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Spontaneous rupture of urinary bladder
SPONTANEOUS RUPTURE CLAUDE
F.
DIXON,
M.D.
OF URINARY AND
E.
STROHL,
M.D.
FeIIow in Surgery, The Mayo Foundation
Division of Surgery, The Mayo Clinic ROCHESTER,
c
LEE
BLADDER
MINNESOTA
in 1924, said that “spontaneous rupture is very rare and aImost never occurs, except where there is disease of the walIs of the bIadder.” In the onIy case which he had encountered the rupture was secondary to a huge carcinoma of the bIadder. By spontaneous rupture is meant that type which occurs without externa1 stimuIi, the exciting cause, regardless of the nature of the rupture being unquestionabIy interna1. Rupture of the bladder per se, secondary to penetrating wounds, was familiar to the ancients. Homer described the death of PherecIus as the result of a wound from a spear which passed from the buttock, through the perineum and into the bIadder. Spontaneous rupture of the bIadder, however, was not recognized unti1 some centuries Iater, Pierus reporting the first case in I 279. The next recorded case of spontaneous rupture was reported by Johnstone in 1773.~ Since that time several cases have been added.4-g In 193 I, StonelO found 40 cases reported in the Iiterature, to which he added 2. The factors which cause such a Iesion are manifold and the classification presented by stone is very compIete (Table I). Despite the many Iesions which may produce this pathologic condition, it is seen 0nIy 0ccasionalIy. l1 At the Cook County HospitaI, between 1889 and r8g3,‘2 onIy 5 instances of a11 types of rupture of the bIadder were seen among 8000 patients admitted to the surgica1 service; at the Rhode IsIand HospitaI, from 1868 to 1929, 2 instances of spontaneous rupture were found among 226,632 patients admitted to the medical and surgica1 services, and at the EpiscopaI HospitaI, of PhiIadeIphia,
from igo0 to 1905, 3 instances of intraperitoneal rupture were found among 8367 patients.
ROSBIE,l
TABLE STONE’S
CLASSIFICATION THE
I
OF SPONTANEOUS
RUPTURE
OF
BLADDER
A. Inffammatory Iesions of the waI1 of the bIadder I. Intramural origin 2. Extramural origin B. MaIignant disease of the waI1 of the bIadder r . IntervesicaI 2. IntravesicaI 3. ExtravesicaI C. Obstructive changes at the neck of the bIadder I. Prostatic enIargement (a) Benign (b) Malignant (c) Inflammatory (inchrding semina1 vesicuIitis) 2. CaIcuIi 3. ParaIytic 4. Uterine and adnexa1 disease in the fernate 5. Occurring during Iabor D. Obstructive lesions in the urethra r. Strictures 2. VaIves diverticuIa 3. Tumors 4. CaIcuIi 5. Peri-urethral inflammation 6. Peri-urethra1 tumors
Rupture of the bIadder, whether traumatic or spontaneous, is either intraperitonea1, extraperitoneal, or both, with obstructive changes at the neck of the bIadder being the commonest findings. IntraperitoneaI rupture occurs about twice as frequentIy as does extraperitoneal rupture, if the etioIogic factor is obstruction. However, if the pathoIogic change is primary in the vesica1 waI1, the extraperitoneal type predominates, in the ratio of about 2: I. The usua1 situation of intraperitonea1 rupture is the vauIt, in the midline.‘3 This is expected when one considers that this situation is probabIy the weakest point in the muscuIature, from an II0
NEW SERIES VOL. XxX111, No. I
Dixon & StrohI-Ruptured
embryonic standpoint, as well as being the farthest removed from the supporting peIvic tissues and framework. Intraperitoneal rupture usualIy extends directIy through a11 the coats of the waI1 of the bIadder and the tear in the peritoneum is adjacent to that in the bladder, but is not as Iarge as the tear in the waI1 of the bIadder. Frequently, the opening into the peritoneum is only a smaI1 fissure, and it was for this reason that A. T. Cabot,14 in I 8g I, advised that exploratory Iaparotomy should be performed, so that the presence of urine might be detected. The opening in the waI1 of the bladder usually is ragged, and only rarely wiI1 microscopic examination reveal any pathoIogic changes in the