RUPTURE OF THE BLADDER. The following remarks oil the subject of this very formidable accident are made in a paper by Dr. J. W. S. Gowley, Surgeon to the Bellevue Hospital, New York, published in the Medical Record:? The following analytical summary of seventy-eight cases of rupture of the bladder, borrowed from Dr. Smith's* paper, will show at a glance the important features of this lesion from all
causes.
Sex.?Males, 67; females, 11; making about six of the former
to
one
of the latter.
Age.?Under ten, 3; ten to twenty, 3; twenty to thirty, 19; thirty to forty, 26; forty to fifty, 7; fifty to sixty, 4; above sixty, none; adults, 16, age not given. Condition.?Bladder distended, 30, of which 10 were intoxicated; 5 from stricture,! intoxicated; condition not given, 14; parturition, 4 ; in good health, 4 ; doubtful, 2 ; no note of 24. Causes.?Direct violence, 48; concussion, 15; internal causes, 9, of which 4 were parturition; 4, results of stricture; 1, retroversio uteri; no note of 6. Primary Symptoms.?Severe 59: of which 43 were ruptured into the peritoneal cavity; 2, not involving the peritonaeum; 10, into cellular tissue; 3, not given. Slight, 9 : of which 7 were into the peritoneal cavity; 1, indefinite; no note of 7. Inability to urinate, 28: of which 22 were into the peritoneal cavity ; 1 not involving the peritonaeum; 5, into the cellular tissue. Power to void urine, 3?2, into the peritoneal cavity; 1, not involving the peritonaeum. Power of locomotion, 7 ; all through the peritonaeum. Felt a sensation as of the bladder bursting, 7. Progress of Cases.?Severe symptoms continued in 48 : of which 39 ruptured into the peritoneal cavity; 7, into cellular tissue ; 2, peritonaeum not involved. Severe symptoms set in, 10?in 1 three hours after the accident ; 6, two days ; 2, four days; 1, threo days?all ruptured into peritonaeum except last. In 1, power to urinato continued, the rupture being into cavity
In 14, it came on : in 12 of these, on the second into the peritonaeum; 2, not involving peritonaeum; 1, into cellular tissue?in 1 on third day; in 1 on the fourth day. Locomotion continued, in 2?both rupture into peritonaeum. Bloody urine drawn in 25 ; clear, in 4. Symptoms were mild in 2?both ruptured into cellular tissue. of abdemen.
day?9 being
Result.?Died, 43 : within five days, 39?26 being ruptures into the peritonaeum ; 9, into the cellular tissue ; 3, not given. Between five and ten days, 22?17. into the peritoneal cavity; 3, into cellular tissue; 2, not involving peritonaeum. Between ten and fifteen days, 2?both into cellular tissue. Between fifteen and twenty days, 3?1 into the peritoneal cavity ; 2 into cellular tissue. Above twenty days, 2?both into cellular tissue; of which 1 lived forty-two days. Recovered, 5?3 into cellular tissue; 1, into peritoneal
cavity; 1, partial. Post-mortem Appearance of Viscera.?External marks of injury in 2?both ruptured into peritoneal cavity. No external marks of injury in 8?7 ruptured into cavity of peritonaeum ; 1 not involving peritonaeum. Fracture and injury of pelvis in 15?11 ruptured into cellular tissue; 3 into peritonaeum; 1 Marks of inflammation in abdomen in 34?27 being not given. into the peritoneal cavity ; 5 into the cellular tissue; 2 not involving the peritonaeum. No marks of inflammation in cavity of abdomen, 7?4 being ruptured into cellular tissue; 3 into cavity of abdomen. Post-mortem Appearances of Bladder.?Rupture into cavity of peritonaeum. 50?39, the result of direct violence; 6, concussion or indirect violence; 4 from parturition; 2, stricture; 1, retroversio uteri, llupture in the anterior wall of the bladder, 9?5 being from direct violence; 3, concussion; 1, stricture. Rupture at neck, 6?5 from direct violence; 1, not given; no bladder found, 2; bladder firmly contracted in 17. Contribution to the Statistics of Kuptnre of the Urinary niadder, Table of Seventy-eight cases. Jiy Stephen Smith, M.D., Assistant Surgeon to Kellevue Hospital. Reprinted from tho iVeio York Journal of Medicine, March, 1851. t One case being doubtful, ie rejected. *
with
A
a
The early symptoms of rupture of the bladder are similar to those of rupture of the urethra, i.e., a sensation of something giving way within, and a sudden relief from the extreme distension, are experienced, though no urine is voided in the natural way; but there is no swelling of the scrotum, and the sinking of the vital powers is more pronounced, and death may take place in consequence within a few hours ; although, as Dr. Smith says, the symptoms may be slight or even absent. Succeeding the collapse there is "intense pain in the hypogastric region, a great desire, but incapacity to expel urine, rapid and feeble pulse, hot skin, thirst." Later there may be symptoms of peritonitis, of pelvic cellulitis, or of both. It