Expansion of Bladder over 
Abdominal Tumors, complicating 
Laparotomy 
BY 
T. GAILLARD THOMAS, M. D. 
NEW YORK 
<®gnecolofltcal Crantfartfantf 
REPRINT FROM VOLUME VI. 
188 a EXPANSION OF THE BLADDER OVER THE SUR- 
FACE OF ABDOMINAL TUMORS AND ITS 
ATTACHMENT TO THEM OR TO THE AB- 
DOMINAL WALLS AS A COMPLICATION OF 
LAPAROTOMY. 
BY T. GAILLARD THOMAS, M. D. 
New York. 
In the whole field of surgery, general as well as special, 
there is no operation which, during the last thirty years, 
has attracted more attention, the various steps of which 
have been more carefully considered, and the complications 
attending which have been more thoroughly investigated, 
than ovariotomy. Not only has a very large experience 
been accumulated concerning it, but the results of this have 
been disseminated in all parts of the civilized world with a 
freedom which has put every practitioner who has had ac- 
cess to the overflowing literature of our profession in full 
possession of them. 
It is a most striking and noteworthy commentary upon 
the amount of careful study and prolonged investigation re- 
quired for the perfection of a capital surgical procedure, 
that, after all this attention to the details of this operation, 
even now special points still make their appearance which 
have thus far almost entirely escaped attention, are un- 
known even to men who are commonly exposing their own 
interests and those of their patients to the arbitrament of 
the knife, and information concerning which is in wain 
sought for in works especially devoted to the consideration 
of this operation and the diseased states which call for it. 
An illustration of this statement is to be found in the 
complication to which I propose to direct the attention of 2 
EXPANSION OF BLADDER OVER TUMORS. 
the Society to-day, the expansion of the bladder over the 
surface of abdominal tumors and its firm adhesion to them 
or to the abdominal walls. 
It must not be supposed that, in this announcement of 
my subject, I refer to mere attachment of the bladder to 
tumors as the intestines, the stomach, the liver, and other 
viscera are attached to them by false membranes. This 
condition is in itself a grave complication of laparotomy, 
but it is a far less serious and perplexing factor than that 
which consists in an apron-like spread of the bladder, which 
is trebled or quadrupled in size, over the whole anterior 
surface of the tumor from the umbilicus, or a point above 
it downwards to the pelvis. Here not only has the sur- 
geon to deal with an important organ attached to the tu- 
mor which he is about to remove, he finds himself shut 
off from contact with the tumor by the intervention of a 
viscus, which under these circumstances is necessarily 
firmly attached, which is susceptible of easy laceration by 
efforts to effect its detachment, and the tearing of which is 
very likely to entail a fatal issue. He is called, too, quite 
unexpectedly to manage a complication, the existence of 
which he had no reason to anticipate, the nature of which 
he is very apt not to recognize, and the presence of which 
is exceedingly likely to lead him into a terrible error which 
will seal the fate of the patient who has entrusted her life 
to his hands. 
Search into the history of the subject furnishes us with 
seven cases of this character in all of which a fatal issue 
has been the consequence of the adhesion, either from di- 
rect injury done to the bladder, the surgeon not recogniz- 
ing the nature of the complication, or from failure to re- 
move the tumor on account of its existence. And yet in 
no work with which I am acquainted is this condition sys- 
tematically dealt with, the surgeon put upon his guard as to 
the possibility of its occurrence, or rules given for his guid- 
ance, if he be so unfortunate as to be forced to face the 
issue. Am I not warranted then in assuming the position 
that in connection with the trite subject of laparotomy T GAILLARD THOMAS. 
3 
for the removal of abdominal tumors there are still some 
points which require careful investigation and study ? 
As to th'e pathology of the condition which we are con- 
sidering little need be said, for it is a perfectly simple 
matter. While the tumor is still so small as to be accom- 
modated within the pelvis it becomes adherent to the blad- 
der under those influences which produce attachments with 
other viscera of the abdomen, the nature of which is too 
well known to require consideration at our hands to-day. 