tissue. The symptoms which are produced depend primarily on whether the lesion is intra- or extraperitoneal. In either type, the history is of unlimited value. The extraperitoneal rupture produces pain and sweIling above the pubis; the swelling soon becomes puruIent. SmaII amounts of urine are passed, which, on gross or microscopic examination, are found to contain blood. Shock and its sequeIa appear rather late. According to Pedersen,r5 a bIuish discoloration and tenderness about the umbilicus are symptoms of extraperitonea1 rupture. ExtraperitoneaI rupture which occurs Iate may be converted into intraperitonea1 rupture by perforation, secondary to changes caused by the urine or pus acting on the outer surface of the perforation. The intraperitonea1 rupture is far more grave than is extraperitoneal rupture, and earIy diagnosis is more urgent and difficult in the intraperitonea1 than it is in the extraperitonea1 type. UsualIy the first evidences of rupture are sharp abdomina1 pain and some shock, which may last onIy a short time; the patient feeIs better after the symptoms disappear, and, as a result, does not cons& a physician for some hours. Urgency of micturition follows in most instances; onIy a few drops or no urine are voided. At first, the abdomen is very rigid or ligneous; Iater, the tenderness becomes
BIadder
American
~~~~~~~ of
surgery I I
I
IocaIized, particuIarIy in the upper portion of the abdomen. The presence of fluid is evidenced by a shifting duIness in the Aank. The most important eIement in estabIishing the diagnosis is the history, carefuIly taken, which coupIed with a thorough physical examination usuaIIy serves to establish a diagnosis. The advisabiIity of checking a known quantity of solution injected into the bladder with the amount returned, is no Ionger considered the diagnostic method of choice. Martin’6 advised the use of a cystogram for detecting rupture of the bladder, while Herbst17 advocated cystoscopy, maintaining that evidence of the rupture and its Iocation wiI1 be obtained by the injection of ffuid, as the opening into the peritonea1 cavity occasionaIIy is suffrcientIy large to permit a11 of the fluid which has been introduced to return through the catheter. Once the diagnosis has been established, a surgicaI procedure must be done for either the intraperitonea1 or extraperitoneal rupture.ls*? Cystostomy is a11 that is required in a case of earIy extraperitoneal rupture. In cases in which the rupture has been present for some time, and in which urinary extravasation has occurred, multipIe incisions are necessary. In the intraperitonea1 type, a thorough inspection should be made of the abdominal cavity, and it, as we11 as the bladder, shouId be drained. It seems to be the opinion that the tear in the bladder need not be sewed, as Iong as adequate drainage is afforded to the bladder. This was first mentioned by A. T. Cabot, in 1891, and Iater, by Thomas2n and by Crosbie.’ If doubt exists as to whether the rupture is intraperitonea1 or extraperitoneal, an expIoratory Iaparotomy is aIways advisabIe.21 NicoIaysen22 has reported a case in which cure was obtained by means of drainage with the catheter alone. REPORT
OF
CASE
A man of Jewish descent, aged forty-seven years, came to the cIinic August 26, 1935, because of a postnasa1 dripping and fatigue
I I2
American Journal of Surgery
Dixon & StrohI-Ruptured
which had followed a nervous breakdown in the spring of 1935. In the course of his iIIness he had been very irritabIe, despondent, and forgetfu1. PhysicaI examination at that time had not reveaIed any abnormaIity. PhysicaI examination at the cIinic did not reveal any abnormaIity except a smaI1, indirect inguina1 hernia on the Ieft side, which had been present for three or four years. Loss of weight had not occurred; the patient weighed 140 pounds (63.5 kg.). The vaIue for the bIood pressure, expressed in miIIimeters of mercury, was IOO systoIic and 70 diastoIic. Examination of the ocuIar fundi did not revea1 any abnormaIity. On neuroIogic examination, the