To ascertain whether a tear be extra peritoneal or not, a measured quantity of a weak boric-acid solution is injected through the catheter. If the full amount is not recovered, the chances are that the rupture is extraperitoneal.
In investigating a suspected case of rupture the greatest care should be taken to keep the bladder aseptic; so that, in case there is a rent, germs cannot spread into the tissues, and especially into the peritoneal cavity. In making the test also of injecting fluids in measured amounts, and then observing whether the same amount is voided, care should be taken not to distend the bladder more than very moderately, lest a partial rupt ure be converted into a complete one. H. Awe (Deutsche Zeit. f. Chin, p. 351, '92).
Rupture into the peritoneal cavity, the intraperitoneal form of lesion, is less urgent as far as symptoms go. One, and even two, days may elapse before active symptoms appear; but, when they do, rapid progress toward a fatal issue from general peritonitis is the rule.
Uncomplicated contusion of the blad der readily yields to a few days' rest, the application of ice, and general symp tomatic treatment. When, however, there is cause for suspecting a rupture from the nature of the accident or the violence of the blow, the catheter should at once be introduced. The presence of ' blood renders operative interference im perative. After the rectum has been distended with a rectal bag an incision three inches long is made in the middle line of the hypogastrium, beginning half an inch below the upper edge of the pubes, as in suprapubic lithotomy.
It is best to first open the prevesical space, when it can be determined whether the rupture is extraperitoneal, and, if so, the necessary treatment to be carried out. If the rupture is found intraperitoneal, the abdominal incision is carried upward and the peritoneal cavity is opened, when the rent is located and properly disposed of. John B.
Deaver (Univ. Med. Mag., July, '96).
The peritoneum is then carefully rolled up, along with the prevesical fat. The bladder being thus exposed, search for the rupture is the next step. The rent is usually found along the poste rior surface vertically down from the urachus; frequently an extravasation of blood and urine indicates the spot.
Occasionally, however, considerable diffi culty is experienced, and opening of the organ is necessary so as to permit the introduction of the finger, and thus allow of exploration of its inner surface.
The rupture may be extraperitoneal or intraperitoneal. If an intraperitoneal laceration is found, the incision should be extended upward, the peritoneal cav ity opened, and the cystic wound closed with fine silk by means of Lembert sutures, one-eighth of an inch apart, including only the peritoneal and mus cular coats. The mucous membrane of the bladder should be respected. Impor tant, in this connection. is the neces sity of ascertaining that the sutures will hold; this may be done by distending the bladder with a lukewarm milk or an alkaline solution.
Of the 28 cases recorded by various operators, 11 recovered and 17 died. Of the II that recovered, in only 1 was peritonitis present at the time of opera tion, while, conversely, of the 17 that died, in 8, and probably in 9, peritonitis had already set in. The causes of death in the 8 cases in which there was no peritonitis at the time of operation were: in 5, shock or haemorrhage or the two combined, and in 3 peritonitis, the peri tonitis in 2 out of the 3 being due to leakage of the rent or giving way of a suture. In no fewer than 4 out of the 28 cases was the bladder found, at the post-mortem examination, to leak. The importance of testing the competency of the bladder by injecting milk or other bland and easily detectable fluid could not, therefore, be too strongly urged. W. J. Walsham (Univ. Med. Jour., July, '95).
The abdominal cavity is then carefully irrigated and closed, leaving a drain if there is any possibility that fluids will accumulate in any of the surrounding tissues.
Wounds.
Wounds of the abdomen may be non penetrating, when the abdominal walls alone are injured, and penetrating, when the peritoneum is included in the lesion, irrespective of the instrument (pistol, knife, etc.) with which the lesion is pro duced.