cyst is required; and as no examination was allowed to be made, it seems to me to be almost impossible to suggest in what way the sac was formed. Sabulous matter, or a few urinary crystals, may probably have been deposited originally in a mucous follicle, lacuna, or fossa, and gradually augmented in quantity, and in this way the sac inclosing the calculus may have been produced. The mother of the girl at four years of age suffered from stone, which was removed by the late Dr. Edward Lubbock; it was the size and shape of a walnut. She has suffered from incontinence since that time.

I believe that it would have been very much better to have removed this stone by cystotomy. Had the patient lived she would have suffered from injured urethra.

(c) Foreign Bodies introduced into the Bladder through the Urethra. -Of these it may be truly said that "their name is legion," for in the literature of the subject we find recorded a most numerous and diverse list of objects found in the bladder of the female. Some of these objects were forced into the bladder by accidents, such as falls or blows; others were intentionally introduced into the urethra for the purpose of masturbation, and then pushed or drawn into the bladder. The same may occur in auto-catheterization, the instrument being sometimes broken off in the bladder, and at others, drawn bodily into the viscus.

Hysterical and foolish women, with or without the intention of masturbating, have passed all manner of things into the bladder, as pins, needles, matches, sand, charcoal, bits of glass, bodkins, and tooth-brush handles.

Masturbators have also forced in various articles, such as twigs, small wax candles, penholders, nails, pencils, and the like. Catheters and clay-pipe stems, that have been used for purposes of catheterization, have been broken off and left in the bladder.

Pessaries, which have been badly fitted, or worn too long, have passed by ulceration from the vagina into the bladder.

Symptomatology.-The symptoms need not be given in detail, as they are the same as those caused by any foreign body, usually aggravated, however, if the body be sharp and have jagged edges. Bleeding is not uncommon, and pain varies in amount and severity with the kind, size, and shape of the foreign body. Hysterical women have been known to conceal the pain and tenesmus for a long time. If the bodies be small and blunt, they may give rise to but little pain or tenesmus, and, remaining in the bladder undisturbed, form nuclei for calculi. I doubt if a modification of the urinary secretion by reflex nerve influence (excited by these bodies) is necessary to

cause incrustation, or form calculi. The hypersecretion of mucus and decomposition of urine is all that is required.

Treatment.-The treatment of a foreign body in the bladder is summed up in two words-remove it. This must first be tried through the urethra. A pair of forceps (those known as the alligator forceps being the best) are guided to the object, which is to be seized and removed. If this is difficult, the operation may be done through the speculum. If the bodies be small, they may possibly be washed out. If they are so situated that their removal by the urethra is impossible, vaginal cystotomy may be performed, and the foreign bodies thus removed, using such after treatment as will relieve any cystitis, which may have been produced.

CHAPTER XLIV.

NON-INFLAMMATORY DISEASES OF THE BLADDER (CONTINUED).

RUPTURE OF THE BLADDER.

RUPTURE of the bladder may be classified according to its location and extent, as follows:

I. Complete and incomplete.

II. (a) Occurring at a point where the bladder is covered with peritonæum.

(b) Where the bladder is not covered with peritonæum.

I. In the complete rupture all the coats of the organ are divided, while in the incomplete variety one coat at least remains undivided.

Pathology. The complete form of rupture is the most common, and the location at which it most frequently occurs is the posterior and upper part; that is, the part where the walls of the bladder are the thinnest, and probably where there is the greatest exposure to the causes of the injury.

There is another reason given why rupture is more frequent where the bladder is covered with peritoneum, and that is because the peritoneal covering is not so elastic as the other coats.

When the laceration occurs within the limits of the peritoneal coat, and is complete, the urine escapes into the peritoneal cavity, and produces shock and peritonitis, which usually prove fatal.

In rupture at any point not covered with peritoneum, infiltration of urine takes place in the tissues beneath, not within, the peritonæum. This infiltration is sometimes very great, extending from the cellular tissue of the pelvis to the labia and thighs.

The clinical history of these two varieties differs in its characteristics because of the fact just mentioned-that in the one variety the urine escapes through the rupture into the peritoneal cavity, while in the other the urine infiltrates the tissues in and about the pelvis.