The tumor in time rises, and as it does so the movable blad- 
der is dragged upwards with it out of the pelvis midway 
between this cavity and the navel, to the navel, and some- 
times, as in a case which I shall relate to-day, midway be- 
tween the navel and the ensiform cartilage. Thus to ele- 
vate the bladder filled with urine, a considerable tractile 
power is necessary; this makes extraordinary demands 
upon the attachments which unite the bladder and tumor, 
stimulates their nutrition and increases their strength and 
density. Hence it is that they have been found strong, un- 
yielding, and difficult of laceration. 
I shall now proceed to give a short sketch of all the 
cases of this kind of which I have been able to learn, clos- 
ing with a fuller account of one which has recently occurred 
in my own practice and which has suggested this paper. 
For the knowledge of three of these cases I am indebted 
to my friend, Dr. Garrigues, who has made careful search 
into the literature of ovariotomy in reference to the sub- 
ject. 
Case I. is reported by Dr. Bergman in the “ Petersburger med- 
icinische Zeitschrift,” 1869. The incision was commenced at 
about an inch and a half below the umbilicus and continued to 
three inches above the symphysis pubis. In cutting through the 
peritoneum the bladder was opened. The bladder lay in front 
of and towards the left side of the uterus, and was very much 
elongated, so as to be shaped like a sausage, and lay between 
two hemispheres of the cyst. The tumor was a polycyst firmly 
adherent to the linea terminalis, and could not be removed. The 
wound in the bladder was closed with silk sutures cut short, and 4 
EXPANSION OF BLADDER OVER TUMORS. 
afterwards the abdominal wound was closed. Death occurred in 
thirteen hours. 
At the autopsy both ovaries were found to contain large cysts 
with extensive and intimate adhesions to the intestines, iliac 
fascia and vessels, ureter, rectum, and vagina. 
Case ll. This case appears in the “Deutsche Klinik ” for 
1869, and is reported by Dr. B. Stilling. The operator, upon 
making an incision, found no peritoneal cavity, the peritoneum 
having everywhere become incorporated with the tumor or the ab- 
dominal organs. The bladder, which was very much elongated 
and pushed over to the left side, appearing like a cyst between 
the intestines, was punctured by the trocar. The tumor, which 
was an ovarian poly cyst, could only be partially removed. The 
wound in the bladder was closed with wire sutures, and the ab- 
dominal opening with interrupted sutures. Death occurred fif- 
teen hours after operation. Autopsy showed the ovarian tumor 
to be a dermoid cyst. 
Case 111. Mr. Richard Neale, of London, published the fol- 
lowing case in the “ Medical Times and Gazette,” November 28, 
1868. 
The catheter having been introduced, an exploratory incision 
was made in the mesial line from one inch below the umbilicus to 
one inch above the symphysis. After opening the peritoneum, 
the appearance presented was that of another layer of altered se- 
rous membrane covering the tumor. The finger met with adhe- 
sions everywhere. The incision was carried above the umbilicus 
and around it, so as to avoid an umbilical hernia of the omen- 
tum, but the adhesions were so universal that no attempt at re- 
moval of the tumor was considered justifiable, and the wound was 
closed with silver wire sutures. The next day urine was dis- 
charged through the wound, and a long male catheter having 
been passed easily up to the umbilicus, was visible through the 
abdominal incision. It was found that an incision an inch and a 
half long had been made in the bladder, and the wound was cov- 
ered with sponges soaked in a carbolized solution. 
Twenty-six days after operation the abdominal wound, which 
had closed almost entirely, except just opposite the incision in 
the bladder, was reopened for several inches, and the thickened 
and everted edges of the wounded bladder were pared and 
brought together with fine wire sutures, and the external incision 
again closed. Thirty-seven days after operation all urine was passed by ure- 
thra, except on one or two occasions, when the bladder, being 
overdistended, gave way in one spot, which gradually healed. 
The abdominal wound was closed, except over the most prom- 
inent part of the abdomen, and through the opening thus left the 
coats of the bladder were visible, and some moisture transuded. 
T. GAILLARD THOMAS. 
5 
The patient died six months after the operation, and an au- 
topsy was made. 
The tumor was found to be a hard fibroid in the uterus, to 
which organ the bladder was closely adherent. The bladder was 
converted into a tube eight inches in length and one inch to one 
and a half in diameter laterally, but the anterior and posterior 
coats met, being crushed between the tumor and abdominal wall. 
