CASE.—In a case of extra-peritoneal rupture of the bladder, which was inflicted by a man falling, while wrestling, and striking his pros trate opponent with his knee just above the pubes, there was the sen sation of contraction experienceed in introducing a metal catheter, but this was due to the catheter having made its way through the rent in the anterior wall of the bladder immediately above the pros tate, which was also involved in the injury. A post-mortem examina tion showed that the instrument had passed through the rupture and had entered the _porta vesicce of Retzius. Death was caused by cellu litis, due to deep urinary extravasation. Had a drainage-tube been carried through the rent from a suprapubic incision into the Aorta vesicce and out by a perineal opening, I believe the man's life might have been saved, as the case really resolved itself into one of urine drainage.
If the catheter does not indicate with clearness that the cavity of the peritoneum is opened, the distention test should be tried, as de scribed by Dr. R. F. Weir,' who, after stating the injuries and the symptoms of a case, remarks : " Only two procedures seemed avail able, therefore, viz., digital exploration by a perineal incision, or by opening into the abdominal cavity. Rather than resort to either of these I thought of using the test of distention of the bladder as em ployed in the supra-pubic opening for calculus, tumors, etc. Ac cordingly, two hours later, the abdominal tenderness having in creased, the patient was etherized, and a rubber catheter first inserted into the bladder, and then Peterson's rubber bag passed into the rec tum and distended with seven and a half ounces of warm water. After this had been done, and the line of supra-pubic flatness, now slightly augmented, outlined by a colored pencil, seven and a half ounces of carbolic acid solution-1 to 100 —were slowly introduced into the bladder. When six ounces had been passed in, the contour of the bladder could be felt above the line of blood extravasation, and the additional quantity of fluid served only to make this more posi tive, especially so on the lateral aspect of the distended viscus. The injected fluid was then allowed to flow from the bladder and meas ured, and found to correspond with the quantity forced in. The de monstration was perfect, not only as to the impossibility of an intra peritoneal, but also, from the non-increase in the line of dulness over the pubes, as to an extra-peritoneal laceration. The rectal bag was thereupon emptied and withdrawn, and the patient saved from any surgical interference of a more heroic character." The diagnosis of intra-peritoneal rupture having been made, lap arotomy should be undertaken. In connection with this proceeding we are indebted to Sir William MacCormac for the first successful records of closure of the ruptured bladder by suture. Without going into the details of the two cases he has published, stress may be laid on some points which are of importance. It does not appear to have been necessary to pare the edges of the wound in the bladder, though great pains were taken, by careful approximation of the sutures, to make the bladder water-tight, and thus to prevent leakage. Car bolized silk sutures were used, and they were introduced as shown in Fig. 33. In reference to the use of a catheter, as well as of drainage of the abdomen, Sir Wil liam remarks "If the rent be sutured effective ly, the patient runs less risk from moderate tention of the bladder, which is all that can pos sibly occur in a case erly watched, than he does from the quences of retaining a ca theter for some days within the viscus. The experience of my two cases goes far to prove that the catheter may in many instances be safely dispensed with er. I am sure, too, an ab dominal drainage-tube is not in most cases ful, and that its presence proves a source of danger to the patient." Though there can be no doubt that laparotomy and suture of the ruptured bladder is the safest course to be pursued in cases of this nature, the question may be raised as to whether, under any other circumstances, repair has been known to take place. In reference to this point, the following case, recorded by Mr. Henry Morris,' is of interest :
CASE.—The patient was received at the Middlesex Hospital in 1879, and treated for a rupture of the bladder consequent upon vio lence. The treatment consisted of fomentations, opium, and the re tention, just within the neck of the bladder, of a gum-elastic catheter. He recovered perfectly. In 1886 he was again admitted into the Mid dlesex Hospital, and died shortly afterward of rupture of the blad der. The parts removed were submitted to a committee who reported "the specimen exhibits all the features which might be expected at a remote period after rupture of the bladder." Mr. Morris remarks : "This case was reported in 1879 as one of recovery from rupture of the bladder. It is now brought before the Society because in its com pleted form it affords conclusive proof that an intra-peritoneal rupture of the bladder is not necessarily fatal, but may be recovered from under the simple treatment employed in this case, provided the urine at the time of the rupture is of normal composition." Such an inference as Mr. Morris's case suggests is warrantable from other circumstances observed in connection with certain appear ances presented after death in some instances of intra-peritoneal rup ture of the bladder, in conjunction with clinical experience relative to the drainage of urine from within the area of the pelvis. The con traction of the bladder after it has been ruptured and its contents ex pelled into the peritoneal cavity, as noted particularly by Mr. Riving ton in his excellent treatise on this subject, is so great as to render it highly probable that if a free and involuntary exit for the urine were provided within a reasonable period after the receipt of this in jury, nature would be able to effect the rest and bring about recovery without the adoption of other means. So far as my experience goes in connection with the various ways of opening the bladder, in all of which I may say I have had some experience, the only one that can be trusted for such a purpose is the incision made for lateral lithotomy, as combining in the one method free, involuntary, and dependent escape of the urine as it emerges from the ureters. On several occasions I have had to put my finger into the bladder, through the wound, within a few days after a lateral lithotomy has been performed, and I have been struck with the firm contraction of the viscus with which this procedure was invariably met. The following case' seems to support this, and shows, where circumstances were propitious, how nearly the imperfect drainage afforded by catheterism was successful: CASE. —At the time of the accident, which was caused by the pa tient's adversary falling upon him during a pugilistic encounter, a sen sation of something having given way was experienced. He walked home, a distance of two miles, when he was seen by his medical atten dant, who drew off twenty ounces of bloody urine, and continued to do so twice a day for three days, until he was admitted into the Lei cester Infirmary under the care of Mr. Crossley. On his admission, November 20th, 1872, he presented the following signs : He was able to walk without assistance; countenance rather anxious; pulse 80, full; skin cold; complained of a sensation of weight in the hypogas tric region, but no tenderness on pressure. On percussion over the abdomen an increased area of dulness was detected, and on palpation a distinct sensation of fluctuation. A silver catheter was introduced, and thirty ounces of clear urine drawn off, the abdominal dulness and fluctuation entirely disappearing. A gum-elastic catheter was subse quently passed night and morning. The patient continued in much the same state up to the evening of December 1st, when, without any premonitory symptoms, he was seized with a severe attack of convul sions, rapidly followed by coma. Every effort was made to rouse him; a catheter was immediately introduced, and about twenty ounces of urine drawn off, consciousness returning in about an hour. On the following day he was again attacked in a similar way, and on December 3d he was seized with a more violent form of convulsions, and sank in three hours in a comatose state.