Ieft pupi reacted sIuggishIy to Iight, and the speech was sIurred somewhat to aIIiteration. The deep refIexes, particuIarIy the knee jerks, were hyperactive, grade 2. The patient was argumentative, a poor caIcuIator and had a poor insight. The specific gravity of the urine was 1.030; the urine contained aIbumin, grade 2+ ; erythrocytes, grade I+, and a few Ieukocytes. The vaIue for the hemogIobin was 15.4 gm. per IOO C.C. of blood, the erythrocytes numbered 4,g6o,ooo and the Ieukocytes, 10,500. A differentiaI count reveaIed 20 per cent Iymphocytes, 12 per cent monocytes, 67 per cent neutrophiIs and I per cent eosinophiIs. Examination of the serum discIosed that the KIine test was positive, grade I + ; the Kahn test was positive, and the Hinton and KoImer tests were negative. On examination of the spina fluid, the KIine test was positive, grade A+; the Nonne-ApeIt reaction was positive, and the Wassermann reaction was strongIy positive. There were 51 ceIIs per cmm. of spina Auid, and the coIIoida1 benzoin curve was 133 333 333 322 ooo. The guaiac and benzidine tests reveaIed the presence of occuIt bIood in the feces. RoentgenoIogic examination of the thorax discIosed that the pIeura was sIightIy thickened at the Ieft apex. A diagnosis of syphiIis of the centra1 nervous system was made and maIaria1 treatment was instituted August 18, 1935. The temperature rose to 105.4’~. (40.7’c.) on that day and again on August 20 and 21. Administration of quinine was commenced August 21 and was continued for forty-eight hours. The patient feIt we11 and was up and about in the hospital from August 22 to August 26.
BIadder
JULY, 1936
At 5:oo A.M. on August 26, 1935, the patient was awakened from a sound sleep by severe pain in the upper portion of the abdomen. He was slightly nauseated but did not vomit. The temperature was 97.8%. (36.5”c.), the puIse rate was 94 beats per minute, and the vaIue for the bIood pressure, expressed in miIIimeters of mercury, was IOO systoIic and 70 diastolic. There was increased resistance over the entire abdomen, but it was more marked over the upper portion with evidence of fluid obtained by a shifting duIness to percussion. The nature of his condition was problematic, and it was thought best to study his progress for the foIIowing two hours. A catheterized specimen of urine reveaIed the specific gravity to be I .OIO; aIbumin, grade 2+, erythrocytes, grade 2+, and 8 Ieukocytes per high power field. The erythyroctes numbered 3,880,000, and the Ieukocytes numbered 12,800 and the vaIue for the hemogIobin was 14.9 gm. per IOO C.C. of bIood. During the four hours immediateIy after the onset of symptoms, shock had occurred. The abdomen became much more rigid and boardIike than it had been. It was thought that perforation of a viscus had occurred, and expIoratory operation was performed. SpinaI anesthesia was given and the abdomen was opened through an upper right rectus incision. When the peritoneum was opened, a large amount of straw-coIored Auid was found in the abdomina1 cavity. A tear, about 2 inches (5 cm.) in circumference, was found on the posterior-superior surface of the bIadder. The peritonea1 opening was about the same size as, and adjacent to, that in the bIadder. The opening in the bIadder was cIosed with sutures of No. 2 chromic catgut. The bladder was drained extraperitoneaIIy by means of a split tube which was inserted into the space of Retzius. A Penrose drain was pIaced in the peIvis to drain the abdomen, and a Pezzer catheter was inserted into the bIadder. ConvaIescence was uneventfu1 unti1 the eIeventh day, at which time the upper angIe of the incision spread suffIcientIy to aIIow a knuckIe of bowe1 to escape between the siIkworm gut sutures. A secondary cIosure was made by using through and through silkworm sutures. The subsequent course was entireIy uneventfu1 and the patient was dismissed from the hospita1 on the twenty-eighth day foIIowing the second operation. At that time, he was abIe to empty the bIadder compIeteIy. During
NEW SERIESVOL. XxX111, No.