The coats were not thickened, but were thrown into rugae capable 
of little if any expansion, and the bladder could not contain more 
than two ounces of fluid. No trace of the wound in it made at 
the time of operation could be discovered. 
Besides these cases, Dr. Garrigues declares that Thiersch is 
said to have cut into the bladder drawn up in front of an ovarian 
tumor. The details of this case are, however, not in my pos- 
session. 
Case IV. occurred in the practice of Dr. Montrose A. Fallen, 
and the following is his report of it: 
In the summer of 1868, whilst I was residing in St. Louis, Mrs. 
X,, aged twenty-six, presented herself for the treatment of an 
enormous abdominal tumor, which was diagnosticated as a thin- 
walled, unilocular cyst of the ovary. The operation of ovari- 
otomy was suggested, and an attempt made at its performance. 
After the division of the linea alba, and an evacuation of the sac, 
the pelvic adhesions were found to be so general and complete 
that it was impossible to differentiate the bladder from the cyst- 
wall. Professor John T. Hodgen strongly advised the abandon- 
ment of any attempt to separate the adhesions. I stitched the 
abdominal edges of the incisions to those of the cyst, literally 
“ marsupializing ” the patient, a procedure since recommended 
by Professor Stimpson (of the University Medical College) as an 
excellent method to shrivel and contract the sac, instead of its 
ablation. The patient died on the fifth day of diffuse peritonitis, 
and an autopsy revealed complete adherence to the rectum, ute- 
rus, and bladder, which could not be overcome in the cadaver. 
The bladder was exceedingly large and dilated, measuring full 6 
9 
nine inches in its longitudinal diameter, and almost as much lat- 
erally. It presented what was deemed to be an insuperable 
barrier to the removal of the cyst, and led me to accept Profes- 
sor Hodgen’s views as to the abandonment of the operation. 
EXPANSION OF BLADDER OVER TUMORS. 
Case Y. I was requested by Dr. X. to assist him in an ope- 
ration for laparotomy, undertaken for the removal of a large 
uterine fibroid, which equaled in size a gravid uterus at the sev- 
enth month. The usual incision through the linea alba having 
been made, a shining, muscular-looking mass was found extend- 
ing over the tumor, and reaching up as high as the umbilicus. 
Very naturally, supposing this to be a thick layer of false mem- 
brane, the operator peeled it off from above, to discover, when 
this detachment had reached the symphysis pubis, that he held 
one wall of the bladder in his hand, while the other was still at- 
tached to the surface of the tumor. Having ascertained this, he 
quickly detached the posterior vesical wall, very skillfully sewed 
the two together with silver sutures, and successfully removed the 
large underlying tumor. The patient, however, did not rally, 
and death ensued a few hours after operation. 
Case VI. This occurred in the practice of Dr. Leroy Mc- 
Lean, of Troy, N. Y., and was published by him in the New York 
“ Medical Record,” of February 8, 1879. 
I describe the case in Dr. McLean’s words. “ Before proceed- 
ing to the operation, a large aspirating needle was introduced to 
the left of the median line, and a quantity of fluid, having the 
consistency and color of molasses, withdrawn. The bladder was 
then evacuated. The incision was commenced half an inch below 
the umbilicus, and extended down two and one half inches. At 
the lower angle of the incision, at a depth of three quarters of an 
inch from the surface, I cut into what appeared to be a cyst in 
the abdominal walls, which contained about two drachms of pale 
fluid. The edges of the incision did not retract as they usually 
do when the abdomen is tense, and not liking the indications pre- 
sented, and not being thoroughly satisfied as to what we had to 
deal with, the incision was carried upwards to a point on a line 
and to the right of the umbilicus, when the unmistakable ova- 
rian sac was reached. Using the finger as a director, the open- 
ing was completed below, and the tumor removed. Suppuration 
had begun in a portion of the sac. It had two strong omental 
adhesions, one of which necessitated the application of a ligature. 
The tumor was of the multilocular character. The pedicle was T. GAILLARD THOMAS. 