is not possible, at first, to ascertain whether the distended bladder has poured its contents into the peritoneal cavity, or among the meshes of the pelvic connective tissue. The degree of collapse may be an indication, but this should not be too much relied upon. If the rent be large, the urine suddenly and in great abundance gushes into the peritoneal cavity and produces fatal collapse; if there be but a small aperture, only a part of the retained urine is forced out, and that gradually too, as is sometimes the case in rupture at the anterior part or near the neck of the bladder. Treatment.?The therapeutic indications in vesical rupture are: first to prevent accumulation of urine in the bladder, and consequently further escape of the fluid into the surrounding areolar tissue, or into the peritoneal cavity; secondly, to remove the urine from the peritoneal cavity, or to provide for its escape from the meshes of the pelvic connective tissue; thirdly, to support the vital powers; fourthly, to relieve pain?by free doses of opium?and to control inflammation. In case of rupture into the peritoneal cavity, Dr. Blundell recommended " the making of an opening above the symphysis pubis so as to withdraw the urine, and the thorough ablution of the cavity and its contents by means of the free injection of distilled water at " ninety-eight degrees F." Then to close the laceration with a ligature and drawing up the bladder to the abdominal opening, etc." This operation has never been performed, and is as unpromising and unsurgical as paracentesis abdominis under the same circumstances. Dr. Harrison proposed the operation of paracentesis through the recto-vesical cul-de-sac, where the urine is apt to gravitate, but it does not appear that the method has ever been carried out. In a case of vesical rupture from injury, with extravasation into the pelvic connective tissue, Dr. "Walker of Boston has been successful in using the lateral operation, as for stone,* which he performed with the double object of favoring the escape of the. extravasated urine and of keeping the bladder empty.f Dr. Thorp mentions a case of rupture of the bladder by a fall from a horse, where he succeeded in passing a catheter through the laceration?after the instrument had traversed the whole length of the urethral canal?and drawing off the effused fluid and injecting warm water through the catheter to wash the peritoneal cavity. His patient recovered. The best manner, in my opinion, of dealing with a case of ruptured bladder from stricture is to divide the stricture, and, at the same time, to combine the methods of Dr. Walker and Dr. Thorp ; that is, to make an external perineal division of the stricture, entering the urethra laterally, and carrying the incision to the neck of the bladder as in lithotomy, and then introducing a catheter through the wound to explore the whole cavity of the viscus until the rent is found, when the point of the catheter is to be insinuated through it. If urine escapes freely and in abundance, the inference is that it comes from the peritoneal cavity ; otherwise it may be concluded that the extravasation has taken place in the pelvic areolar tissue. In either case the operation is not only justifiable, but, I think, offers better chances than any other plan proposed. Its advantages are, that it disposes of the stricture, provides for the thorough drainage of the bladder, forms an outlet for the extravasated fluid from the connective tissue and for the escape of matter, and is the best means of arriving at a correct diagnosis. It is certainly easier to find the rent with a catheter passed through a wound in the perinajum than with the same instrument introduced through the whole length of the urethra. In cases such as Ohas. D , (extravasation into cellular *
The New Yor/c Hiedical Journal for August, 1872, contains an interesting article, by Professor Erskine Mason, on rupture of the bladder from violence, with an illustrative case successfully treated according; to l)r Walker's plan. The operation was performed by Dr. Mason about forty hours after the injury, and the patient discharged from hospital well on the thirty-uinth day. f Observations on llupturo of the Urinary M.D. Dublin Quarterly, I8K8, page 300.
perfectly
Bladder, by Henry Thorp,
2S
THE INDIAN MEDICAL GAZETTE.
a supra-pubic incision below the peritoneal reflection will be needed as an additional outlet for pus and urine. There is nothing to be gained from puncture of the bladder; and if the stricture should be dilated or divulsed as in Chas. D the retention of a catheter for the purpose of drain, age does not seem to fulfil the indication, and there can be no better instance, to prove its injurious effect upon the urethra, bladder, and kidneys, than the case of Charles D
tissue)
.