I
Dixon
& StrohI--Ruptured
convaIescence, 0.4 gm. of neoarsphenamine administered once a week.
was
In a letter received three weeks Iater, the patient stated that he apparentIy was in spIendid health. SUMMARY
A case of a ruptured urinary bIadder is reported because of the rarity of the pathologic condition. It aIso emphasizes the importance of surgica1 interference in acute abdomina1 disorders when certain signs, such as acute pain and generahzed rigidity are present. The character of the fluid in the abdomina1 cavity, aIthough it is no different in appearance than that frequently found in cases in which ascites occurs as a resuIt of a variety of causes, suggested the possibihty of urine from a ruptured bladder. The cause of rupture of the bIadder in this case is not known. The patient said that he had voided 3 or 4 ounces (go to
BIadder
American~~~~~~~ or surgery
I I3
120 c.c.) of urine soon after the onset of the acute pain in the upper part of the abdomen, and that he had voided before retiring, eight or nine hours previously. The urine obtained by passage of a catheter three or four hours before operation evidently came from the abdomina1 cavity. The edges of the opening in the bladder were ragged and appeared necrotic. They were trimmed unti1 healthy appearing tissue was reached. Unfortunately, the excised portion of the vesica1 waIi was not preserved for microscopic study. Syphilitic ulcerations do have a tendency to occur in the midIine, for instance, uIcerations in the midIine of the anterior thoracic wall and sternum are seen occasionaIIy. In such instances, syphiIis is always to be ruIed out as a possible etioIogic factor. In this case, the rupture was in the midline, and obstruction of the neck of the bladder was not a factor, as it previously has been reported to be in some of the cases.23
REFERENCES I.
2.
3. 4. 5.
6.
7.
8.
9.
IO. II.
12.
CROSBIE, A. H. Rupture of the urinary bladder. Jour. urol., 12: 431-443 (tit.) 1924. PIERUS. Quoted by Stone. JOHNSTONE,J. Rupture of the bladder. Mem. Med. Sot. London, 3: 543-546, 1772. BROWN, W. H. A case of spontaneous rupture of the bIadder. Lancet, 2: 612-613 (Sept. 12) 1891. FRASER, LACHLAN. Case of idiopathic intraperitonea rupture of the bladder. &it. Med. Jour., I : 921 (ApriI 21) 1906. KING, T. W. Impervious urethra; accumuIated urinary secretion; diIated ureter; bursting of the distended bIadder; peritonitis and ascites at the fourth month of foeta1 Jife. Guy’s Hosp. Rep., 2: 508-513, 1837. SISK, I. R. and WEAR, J. B. Spontaneous rupture of the urinary bIadder. Jour. urol., 21: 517-522 (ApriI) I 929. WHITE, SINCLAIR and WIGRAM, N. J. Rupture of the urinary bIadder. &it. Jour. Surg., 4’ 324-325 (Oct.) 1916. WOOLSEY, GEORGE. Rupture of the bladder with report of three unusua1 cases. Ann. Surg., 58: 244-251, 1913. STONE, ERIC. Spontaneous rupture of the urinary bladder. Arch. Surg., 23: 129-144 (July) 1931. RIVINGTON, WALTER. Rupture of the urinary bIadder (Hunterian Iecture). Lancet, I : 903-905 (June 3); 944-946 (June IO); 982-983 [June 17); 1024-1026 (June 26) 1882. BESL&, F. A: Rupture of the urinary bIadder. A report and analysis of 23 cases from the records
I 3. 14.
15. 16.
I 7. 18. 19. 20. 21. 22.
23.