7 
secured with a silk ligature, and returned, it being too short to 
admjt of changing. Then was discovered the condition shown in 
the drawing [which I do not exhibit here], and the injury done 
to the bladder, it having been cut through on its anterior and 
posterior surfaces down to the lower end of the incision. The 
anterior surface was strongly adherent to the abdominal wall. It 
was not adherent to the tumor. In completing the incision from 
above downwards the finger used as a director had passed behind 
the bladder (its walls being then in close contact from pressure 
of tumor behind), and the injury done as shown. The bladder 
was repaired with interrupted silk sutures. The adhesions of its 
anterior surface to the abdominal walls were not disturbed. Ab- 
dominal incision closed with silver wire. 
“ The patient was carried to her bed, and one hour after a soft 
rubber self-retaining catheter (which we were obliged to send for 
at some distance) introduced, and two ounces of urine withdrawn, 
showing that the bladder was still capable of performing that por- 
tion of its functions. -The catheter was left in situ, the urine 
being thus allowed to escape as soon as secreted. Previous to 
the introduction of the catheter she had expressed a desire to 
micturate. 
“At ten p, m., ten hours after the operation, her condition was 
good. She had rallied, but complained of feeling very tired. 
She expressed a desire for food. Pulse, 112 ; temperature, ioo°. 
Five a. m., pulse, 125 ; temperature, ioi°. She has begun to 
show evidences of approaching dissolution. She gradually sank 
from this hour, death occurring at seven p. m., thirty hours from 
time of operation. Her temperature did not at any time exceed 
ioif°. The secretion of urine was normal. 
“ Postmortem in the presence of Drs. Vanderveer, Ward, Snow, 
Edward Hun, and Schuyler. Primary union of abdominal incis- 
ion ; no evidence of peritoneal inflammation; the bladder intact, 
good primary union, and no escape of urine into the cavity of the 
abdomen. The effort of nature at repair beautifully shown in 
portion of omentum which had been ligated, a fibrous clot had 
been thrown out which covered the ligature, and formed a strong 
adhesion of cut end to a fold of the intestine. There was no 
evidence of sloughing of the pedicle. The adhesions of bladder 
to abdominal wall so firm that they cannot be separated without 
tearing that viscus. The uterus was anteflexed and bound down 
by strong adhesions.” 8 
EXPANSION OF BLADDER OVER TUMORS. 
Case VII. This was a case of ovariotomy performed for the 
removal of a large tumor by Dr. E. Noeggerath, in Mount Sinai 
Hospital, in this city, in October, 1880. 
I transcribe the report of the case, made by him to the New 
York Obstetrical Society, and published in its Transactions. 
“Dr. Noeggerath operated on the 18th of October, at three 
p. M, Chloroform was given ; but before the abdomen was 
opened the patient’s pulse became small and irregular, and she 
vomited. Ether was then substituted for chloroform, and the 
operation was continued by cutting through the abdominal walls, 
when a dense layer of cellular tissue was encountered; but he 
was unable to find any peritoneum. He then introduced a trocar, 
and drew off about a pailful of true colloid material, with a large 
amount of fat, and then proceeded to open the tumor in such a 
way as to leave the trocar in situ, lifting the mass up and cutting 
on the trocar. He was then convinced that there were strong 
and very extensive adhesions between the mass and the abdom- 
inal walls. He continued cutting, and finally reached a cystic 
cavity which he incised ; and after he had opened it, he found 
that its apex reached upwards to within two and a half inches of 
the umbilicus. Upon closer examination, he found that he had 
opened the bladder, which had been carried upwards, and be- 
come so attached to the anterior wall of the abdomen as to ap- 
pear like a portion of the cyst itself. The opening was then 
sewed up with catgut, and the bladder was kept empty with a 
catheter. The operation for the removal of the tumor was then 
continued, when it was found that the peritoneum was consider- 
ably thickened, and that the tumor could not be separated from 
it, the cyst-wall and the peritoneum were so completely united 
that they appeared to be a single structure. He then lengthened 
the abdominal incision to an inch and a half above the umbilicus. 
