the admixture of blood, passing by the catheter. On the third day the intervals between the doses of opium were lengthened to two hours; on the fifth, to three, and thus gradually decreased as all signs of inflammation had passed. At the end of a week the abdominal wound appeared to be closed by first intention; the stitches, however, were not removed till a week later. The guin-elastic catheter was replaced by a new one every two days, and was not withdrawn for two weeks after the injury had been received, and then only for a short time. At the expiration of two weeks, with the absence of all pain and tenderness, opium was omitted. The intestines were relieved by warm-water injections on the tenth day, when mild nourishment was ordered. Between the second and third week the catheter was permanently withdrawn, and only introduced every four hours for the evacuation of urine. After the third week, the patient left his bed. He has remained well, working at his trade, and feeling no impediment in his urinary organs.

(Alfred Willett).—An incision some five to six inches in length, from the umbilicus to the pubes, was made in the mesial line and carried through the parietes. All bleeding points having been secured, the peritoneum was opened, and at once several ounces of dull, brownish fluid, with strong urinous odor, escaped. The intestines were greatly distended, and instantly bulged out through the wound. The peritonæum generally was highly injected, and adjacent surfaces were glued together. Passing my hand into the pelvis I detected a laceration of the bladder. The coils of gut were only slightly more adherent here than in the abdomen proper; I satisfied myself that there was no protrusion of bowel into the lacerated bladder. The omentum was raised from off the intestines, and so much of the latter as lay in the pelvis was drawn up, laid upon the upper part of the patient's abdomen, and protected from harm and chill by flannels wrung out of moderately hot water. There was about half a pint of bloody, urinous fluid in the pelvis, and when this had been sponged away, a rent of the bladder some three and one half inches in extent was exposed. It extended diagonally across the fundus, having a direction from before backward and from right to left. The appearance was that of a nearly straight tear through all the coats of the bladder, except at its most dependent parts, where it was jagged and uneven. The bladder was flaccid, but, of course, quite empty, and at the site of rupture its walls were fully half an inch in thickness. I brought the torn edges easily in apposition, and united them by eight interrupted sutures of fine Chinese silk. The sutures were placed at intervals of rather less than half an inch, and seemed

to close the rent completely. Before returning the intestines I cleaned out the abdomen as thoroughly as I was able; but the mes entery of the gut lying outside the abdomen acted as a transverse diaphragm, and I was disappointed to find on replacing these coils that some of the fluid had been pent up above it. Owing to gaseous distention, very considerable difficulty was experienced in replacing all the intestines within the abdomen, and I was quite unable to introduce my hand and cleanse the upper part of the peritoneal cavity as satisfactorily as I could have wished; but the patient's shoulders were raised in order to make the pelvis more dependent, and all fluid that found its way there was removed. The intestines that had been lying out of the abdomen during the operation were sponged over with warm water and carefully cleansed before returning them. extreme was their distention that to enable me to introduce sutures, and close the external wound, Mr. Langton, who assisted me, was obliged to spread out his hand and restrain the bowels from forcing their way through the wound, withdrawing his hand gradually as the successive sutures, also of Chinese silk, were tightened. Through the lower angle of the abdominal wound I passed a carbolized drainage-tube into the pelvis, securing it to the edge of the external wound, which was then dressed precisely as after ovariotomy. A Thompson's catheter was introduced and retained in the bladder. On being replaced in bed, hot bottles were placed beside the patient, and he was well covered up. The wound in the abdominal parietes was found on the autopsy to be adherent almost along its whole line; not much swelling of abdomen. The intestines immediately behind the wound were adherent to it. All the coils of intestine in the lower half of the abdomen were adherent to each other and to the abdominal walls by recent lymph. The intestines in contact with the bladder were adherent to it. There were about two ounces of bloody fluid at the back of the peritoneal cavity; about an ounce of this lay just above the bladder. The opening in the bladder was everywhere well closed, except between the posterior two stitches, where there was an orifice through which water injected per urethram escaped very freely. Even here there appeared to be an attempt at repair. Elsewhere the edges of the wound were adherent. There was very little sign of inflammation in the interior of the viscus.

(Christopher Heath).-Man, aged forty-seven. Pubes being shaved and washed with carbolic lotion, an incision was made in the middle line just above the pubes for two inches, and the tissues divided down to the peritoneum, which appeared blue, the recti muscles, which were firmly contracted, being held aside by retractors