of the Cook County HospitaI, with an experimenta1 study of the mechanism of blidder rupture. Surg., Gynec. and Obst., 4: 514-53: (ApriI) I 907. CHANG-KEN, CHI. Bladder, rupture, spontaneous, case. Cbinese Med. Jour., 46: 69-75 (Jan.) 1932. CABOT, A. T. A contribution to the treatment of rupture of the bladder. Boston Med. and Surg. Jour., 125: 396-400 (Oct. 15) 1891. PEDERSEN, J. Rupture of the bIadder. Tr. Am. Ural. Assn., 8: 266-270, 1913. MARTIN, H. W. Ruptuked bIadder, a method of diagnosis. Calijornia and West. Med., 36: 230-232 (April) 1932. HERBST, R. H. Discussion, Jour. Ural., I 2: 44~441 (Oct.) 1924. YOUNG, HUGH. Rupture of the Bladder. Practice Of UrOIOgy, 2: 146-152, 1926. CABOT, HUGH. Persona1 communication to the authors. THOMAS, T. T. Intraperitoneal rupture of the bIadder. Ann. Surg., 76: 64-69 (July) 1922. NEGLEY, J. C. Rupture of the bIadder. Jour. Ural., 18: 307-314 (Sept.) 1927. NICOLAYSEN, N. A. Spontaneous rupture of bIadder; heaIing without operation. Acta c&r. Scandin., 54: 507-513 (April) 1922; A&r. In: J. A. M. A., 79: 338 (JuIy 22) 1922. GEISINGER, J. F. Spontaneous intraperitoneaI rupture of the bIadder. Ann. Surg., 77: 206-209 (Feb.) 1923.
F.
DIXON,
M.D.
OF URINARY AND
E.
STROHL,
M.D.
FeIIow in Surgery, The Mayo Foundation
Division of Surgery, The Mayo Clinic ROCHESTER,
c
LEE
BLADDER
MINNESOTA
in 1924, said that “spontaneous rupture is very rare and aImost never occurs, except where there is disease of the walIs of the bIadder.” In the onIy case which he had encountered the rupture was secondary to a huge carcinoma of the bIadder. By spontaneous rupture is meant that type which occurs without externa1 stimuIi, the exciting cause, regardless of the nature of the rupture being unquestionabIy interna1. Rupture of the bladder per se, secondary to penetrating wounds, was familiar to the ancients. Homer described the death of PherecIus as the result of a wound from a spear which passed from the buttock, through the perineum and into the bIadder. Spontaneous rupture of the bIadder, however, was not recognized unti1 some centuries Iater, Pierus reporting the first case in I 279. The next recorded case of spontaneous rupture was reported by Johnstone in 1773.~ Since that time several cases have been added.4-g In 193 I, StonelO found 40 cases reported in the Iiterature, to which he added 2. The factors which cause such a Iesion are manifold and the classification presented by stone is very compIete (Table I). Despite the many Iesions which may produce this pathologic condition, it is seen 0nIy 0ccasionalIy. l1 At the Cook County HospitaI, between 1889 and r8g3,‘2 onIy 5 instances of a11 types of rupture of the bIadder were seen among 8000 patients admitted to the surgica1 service; at the Rhode IsIand HospitaI, from 1868 to 1929, 2 instances of spontaneous rupture were found among 226,632 patients admitted to the medical and surgica1 services, and at the EpiscopaI HospitaI, of PhiIadeIphia,
from igo0 to 1905, 3 instances of intraperitoneal rupture were found among 8367 patients.