Suddenly the patient became very pale, and upon close examina- 
tion it was found that the large cavity of the cyst was filled with 
fluid blood. No bleeding vessel was discovered, but after re- 
moving all the blood there was found in one of the pouches of 
the tumor a very soft mass, about half as large as a kidney, which 
was the source of hemorrhage. How it had been injured he was 
unable to say. A thick ligature was thrown around the base of 
the mass, and the bleeding at once ceased. In the mean time 
the patient had become very anemic. The cutting operation was 
discontinued because of the extensive adhesions and the low con- T. GAILLAKD THOMAS. 
9 
clition of the patient, and the case was further treated by simple 
drainage of the sac. An antiseptic bandage was applied, and the 
patient was removed to her bed. At first she rallied somewhat, 
but death occurred twenty-six hours after the operation as the re- 
sult of acute anemia, complicated with septicemia. On the morn- 
ing following the operation the patient’s temperature had been 
105° F., when twenty grains of quinine were given per rectum, 
and within three hours the temperature fell to 990 F. At au- 
topsy, besides finding very extensive adhesions, it was found that 
the tumor had no pedicle. In its lower section the tumor was a 
part of the broad ligament, and therefore had the operation been 
continued it would have been necessary to leave the lower part 
of it to be treated by drainage. There was no peritonitis.” 
Case VIII. I now come to the relation of the case which 
suggested this paper, and which embodies my personal expe- 
rience in dealing with the complication of which it treats. In 
November, 1880, Miss C., aged about thirty-eight years, a na- 
tive of Canada, entered my service in the Woman’s Hospital, on 
account of a large multilocular ovarian tumor, and on the sixth of 
that month she was submitted to operation. 
Making an incision of about three and a half inches in length 
through the median line and through the peritoneum, I discovered 
the surface of the tumor presenting a peculiar appearance, which 
arrested my hand as I was about to plunge in the trocar and ca- 
nula. I then enlarged the abdominal incision, and upon careful 
examination I was led to suspect that the mass overlying the 
tumor might be the bladder. To settle this point I endeavored 
to pass a long catheter, but the tumor pressed so firmly against 
the pubes that the instrument would not pass beyond that point. 
Becoming more and more convinced that I had to deal with a 
case of extensive vesical adhesion, while at the same time I was 
unable to prove that this suspicion was correct, I tried to deter- 
mine the points at which the bladder attached itself to the tumor, 
but in vain ; so completely did the bladder seem amalgamated 
with the tumor that I could not discover where it ended in its 
extension over it. 
I now found myself in this dilemma : there intervened between 
the abdominal incision and the tumor a mass which I regarded 
as the bladder, and which spread over on both sides to such an 
extent that I could not evacuate it by the trocar nor tear off 
the adherent organ on account of the firmness of its attachment EXPANSION OF BLABBER OVER TUMORS. 
and my uncertainty as to the limits of the misplaced viscus. 
From this dilemma I endeavored in vain to escape by enlarging 
the abdominal incision above the umbilicus ; but in this effort 
I was defeated by the discovery that the mass extended upwards 
even above this point. For a time I seriously contemplated 
closing the abdominal wound and leaving my patient to a fate 
which I- felt powerless to avert. But this thought occurred at 
that moment to my mind: while I could not tear away the ad- 
herent bladder for fear of injuring it, I could cut the attached 
viscus away with ease and certainty, if I could only estimate ex- 
actly where its outward limits lay. 
To accomplish this I decided to cut directly through the an- 
terior wall of the bladder so that one or two fingers could be in- 
serted. This I did, and at once a flood of light was thrown upon 
the case. Passing the index finger of the left hand into the 
bladder and as far as it could be carried to one side I learned 
exactly the extent of the viscus and cut down upon the tumor 
severing the strong attachments. In this way, exploring with the 
finger or two fingers of the left hand, cutting down at the ap- 
propriate point, and tearing adhesions after cutting, I soon freed 
the bladder entirely from the attachments, for there were none 
between the posterior wall and the tumor, but only at the cir- 
cumference. A great deal of hemorrhage followed this procedure, 
and quite a number of ligatures had to be applied to bleeding 
vessels. 
The bladder was so immense in weight and dimensions that 
it was difficult to believe in its identity, but the introduction of a 
long elastic catheter had before this put the question at rest. It 
had extended upwards to a point midway between the umbilicus 
and ensiform cartilage and laterally well down into the lumbar 
regions. 
