there is collapse, frequent hypodermic injections of 30 minims of ether (every to 1 hour) should be persisted in; it not only stimulates the patient, but it renders the bladder less sensitive under the necessary manipulations.
As in cases of acute " perforation-peritonitis," in acute cases of not too extensive rupture of the bladder, the patient's life may be saved by laparotomy with subsequent suture of the bladder walls.
Pathological Anatomy.—The following new growths have been observed as affecting the walls of the female bladder: Polypi and polypoid hyper trophies of the mucous membrane, cysts of the mucous membrane, papil lary tumors, fibroid tumors, fibromyomata, sarcomata, and carcinomata. In 119 cases of primary vesical tumor in both sexes, Sperling found 41 fungoid growths, fibromata and papillomata, 19 medullary carcinomata (24 cancers altogether), 6 scirrhi, 10 mucoid polypi, 6 myomata, 7 sarco mata, and 6 fibro-sarcomata. Of the fibromata ft occurred in males and in females; and carcinoma was 4 times as frequent in mon as in women. Rauschenbusch (J. D. Halle, 1882), found 10 females affected in 22 cases of papilloma of the bladder.
a. Mucoid Polypi and Polypoid Hypertrophy of the Mucous Membrane. --The mucosa is spongy, thickened and soft, either diffusely or over limited areas. It bleeds easily and is often encrusted with salts. Its tissue is infiltrated with a serous or jelly-like matter, its capillaries are enlarged, and on its surface there is abundant cell-proliferation. Mus cularis and serosa are usually thickened and hypertrophic. Some polypi are congenital; thus I found in 1875 two pediculated polypi of the posterior bladder wall in a new-born infant.
No. 426. (1875.) A secundipara had been under treatment for some time for Bright's disease, and gave birth, on May 12th, 1875, at 3 o'clock A.m., to a girl at S months, 15 inches long and weighing 43 ounces. The child died in 32 hours. The necropsy showed the subcutaneous tissue to be generally cedematous. Lungs atelectatic in places. Abdomen con tained some free fluid. Bladder contracted; mucosa hyperxmic. At the fundus vesiew was a pea-sized round, soft and vascular mucoid polypus, attached by a pedicle; in the lower part of the bladder was another similar and somewhat smaller one. The walls of the bladder were compamtively thick, and the pelvic and retro-peritoneal connective tissue very cedema tons. Single polypi may attain the size of a hen's egg (Hutchinson's cases), and are occasionally found in conjunction with uterine polypi. They consist of a connective tissue of varying density covered by a hyper plastic and fringed mucous membrane (cases of Warner, Guersant, Spie gelberg.) Kaltenbach has noticed a walnut-sized pedunculated papillary adenoma growing from the mucous follicles of the bladder.