ROSBIE,l
TABLE STONE’S
CLASSIFICATION THE
I
OF SPONTANEOUS
RUPTURE
OF
BLADDER
A. Inffammatory Iesions of the waI1 of the bIadder I. Intramural origin 2. Extramural origin B. MaIignant disease of the waI1 of the bIadder r . IntervesicaI 2. IntravesicaI 3. ExtravesicaI C. Obstructive changes at the neck of the bIadder I. Prostatic enIargement (a) Benign (b) Malignant (c) Inflammatory (inchrding semina1 vesicuIitis) 2. CaIcuIi 3. ParaIytic 4. Uterine and adnexa1 disease in the fernate 5. Occurring during Iabor D. Obstructive lesions in the urethra r. Strictures 2. VaIves diverticuIa 3. Tumors 4. CaIcuIi 5. Peri-urethral inflammation 6. Peri-urethra1 tumors
Rupture of the bIadder, whether traumatic or spontaneous, is either intraperitonea1, extraperitoneal, or both, with obstructive changes at the neck of the bIadder being the commonest findings. IntraperitoneaI rupture occurs about twice as frequentIy as does extraperitoneal rupture, if the etioIogic factor is obstruction. However, if the pathoIogic change is primary in the vesica1 waI1, the extraperitoneal type predominates, in the ratio of about 2: I. The usua1 situation of intraperitonea1 rupture is the vauIt, in the midline.‘3 This is expected when one considers that this situation is probabIy the weakest point in the muscuIature, from an II0
NEW SERIES VOL. XxX111, No. I
Dixon & StrohI-Ruptured
embryonic standpoint, as well as being the farthest removed from the supporting peIvic tissues and framework. Intraperitoneal rupture usualIy extends directIy through a11 the coats of the waI1 of the bIadder and the tear in the peritoneum is adjacent to that in the bladder, but is not as Iarge as the tear in the waI1 of the bIadder. Frequently, the opening into the peritoneum is only a smaI1 fissure, and it was for this reason that A. T. Cabot,14 in I 8g I, advised that exploratory Iaparotomy should be performed, so that the presence of urine might be detected. The opening in the waI1 of the bladder usually is ragged, and only rarely wiI1 microscopic examination reveal any pathoIogic changes in the tissue. The symptoms which are produced depend primarily on whether the lesion is intra- or extraperitoneal. In either type, the history is of unlimited value. The extraperitoneal rupture produces pain and sweIling above the pubis; the swelling soon becomes puruIent. SmaII amounts of urine are passed, which, on gross or microscopic examination, are found to contain blood. Shock and its sequeIa appear rather late. According to Pedersen,r5 a bIuish discoloration and tenderness about the umbilicus are symptoms of extraperitonea1 rupture. ExtraperitoneaI rupture which occurs Iate may be converted into intraperitonea1 rupture by perforation, secondary to changes caused by the urine or pus acting on the outer surface of the perforation. The intraperitonea1 rupture is far more grave than is extraperitoneal rupture, and earIy diagnosis is more urgent and difficult in the intraperitonea1 than it is in the extraperitonea1 type. UsualIy the first evidences of rupture are sharp abdomina1 pain and some shock, which may last onIy a short time; the patient feeIs better after the symptoms disappear, and, as a result, does not cons& a physician for some hours. Urgency of micturition follows in most instances; onIy a few drops or no urine are voided. At first, the abdomen is very rigid or ligneous; Iater, the tenderness becomes
BIadder
American
~~~~~~~ of
surgery I I
I
IocaIized, particuIarIy in the upper portion of the abdomen. The presence of fluid is evidenced by a shifting duIness in the Aank. The most important eIement in estabIishing the diagnosis is the history, carefuIly taken, which coupIed with a thorough physical examination usuaIIy serves to establish a diagnosis. The advisabiIity of checking a known quantity of solution injected into the bladder with the amount returned, is no Ionger considered the diagnostic method of choice. Martin’6 advised the use of a cystogram for detecting rupture of the bladder, while Herbst17 advocated cystoscopy, maintaining that evidence of the rupture and its Iocation wiI1 be obtained by the injection of ffuid, as the opening into the peritonea1 cavity occasionaIIy is suffrcientIy large to permit a11 of the fluid which has been introduced to return through the catheter. Once the diagnosis has been established, a surgicaI procedure must be done for either the intraperitonea1 or extraperitoneal rupture.ls*? Cystostomy is a11 that is required in a case of earIy extraperitoneal rupture. In cases in which the rupture has been present for some time, and in which urinary extravasation has occurred, multipIe incisions are necessary. In the intraperitonea1 type, a thorough inspection should be made of the abdominal cavity, and it, as we11 as the bladder, shouId be drained. It seems to be the opinion that the tear in the bladder need not be sewed, as Iong as adequate drainage is afforded to the bladder. This was first mentioned by A. T. Cabot, in 1891, and Iater, by Thomas2n and by Crosbie.’ If doubt exists as to whether the rupture is intraperitonea1 or extraperitoneal, an expIoratory Iaparotomy is aIways advisabIe.21 NicoIaysen22 has reported a case in which cure was obtained by means of drainage with the catheter alone. REPORT