After this the trocar was plunged into the tumor and it was 
removed in the usual way and its pedicle cut, ligated, and re- 
turned to the peritoneal cavity. 
I now found myself freed from the tumor but embarassed by 
the existence of an immensely hypertrophied bladder with an in- 
cision through its anterior wall. This difficulty I met by using 
the abdominal walls as a pair of clamps, and by their instrumen- 
tality clamping the vesical walls securely together. By this plan 
I succeeded in so bringing the incision in the bladder externally 
that if leakage did occur it would not take place into the peri- T GAILLARD THOMAS. 
toneum. But this procedure I must give in detail. Employing 
Vidal’s needle, which has an eye near its extremity, I closed 
the abdominal wound from above downwards, and twisted the 
silver sutures employed until the wound was closed down to the 
opening in the bladder. Arrived at this point I passed the needle 
through the abdominal wall, then through one vesical wall, then 
through the other, and lastly through the opposite abdominal wall, 
and this I continued to do until the whole opening was traversed 
by sutures. The sutures were then twisted, care being taken to 
lift the bladder well up to the surface, and the operation was com- 
pleted. A Sims’ sigmoid catheter was kept in the bladder, the 
patient removed to bed, and the after treatment conducted upon 
general principles. 
Convalescence was regular and rapid, the temperature reach- 
ing only i 00.6° on the third day and the pulse 118 on the fourth. 
Slight hemorrhage took place on the second day, and two or 
three small vessels in the edge of the protruding bladder were 
caught by the artery forceps and tied, and a little persulphate of 
iron was applied. 
The sutures were removed on the tenth day and all went well 
until the fourteenth day when a slight oozing of urine was dis- 
covered from an opening not larger than a cambric needle in the 
line of incision. This did not annoy the patient, so I did not 
interfere with it until the fortieth day, when she was up and 
walking about. At that time I twirled a small tenotome in the 
minute opening and passed a suture which closed it entirely. 
At the end of three months the patient went back to Canada 
perfectly well. 
Before concluding this paper, a few words concerning 
the diagnosis and management of this complication of lapa- 
rotomy. As to diagnosis I have little to say, for I be- 
lieve it to be impossible before the abdominal incision. 
The only method by which it could be accomplished is 
the use of the sound or catheter, and the value of this 
one who has had no experience in such cases would nat- 
urally regard as very great. In my case, employed even 
after abdominal incision had excited a strong suspicion 
as to the existence of the complication, it was entirely in- 
efficient on account of the great size of the tumor and 12 
EXPANSION OF BLADDER OVER TUMORS. 
the pressure which it exerted upon the bladder at the sym- 
physis pubis. These cases are very rare, and it will read- 
ily be conceived that energetic efforts to explore the blad- 
der will very seldom be practiced when there exists no 
evidence whatever that that organ is misplaced. The oper- 
ator will have to depend upon his own quickness of per- 
ception and upon the careful investigation of suspicious 
tissue by sight, touch, the tenaculum, and the scalpel. If 
the bladder be attached to the tumor extensively and closely, 
diagnosis by these means will generally prove difficult; if 
it be attached to the abdominal wall it will be still more 
so. 
As to treatment of the condition I would say that if the 
bladder be attached to the abdominal parietes its anterior 
wall will usually be cut through before the existence of 
the complication is even suspected, and that while this may 
likewise be so if it be attached to the tumor the danger 
of such an accident is decidedly less. 
After the diagnosis is once made the adherent bladder 
should, if possible, be separated by digital detachment. If, 
as in my case, these attachments are so strong that they 
cannot be broken without the danger of lacerating the 
bladder I think that making an incision into the anterior 
wall of the organ, introducing the index finger as a guide 
to its outer limits, and then cutting through the adhesions, 
is the wisest course that offers itself. 
If the anterior wall of the bladder has been incised, 
either by accident or intention, it appears to me that the 
plan of clamping the lips of the incision between those of 
the abdominal wound, as was done by myself in the last 
case related, promises much better results than that of 
sewing up the opening by sutures, and returning the re- 
paired viscus to the abdominal cavity.