with difficulty. The peritoneum was then picked up and a cut made into it, when a gush of fluid, like that drawn off by the catheter, came out. A large quantity of clots was then taken out from the peritoneal cavity. The finger introduced into the peritoneal cavity found a long rent in the posterior wall of the bladder high up. This was sewed up by a continuous catgut suture firmly tied at both ends. The clots were removed as far as possible from the peritonæum, and the cavity sponged out after injection with warm water, and a long large-sized drainage-tube was inserted at the lower angle of the wound, the upper part of the wound being brought together by deep and superficial sutures. A catheter was passed into the bladder, to which was afterward attached some India-rubber tubing leading into a vessel under the bed. Hot poultices were applied to the abdomen, and one grain of opium was administered every four hours. The further history shows great relief and improvement, but on the fourth day after the operation the patient became rapidly worse and died. Autopsy. Small intestines considerably distended. For two inches around the abdominal wound the intestines were adherent by recent lymph to each other, and to the abdominal parietes. Above and on each side of these adhesions there was no trace of peritonitis. On tearing away these adhesions some coils of intestines were seen lying over the pelvis glued together, and to adjacent parts by recent bloodstained lymph. On lifting these coils upward, the recto-vesical pouch of peritoneum was exposed, containing about six ounces of clotted blood, black in color, and moderately offensive odor. There was a rent in the mid line of the posterior wall of the bladder two inches in length, extending upward as high as the apex. The lower third of the rent was gaping; the edges of the rest were approximated by the catgut suture, the lower end of which was free and loose.

CHAPTER XLV.

NON-INFLAMMATORY DISEASES OF THE BLADDER (CONTINUED).

NEOPLASMS, HYPERPLASIA, ATROPHY.

OWING to the very imperfect facilities for observing the internal surface of the bladder during life, the study of vesical neoplasms up to within a few years was chiefly post-mortem, and of course their therapeutics was almost nil. At the present time, however, by means of the endoscope, the microscope, and the operation of cystotomy, more accurate methods of diagnosis and of rational and successful treatment have been developed.

The neoplasms of the bladder may be classified as follows: Benign. Myxoma, fibroma, myoma, myo-fibroma, tubercle. Malignant.-Epithelioma, encephaloid, scirrhus, sarcoma. Tumors of the bladder and deposits in its walls are by no means common, and those of a benign nature are less common than those that are malignant. There has been some dispute as to whether some of these neoplasms are malignant. This is especially the case in regard to the villous growth, the German and some English authorities ranking them as essentially malignant, while some American authors, as Van Buren and Keyes, deny in toto that they have any such property. More will be said of this when I come to the class in which I have placed them; not that I am satisfied that they are malignant, but for lack of positive evidence of the new idea, temporarily at least, I adhere to the old one.

Benign Growths.-Myxomata, Mucous Polypi, and Polypoid Hypertrophies, while having nearly the same anatomical characters, are really different affections as regards etiology, symptomatology, prognosis, and treatment.

Mucous polypi are isolated hypertrophies of the mucous membrane, varying in size, and giving rise to trouble only in proportion to their size. They may exist at birth, or be developed at any time during life, being more common, however, in youth and middle

age. The mucous membrane covering them is thickened and pulpy, and that about their base and in their immediate neighborhood is somewhat thickened, and more vascular than normal. If the polypi are situated at or near the neck, or in other portions of the bladder, where their long, narrow pedicles admit of a blocking of the urethra, the entire mucous membrane of the organ suffers, as in all cases of retention and decomposition of urine. If the obstruction is great, and the organ requires spasmodic and irregular muscular effort to empty it, there will be, sooner or later, not only cystitis, but muscular as well as mucous hypertrophy.

These growths may be as small as the head of a pin, or as large as a goose-egg; they consist of hypertrophied and hyperplastic connective tissue, covered by soft, pulpy, hyperplastic mucous membrane, that bleeds easily on touch. They may coexist with uterine fibroids. Their favorite seat is the posterior wall of the bladder.

General polypoid hypertrophy of the mucous membrane consists in an irregular thickening of the mucous membrane throughout, accompanied as a rule by hypertrophy of the muscular and serous coats. There is an increased blood-supply, the membrane being bright red in color, the capillaries dilated, and the whole mass bleeding easily on the touch. It has somewhat the appearance of fresh granulations. Upon the free surface of the mucous membrane, there is, as we should expect, an excessive cell proliferation, these cells being in a transitional condition, i. e., occupying the position between imperfect and perfect, and not all of the same degree of perfection or imperfection of development. There may be either serous or gelatinous infiltration, giving it a heavy, sodden look. Upon the surface are often found incrustations of the urinary salts.

It appears to me that there has been an undue complexity of classification of this subject, especially among the German pathologists, some of whose differences are too minute to be of any practical value from either a pathological, diagnostic, or remedial point of view. Tumors which they call villous or papilloma vesica are, in many, if not all respects, identical with the so-called polypoid hypertrophy of the vesical mucous membrane. For all practical purposes they are essentially the same.

They have been described as enlarged papillæ, the vessels of which are dilated, and their walls thinned. They only differ from the polypoid hypertrophy in increase of vascularity, and the fact that they are usually limited to the trigone. Underlying and about them is a thin, wavy stroma of connective tissue, that becomes increased as the disease advances.