OF
CASE
A man of Jewish descent, aged forty-seven years, came to the cIinic August 26, 1935, because of a postnasa1 dripping and fatigue
I I2
American Journal of Surgery
Dixon & StrohI-Ruptured
which had followed a nervous breakdown in the spring of 1935. In the course of his iIIness he had been very irritabIe, despondent, and forgetfu1. PhysicaI examination at that time had not reveaIed any abnormaIity. PhysicaI examination at the cIinic did not reveal any abnormaIity except a smaI1, indirect inguina1 hernia on the Ieft side, which had been present for three or four years. Loss of weight had not occurred; the patient weighed 140 pounds (63.5 kg.). The vaIue for the bIood pressure, expressed in miIIimeters of mercury, was IOO systoIic and 70 diastoIic. Examination of the ocuIar fundi did not revea1 any abnormaIity. On neuroIogic examination, the Ieft pupi reacted sIuggishIy to Iight, and the speech was sIurred somewhat to aIIiteration. The deep refIexes, particuIarIy the knee jerks, were hyperactive, grade 2. The patient was argumentative, a poor caIcuIator and had a poor insight. The specific gravity of the urine was 1.030; the urine contained aIbumin, grade 2+ ; erythrocytes, grade I+, and a few Ieukocytes. The vaIue for the hemogIobin was 15.4 gm. per IOO C.C. of blood, the erythrocytes numbered 4,g6o,ooo and the Ieukocytes, 10,500. A differentiaI count reveaIed 20 per cent Iymphocytes, 12 per cent monocytes, 67 per cent neutrophiIs and I per cent eosinophiIs. Examination of the serum discIosed that the KIine test was positive, grade I + ; the Kahn test was positive, and the Hinton and KoImer tests were negative. On examination of the spina fluid, the KIine test was positive, grade A+; the Nonne-ApeIt reaction was positive, and the Wassermann reaction was strongIy positive. There were 51 ceIIs per cmm. of spina Auid, and the coIIoida1 benzoin curve was 133 333 333 322 ooo. The guaiac and benzidine tests reveaIed the presence of occuIt bIood in the feces. RoentgenoIogic examination of the thorax discIosed that the pIeura was sIightIy thickened at the Ieft apex. A diagnosis of syphiIis of the centra1 nervous system was made and maIaria1 treatment was instituted August 18, 1935. The temperature rose to 105.4’~. (40.7’c.) on that day and again on August 20 and 21. Administration of quinine was commenced August 21 and was continued for forty-eight hours. The patient feIt we11 and was up and about in the hospital from August 22 to August 26.
BIadder
JULY, 1936
At 5:oo A.M. on August 26, 1935, the patient was awakened from a sound sleep by severe pain in the upper portion of the abdomen. He was slightly nauseated but did not vomit. The temperature was 97.8%. (36.5”c.), the puIse rate was 94 beats per minute, and the vaIue for the bIood pressure, expressed in miIIimeters of mercury, was IOO systoIic and 70 diastolic. There was increased resistance over the entire abdomen, but it was more marked over the upper portion with evidence of fluid obtained by a shifting duIness to percussion. The nature of his condition was problematic, and it was thought best to study his progress for the foIIowing two hours. A catheterized specimen of urine reveaIed the specific gravity to be I .OIO; aIbumin, grade 2+, erythrocytes, grade 2+, and 8 Ieukocytes per high power field. The erythyroctes numbered 3,880,000, and the Ieukocytes numbered 12,800 and the vaIue for the hemogIobin was 14.9 gm. per IOO C.C. of bIood. During the four hours immediateIy after the onset of symptoms, shock had occurred. The abdomen became much more rigid and boardIike than it had been. It was thought that perforation of a viscus had occurred, and expIoratory operation was performed. SpinaI anesthesia was given and the abdomen was opened through an upper right rectus incision. When the peritoneum was opened, a large amount of straw-coIored Auid was found in the abdomina1 cavity. A tear, about 2 inches (5 cm.) in circumference, was found on the posterior-superior surface of the bIadder. The peritonea1 opening was about the same size as, and adjacent to, that in the bIadder. The opening in the bIadder was cIosed with sutures of No. 2 chromic catgut. The bladder was drained extraperitoneaIIy by means of a split tube which was inserted into the space of Retzius. A Penrose drain was pIaced in the peIvis to drain the abdomen, and a Pezzer catheter was inserted into the bIadder. ConvaIescence was uneventfu1 unti1 the eIeventh day, at which time the upper angIe of the incision spread suffIcientIy to aIIow a knuckIe of bowe1 to escape between the siIkworm gut sutures. A secondary cIosure was made by using through and through silkworm sutures. The subsequent course was entireIy uneventfu1 and the patient was dismissed from the hospita1 on the twenty-eighth day foIIowing the second operation. At that time, he was abIe to empty the bIadder compIeteIy. During
NEW SERIESVOL. XxX111, No.