[Januaby 1,
1873.
causes.
Sex.?Males, 67; females, 11; making about six of the former
to
one
of the latter.
Age.?Under ten, 3; ten to twenty, 3; twenty to thirty, 19; thirty to forty, 26; forty to fifty, 7; fifty to sixty, 4; above sixty, none; adults, 16, age not given. Condition.?Bladder distended, 30, of which 10 were intoxicated; 5 from stricture,! intoxicated; condition not given, 14; parturition, 4 ; in good health, 4 ; doubtful, 2 ; no note of 24. Causes.?Direct violence, 48; concussion, 15; internal causes, 9, of which 4 were parturition; 4, results of stricture; 1, retroversio uteri; no note of 6. Primary Symptoms.?Severe 59: of which 43 were ruptured into the peritoneal cavity; 2, not involving the peritonaeum; 10, into cellular tissue; 3, not given. Slight, 9 : of which 7 were into the peritoneal cavity; 1, indefinite; no note of 7. Inability to urinate, 28: of which 22 were into the peritoneal cavity ; 1 not involving the peritonaeum; 5, into the cellular tissue. Power to void urine, 3?2, into the peritoneal cavity; 1, not involving the peritonaeum. Power of locomotion, 7 ; all through the peritonaeum. Felt a sensation as of the bladder bursting, 7. Progress of Cases.?Severe symptoms continued in 48 : of which 39 ruptured into the peritoneal cavity; 7, into cellular tissue ; 2, peritonaeum not involved. Severe symptoms set in, 10?in 1 three hours after the accident ; 6, two days ; 2, four days; 1, threo days?all ruptured into peritonaeum except last. In 1, power to urinato continued, the rupture being into cavity
In 14, it came on : in 12 of these, on the second into the peritonaeum; 2, not involving peritonaeum; 1, into cellular tissue?in 1 on third day; in 1 on the fourth day. Locomotion continued, in 2?both rupture into peritonaeum. Bloody urine drawn in 25 ; clear, in 4. Symptoms were mild in 2?both ruptured into cellular tissue. of abdemen.
day?9 being
Result.?Died, 43 : within five days, 39?26 being ruptures into the peritonaeum ; 9, into the cellular tissue ; 3, not given. Between five and ten days, 22?17. into the peritoneal cavity; 3, into cellular tissue; 2, not involving peritonaeum. Between ten and fifteen days, 2?both into cellular tissue. Between fifteen and twenty days, 3?1 into the peritoneal cavity ; 2 into cellular tissue. Above twenty days, 2?both into cellular tissue; of which 1 lived forty-two days. Recovered, 5?3 into cellular tissue; 1, into peritoneal
cavity; 1, partial. Post-mortem Appearance of Viscera.?External marks of injury in 2?both ruptured into peritoneal cavity. No external marks of injury in 8?7 ruptured into cavity of peritonaeum ; 1 not involving peritonaeum. Fracture and injury of pelvis in 15?11 ruptured into cellular tissue; 3 into peritonaeum; 1 Marks of inflammation in abdomen in 34?27 being not given. into the peritoneal cavity ; 5 into the cellular tissue; 2 not involving the peritonaeum. No marks of inflammation in cavity of abdomen, 7?4 being ruptured into cellular tissue; 3 into cavity of abdomen. Post-mortem Appearances of Bladder.?Rupture into cavity of peritonaeum. 50?39, the result of direct violence; 6, concussion or indirect violence; 4 from parturition; 2, stricture; 1, retroversio uteri, llupture in the anterior wall of the bladder, 9?5 being from direct violence; 3, concussion; 1, stricture. Rupture at neck, 6?5 from direct violence; 1, not given; no bladder found, 2; bladder firmly contracted in 17. Contribution to the Statistics of Kuptnre of the Urinary niadder, Table of Seventy-eight cases. Jiy Stephen Smith, M.D., Assistant Surgeon to Kellevue Hospital. Reprinted from tho iVeio York Journal of Medicine, March, 1851. t One case being doubtful, ie rejected. *
with
A
a
The early symptoms of rupture of the bladder are similar to those of rupture of the urethra, i.e., a sensation of something giving way within, and a sudden relief from the extreme distension, are experienced, though no urine is voided in the natural way; but there is no swelling of the scrotum, and the sinking of the vital powers is more pronounced, and death may take place in consequence within a few hours ; although, as Dr. Smith says, the symptoms may be slight or even absent. Succeeding the collapse there is "intense pain in the hypogastric region, a great desire, but incapacity to expel urine, rapid and feeble pulse, hot skin, thirst." Later there may be symptoms of peritonitis, of pelvic cellulitis, or of both. It is not possible, at first, to ascertain whether the distended bladder has poured its contents into the peritoneal cavity, or among the meshes of the pelvic connective tissue. The degree of collapse may