PRACTICAL CONSIDERATIONS : THE BLADDER. 1913 



follow chronic cystitis, uterine or periuterine inflammation, post-partum suppuration 

 of the symphysis pubis, and purulent thrombosis of the umbilical vein in a new-born 

 infant (Thorndike). 



Collections of pus have opened from here spontaneously through the anterior 

 abdominal wall, into the rectum, the bladder, or the urethra, and into the peritoneal 

 cavity. 



Rupture of the bladder rarely follows distention alone, but is not uncommon as 

 a result of trauma expended upon the pelvis or lower abdomen when the bladder is dis- 

 tended. The cases in which rupture follows over-distention from obstructive disease, 

 without the intervention of force, are usually prostatic in origin, as in retention from 

 stricture the urethra ordinarily ulcerates behind the constriction and periurethral 

 extravasation of urine relieves the tension. 



The liability to traumatic rupture is directly proportionate to the degree of dis- 

 tention and consequent elevation of the viscus, and if that condition exists in a blad- 

 der the subject of chronic dilatation and atrophy, or in one rendered unnaturally 

 immobile by pericystitis or pelvic cellulitis, the force required to produce rupture is 

 much lessened. Occasionally in the presence of fracture of the pelvis it is difficult to 

 decide whether a given lesion of the bladder is a rupture or a wound from a fragment 

 of bone. 



Eighty-five per cent, of ruptures are intraperitojieal, because, (a) in distention 

 the peritoneal becomes the most tense of the coats of the bladder-wall ; {b) it is the 

 least elastic ; {c) it covers that portion of the bladder which, as it rises into the 

 abdomen, first loses the protection afforded by the pelvis, and is less reinforced by 

 pressure from surrounding tissues ; {d ) the bladder- walls are thinnest over that 

 area ; (<?) the region is e.xposed to counter-pressure against the promontory of the 

 sacrum. These conditions also explain the usual situation of intraperitoneal ruptures 

 in the upper and posterior bladder-wall. 



Extraperitoneal rupture is apt to be in the anterior wall, — i.e., that portion most 

 immediately in contact with the pelvic bones, which in these cases are often found 

 to be fractured. 



Pathological (spontaneous) rupture is usually in the extraperitoneal portion of 

 the bladder, because there the influence of gravity is most potent in aiding in the 

 production of the protrusion of the thinned mucosa between the often hypertrophied 

 bands of muscular fibres. The early stage of this condition — in which the muscle 

 hypertrophy is the prominent change — constitutes the so-cd\\ed fasciailated bladder ; 

 later, when the pouching has become marked, it is known as sacculated bladder. 



In children rupture of the bladder is rare in spite of its thinness and of the fact 

 that in- them it is an abdominal rather than a pelvic organ, because (a) the chief 

 causes of distention are absent ; (3) the greater sensibility of the bladder renders its 

 evacuation more frequent or less likely to be neglected ; in the adult incontinence of 

 urine generally means distention, in the child irritation (Owen) ; (r) owing to the 

 undeveloped condition of the prostate the bladder is more movable. 



JVounds of the bladder may occur from within, — during instrumentation, — or the 

 bladder may be reached by weapons, missiles, or vulnerating bodies of any sort, 

 through the suprapubic region, the rectum, the perineum, the obturator or the 

 sciatic foramen. They often result from the direct laceration of the bladder-wall by 

 a bony fragment in fracture of the pelvis. Like ruptures, they may or may not in- 

 volve the peritoneum. 



The symptoms of rupture or wound will obviously vary with the situation of the 

 lesion. The most important are due to the escape of urine from the bladder either 

 into the space of Retzius or into the peritoneal cavity. The determination of the 

 general character of the injury— made in part by catheterization, which, in the 

 presence of inability to urinate, yet fails to draw more than a little bloody urine, and 

 does not withdraw all of a measured quantity of injected fluid — should be followed 

 by instant operation, whether the lesion is extra- or intraperitoneal in its situation. 



Occasionally, after a small stab or pistol wound, the loose mucosa mav act as a 

 plug, and, aided by the muscular contraction of the bladder-wall, will for a time 

 prevent extravasation, and then the above-mentioned signs may be absent or may 

 appear later, when ulcerative or necrotic processes have opened the way for the 