I
Dixon
& StrohI--Ruptured
convaIescence, 0.4 gm. of neoarsphenamine administered once a week.
was
In a letter received three weeks Iater, the patient stated that he apparentIy was in spIendid health. SUMMARY
A case of a ruptured urinary bIadder is reported because of the rarity of the pathologic condition. It aIso emphasizes the importance of surgica1 interference in acute abdomina1 disorders when certain signs, such as acute pain and generahzed rigidity are present. The character of the fluid in the abdomina1 cavity, aIthough it is no different in appearance than that frequently found in cases in which ascites occurs as a resuIt of a variety of causes, suggested the possibihty of urine from a ruptured bladder. The cause of rupture of the bIadder in this case is not known. The patient said that he had voided 3 or 4 ounces (go to
BIadder
American~~~~~~~ or surgery
I I3
120 c.c.) of urine soon after the onset of the acute pain in the upper part of the abdomen, and that he had voided before retiring, eight or nine hours previously. The urine obtained by passage of a catheter three or four hours before operation evidently came from the abdomina1 cavity. The edges of the opening in the bladder were ragged and appeared necrotic. They were trimmed unti1 healthy appearing tissue was reached. Unfortunately, the excised portion of the vesica1 waIi was not preserved for microscopic study. Syphilitic ulcerations do have a tendency to occur in the midIine, for instance, uIcerations in the midIine of the anterior thoracic wall and sternum are seen occasionaIIy. In such instances, syphiIis is always to be ruIed out as a possible etioIogic factor. In this case, the rupture was in the midline, and obstruction of the neck of the bladder was not a factor, as it previously has been reported to be in some of the cases.23
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of the Cook County HospitaI, with an experimenta1 study of the mechanism of blidder rupture. Surg., Gynec. and Obst., 4: 514-53: (ApriI) I 907. CHANG-KEN, CHI. Bladder, rupture, spontaneous, case. Cbinese Med. Jour., 46: 69-75 (Jan.) 1932. CABOT, A. T. A contribution to the treatment of rupture of the bladder. Boston Med. and Surg. Jour., 125: 396-400 (Oct. 15) 1891. PEDERSEN, J. Rupture of the bIadder. Tr. Am. Ural. Assn., 8: 266-270, 1913. MARTIN, H. W. Ruptuked bIadder, a method of diagnosis. Calijornia and West. Med., 36: 230-232 (April) 1932. HERBST, R. H. Discussion, Jour. Ural., I 2: 44~441 (Oct.) 1924. YOUNG, HUGH. Rupture of the Bladder. Practice Of UrOIOgy, 2: 146-152, 1926. CABOT, HUGH. Persona1 communication to the authors. THOMAS, T. T. Intraperitoneal rupture of the bIadder. Ann. Surg., 76: 64-69 (July) 1922. NEGLEY, J. C. Rupture of the bIadder. Jour. Ural., 18: 307-314 (Sept.) 1927. NICOLAYSEN, N. A. Spontaneous rupture of bIadder; heaIing without operation. Acta c&r. Scandin., 54: 507-513 (April) 1922; A&r. In: J. A. M. A., 79: 338 (JuIy 22) 1922. GEISINGER, J. F. Spontaneous intraperitoneaI rupture of the bIadder. Ann. Surg., 77: 206-209 (Feb.) 1923.