In the one, peritonitis is speedily developed, as a rule, and generally proves fatal; in the other, the progress is slower, and the chief danger is from septicemia. There is another class of cases having a pathological history which holds an intermediate position between the two already described.

In this class the history points to the fact that the rupture has been at a point destitute of peritonæuin, or else the rupture has been incomplete, not involving the peritonæum.

This gives rise to symptoms of severe internal injury, but less severe than in complete rupture, which is followed by a sudden giving way and escape of urine into the peritoneal cavity, and subsequent peritonitis. This opening into the peritoneal cavity at a period remote from the injury, is due to pressure or ulceration or sloughing, which completes the rupture.

Symptomatology.-The symptoms of rupture of the bladder are ordinarily developed as follows: There is usually shock in a marked degree, and if the pelvic bones are broken—a frequent complication of this injury--the patient is unable to move after having rallied from the shock. Severe pain is felt in the hypogastric region, and a continual desire to urinate, without the power to void the smallest quantity of urine, or possibly but a few drops mixed with blood. The constitutional symptoms indicate great prostration, which rapidly ensues. The patient has an anxious look, the countenance is pale, the pulse feeble and fluttering, respiration sighing, skin clammy; the abdomen in a short time becomes tympanitic. There is also a rise in temperature after a time, but during the shock the temperature may be sub-normal; delirium, convulsions, and coma may occur, and death may take place in a few hours in severe cases, or it may be delayed a few days. A fatal result occurs sooner in complete than in incomplete rupture.

If the patient survives the shock or collapse, life may be endangered by the development of peritonitis or septicemia. The physical signs of rupture are few and by no means reliable. I must therefore give more attention to the clinical history and symptoms, incidentally bringing out the only physical signs obtainable, such as the empty state of the bladder found when that viscus has not been emptied in several hours, and the withdrawal of a small quantity of bloody urine by means of the catheter.

The surgeon is not able to make a certain diagnosis in all cases, as the symptoms are not always pathognomonic. The statement of the patient that she received a blow over the hypogastrium, or that while in the act of straining she felt something give way, are valu

able as evidence when acute pain and other symptoms of rupture follow.

The evidence obtained from the use of the catheter is of value, especially when it is known that the patient had not urinated for several hours prior to the accident.

Under these circumstances when the bladder may contain a small quantity of bloody urine or when the bladder is empty, there is strong evidence of the bladder being lacerated. But the evidence pointing to rupture is by no means always certain. And again very often signs and symptoms which the diagnostician depends upon most are absent, and those that are present are liable to mislead. This is very unfortunate, but true. The diagnosis is especially obscure when there has been a long interval between the receipt of the injury and the development of characteristic symptoms. It is therefore necessary to watch a patient in whom there is suspicion that rupture of the bladder may have occurred. The symptoms may be for a time concealed and then develop rapidly. The first symptoms may be delayed or be obscure and not attract attention, because the vesical rupture may be involved with other injuries whose symptoms for the time hide the more dangerous lesions. As a rule, it is rare to find any external signs or mark of injury on examination of the abdomen. When much depends on the history given by the patient regarding the nature of the accident and the condition of the bladder at the time, it frequently happens that she is not able to answer questions correctly, because of the shock and the fact that this accident often occurs while the patient is intoxicated.

Strange as it may appear, in exceptional cases the patient may have no difficulty in urinating, and indeed may pass a large quantity of water. Cases have been recorded where the patient regained the power of voluntary urination after the catheter was passed for the first time.

Although it is important to make a diagnosis early in all cases, yet it is of equal importance to know whether the rupture is complete or incomplete. This can be done by noting the fact that in the one case there will be infiltration of the urine into the cellular tissue of the pelvis, and in the other such infiltration is absent.

It is often necessary to pass the catheter both for diagnosis and treatment, and great care should be taken in its introduction, for sometimes by using too much force it is accidently pushed through the viscus into the abdominal cavity.

Prognosis. The chances of recovery are not favorable, especially when the urine passes into the peritoneal cavity through a