be an indication, but this should not be too much relied upon. If the rent be large, the urine suddenly and in great abundance gushes into the peritoneal cavity and produces fatal collapse; if there be but a small aperture, only a part of the retained urine is forced out, and that gradually too, as is sometimes the case in rupture at the anterior part or near the neck of the bladder. Treatment.?The therapeutic indications in vesical rupture are: first to prevent accumulation of urine in the bladder, and consequently further escape of the fluid into the surrounding areolar tissue, or into the peritoneal cavity; secondly, to remove the urine from the peritoneal cavity, or to provide for its escape from the meshes of the pelvic connective tissue; thirdly, to support the vital powers; fourthly, to relieve pain?by free doses of opium?and to control inflammation. In case of rupture into the peritoneal cavity, Dr. Blundell recommended " the making of an opening above the symphysis pubis so as to withdraw the urine, and the thorough ablution of the cavity and its contents by means of the free injection of distilled water at " ninety-eight degrees F." Then to close the laceration with a ligature and drawing up the bladder to the abdominal opening, etc." This operation has never been performed, and is as unpromising and unsurgical as paracentesis abdominis under the same circumstances. Dr. Harrison proposed the operation of paracentesis through the recto-vesical cul-de-sac, where the urine is apt to gravitate, but it does not appear that the method has ever been carried out. In a case of vesical rupture from injury, with extravasation into the pelvic connective tissue, Dr. "Walker of Boston has been successful in using the lateral operation, as for stone,* which he performed with the double object of favoring the escape of the. extravasated urine and of keeping the bladder empty.f Dr. Thorp mentions a case of rupture of the bladder by a fall from a horse, where he succeeded in passing a catheter through the laceration?after the instrument had traversed the whole length of the urethral canal?and drawing off the effused fluid and injecting warm water through the catheter to wash the peritoneal cavity. His patient recovered. The best manner, in my opinion, of dealing with a case of ruptured bladder from stricture is to divide the stricture, and, at the same time, to combine the methods of Dr. Walker and Dr. Thorp ; that is, to make an external perineal division of the stricture, entering the urethra laterally, and carrying the incision to the neck of the bladder as in lithotomy, and then introducing a catheter through the wound to explore the whole cavity of the viscus until the rent is found, when the point of the catheter is to be insinuated through it. If urine escapes freely and in abundance, the inference is that it comes from the peritoneal cavity ; otherwise it may be concluded that the extravasation has taken place in the pelvic areolar tissue. In either case the operation is not only justifiable, but, I think, offers better chances than any other plan proposed. Its advantages are, that it disposes of the stricture, provides for the thorough drainage of the bladder, forms an outlet for the extravasated fluid from the connective tissue and for the escape of matter, and is the best means of arriving at a correct diagnosis. It is certainly easier to find the rent with a catheter passed through a wound in the perinajum than with the same instrument introduced through the whole length of the urethra. In cases such as Ohas. D , (extravasation into cellular *
The New Yor/c Hiedical Journal for August, 1872, contains an interesting article, by Professor Erskine Mason, on rupture of the bladder from violence, with an illustrative case successfully treated according; to l)r Walker's plan. The operation was performed by Dr. Mason about forty hours after the injury, and the patient discharged from hospital well on the thirty-uinth day. f Observations on llupturo of the Urinary M.D. Dublin Quarterly, I8K8, page 300.
perfectly
Bladder, by Henry Thorp,
2S
THE INDIAN MEDICAL GAZETTE.
a supra-pubic incision below the peritoneal reflection will be needed as an additional outlet for pus and urine. There is nothing to be gained from puncture of the bladder; and if the stricture should be dilated or divulsed as in Chas. D the retention of a catheter for the purpose of drain, age does not seem to fulfil the indication, and there can be no better instance, to prove its injurious effect upon the urethra, bladder, and kidneys, than the case of Charles D
tissue)
.
[Januaby 1,
1873.
