A MIRROR OF HOSPITAL PRACTICE, CASES OF EVERSION OF BLADDER.

By Surgeon T. J. McGann, Civil Surgeon, Mysore. Eversion of the bladder is described as an exceedinglyaffection, and found exclusively among female children. Sir H. Thompson, in his article in Holmes' System, states that only three cases had come to his know-, ledge, their ages when first seen being from two to four years, although the condition, he says, had probably commenced at a very early age. That it is a rare affection is probable, judging from the frequency with which any description of it is omitted in books treating of diseases of females, and the scanty notices of it in others. Its rarity of occurrence must be the cause of this, as it is not a difficult affection to recognize when met with. It so happens, however, that I have, within the last few years, met with two cases of eversion of the bladder in women of middle age. Both cases were very similar in their histories and appearances. Of the first, which I saw about four years ago, I have kept no notes, but I remember that the woman, who was a very unintelligent one, stated that it came on after parturition, but further information she could not On superficial inspection a pyriform, or would not give. red, vascular tumour was seen protruding from the vulva. As I shall notice the more recent case more in detail, and their histories are so like, I. shall merely state regarding this, that the everted bladder was reduced ; that incontinence of urine remained ; that the distended and lacerated urethra was contracting, and before further means could be brought to bear on it, the woman absconded. I would also mention that, before I had fuliy examined it, and come to a conclusion as to its nature, its removal was pointed out to me as the proper treatment for the supposed polypoid urethral tumour. T he history of the second case is as follows On rare

visiting the Famine Relief Hospital in September last, the hospital assistant directed my attention to a patient suffering from what he considered to be prolapse of the uterus. I made a superficial inspection of her, and ordered her removal to the Civil Hospital. The following are the notes of her case, taken by Assistant Apothecary J. A. Costello :? Davee, Hindu, aged about 40 years, but looks more ; admitted on the 13th September 1878 into the Civil Hospital by. transfer from.the Famine Relief Hospital; suffering from diarrhoea, and she is haggard and emaciated. From between the vulva a pyriform tumour, about the size of a small orange, is seen protruding, with the mucous surface thickened and presenting a granular vascular appearance. The openings of the ureters are not distinguishable, and the urine dribbles as it were from the surface of the tumour. The uterus has prolapsed, the os being just visible at the vulva, and it has a fold of vaginal mucous membrane both in front and behind it. The patient, who followed the calling of a prostitute, states that it occurred as follows, viz., about seven months ago che became pregnant, and being desirous of getting rid of the products of conception, she took some native drugs for the purpose of procuring abortion The desired effect was produced, so far as the abortion was concerned, but the effects of the medicines were so violent, and the expulsive pains so strong, that prolapse of the uterus of the secoud degree occurred, as also did eversion of the bladder; her health gave way, and this state of affairs interfering with her calling, she was driven to the Relief Hospital. She is suffering from diarrhoea, and the frequent calls to stool and straining aggravate her condition and keep up the congestion, &c., of the protruded organ. On the 14th an attempt was made to replace the bladder, but the pain and resistance were too great, and it was postponed until next day when chloroform having been administered, reduction was effected with comparative facility. The urethra was found to be much lacerated aud dilated, with a diameter of over three-fourths of an inch; the patient was removed to bed, and had opiates

February 1,

1879.]

A MIRROR OF HOSPITAL PRACTICE.

arid astringents given her; a pad and bandage were applied, and the bladder washed out two or three times a day with a weak carbolate of lead lotion. On the 17th eversion again occurred, owing to the persistence of the diarrhoea and straining, and utter carelessness and apathy on the patient's part. The tumour

had

a

purple congested appearance, and was very tender however, replaced with less difficulty

to the touch ; it was,

than on the first occasion. From this date up to the time of the patient's death on the 9th of October, there is but little to record ; there was no recurrence of the eversion. and the patient gradually sank from the diarrhoea which has been so fatal and uncontrollable among the famine-stricken. Remarks.?The above are perhaps more matters of curiosity than of practical value, they are but of rare occurrence, whilst they are easy of recognition when they do happen, even though perhaps not so easy of treatment. Prolapse of the uterus would, I should say, be an almost constant complication or accompaniment in the adult, even if it did not frequently precede the eversion of the bladder. The diagnosis is easy. The uterus is found prolapsed in the second or third degree, more frequently the former ; in front, and in the normal situation of the urethra, is found protruding a pyriform, red vascular tumour, wet from the constant dribbling of urine over its surface, with, possibly, the orifices of the ureters discernible on it. A probe or catheter fails to find the urethra, and is arrested at the neck of the tumour on every side, and the finger, if passed, finds a circular gutter closed ail round. Conjoined manipulation by means of a finger, or two in the vagina, pushing the uterus up a little, and the other hand on the abdomen above the pubis demonstrates the absence of the bladder. The diseases with which it is most likely to be confounded on superficial examination are, prolapsus urethra, vascular tumour, or polypus of the urethra, or venous angioma, or possibly syphilitic growths from about the urinary aperture. The treatment would consist of reduction, rest, constitutional treatment to subdue irritation and pain, and restore or improve the general health ; support with a T bandage and pad and topical applications, anodyne and

astringent.

Cauterizations of the urethra' with a heated iron and the maintenance of a silver catheter with a bulbous extremity in the bladder, are recommended by Dr. Lowe of Lynn, in the case of children ; but in the adult, from the laceration, distension, and subsequent absorption or atrophy, of the urethral structures, they would probably be insufficient, and a plastic operation for diminishing the size of the aperture would be required. In addition, from the dilated condition of the vagina, rendering it

incapable of giving any support to the prolapsed uterus, and from the stretched, or toneless condition

torn vesical and uterine ligaments, mechanical in the shape of a pessary, would be required to sustain the pelvic viscera. An internal pessary would be insufficient, and an external one, such as that of Cutter, described by Gaillard Thomas, would be necessary. This instrument, which consists of a cup at one end which receives the cervix uteri, a stem passing out of the of the

support,

vagina, and curling over the perineum, or passing over the symphysis pubis, and attached to a band or strap round the waist, supplements the action of the utero sacral and vesical ligaments, and sustains the uterus, vagina, blad>ier, and rectum. Mysore, oth December, 1878. A death from tetanus occasioned

by

the

hypodermic

injection of quinine is reported from Iowa, U. S.

The surgeon administered subcutaneously 15 grains of bromide of quinine in dilute alcohol for the relief of an " intractable periodic neuralgia." The neuralgia was relieved, but the patient was seized with tetanus and died in 23 hours. ?Lancet.

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Case of Eversion of Bladder.

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