RECBRINTED FROM 
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SURGERY 
• MONTHLY MVIBW OF BUROICAL aClBMCB AMD HUCTX* 
EDITED BY 
L S PILCHER. AM, M D, J,WILLIAM WfirTE. M D« 
FKEDERICKTREVES.FR.C&, WILLIAM MACEWEN. 
TABLE OP CONTENTS* 
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index of buroical froorrm 
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UNIVERSITY OF PENNSYLVANIA PRESS 
PHILADELPHIA, PA. 
Great Britain: Caaaell and Company. London. 
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DKCEMBER, 1893 
•U(l* C»»U«. Tw» auuian 
A CASE OF INTRA-PERITONEAL RUPTURE OF THE 
BLADDER; RECOVERY AFTER LAPAROTOMY. 
By JAMES KERR, M.D., 
OF WASHINGTON, D. C. 
SURGEON TO EMERGENCY AND PROVIDENCE HOSPITALS, PROFESSOR OF 
SURGERY, GEORGETOWN UNIVERSITY. A CASE OF INTRA-PERITONEAL RUPTURED OF THE 
BLADDER; RECOVERY AFTER LAPAROTOMY. 
By JAMES KERR, M.D., 
OF WASHINGTON, D. C. 
SURGEON TO EMERGENCY AND PROVIDENCE HOSPITALS, PROFESSOR OF 
SURGERY, GEORGETOWN UNIVERSITY. 
THE patient, W. H. B., a white male, thirty-three years old, 
May 13, 1892, fell thirty-five feet down the outside of an 
elevator shaft, striking the ground "all doubled up," with 
most of his weight on his left hip. 
He was brought to the Emergency Hospital about one-half hour 
later, in a state of shock and complaining of great pain over the 
region of the hip and hypogastrium. Was very sore on any move- 
ment. Sent to the ward and kept under observation. 
Eight hours later the shock and pain continued, the latter most 
marked over hypogastrium, where there was some ecchymosis and 
swelling. There was also marked abdominal tenderness, and the 
pulse small and thready. Catheterizing him, a small quantity, half- 
ounce. of bloody urine was withdrawn. 
Rupture of the bladder was diagnosed and an operation deter- 
mined on. 
Incision was first made into the prevesical space. The cellular 
tissue was found extensively infiltrated. On cutting down to the bladder 
it was collapsed, but no extra-peritoneal injury could then be detected. 
Fracture involving the symphisis and descending ramus of the pubis 
on the left side was made out. On injecting a solution of boracic 
acid per urethram it was felt to well up at the bottom of the incision. 
As only a small part of the fluid returned in this way, and the balance 
not distending the bladder, it was supposed to be escaping into the 
pelvic cavity. 
It was, therefore, deemed advisable to open the general perito- 
neal cavity, and the original incision was prolonged upward. The 
intestines distended, and, showing signs of peritonitis, crowded into 
the wound. Arrangements being made for the Trendelenburg posi- 
tion, after the elevation of the pelvis the intestines gave little 
further trouble. 2 
JAMES KERR. 
On injecting more of the boracic lotion it could be felt to well 
up in the bottom of the pelvis, with a-distinctly urinous odor, proving 
that the rupture was intra-peritoneal and beyond the reflexion of the 
pelvic fascia. 
The bladder was carefully examined to locate the injury, but 
without success. It was then opened and a Trendelenburg tube 
introduced. An effort was then made to close in the ruptured area by 
suturing the side of the bladder as low down as it could be reached 
to the pelvis in front. The general peritoneal cavity was then irri- 
gated with a 1-10,000 bichloride solution and a drainage tube intro- 
duced in front of the bladder. The operation was completed by 
placing a tampon of iodoform gauze in the abdomen behind the 
bladder. 
The shock following the operation was severe, but the patient 
made a good recovery. Temperature and pulse became normal on 
the fifth day. He left the hospital one month from admission, and 
when seen four months afterward was in perfect health. 
The after-treatment consisted of free saline catharsis and boracic 
fomentations to absorb the urine from the anterior wound. These 
were changed at first every hour, the interval being increased as the 
wound in the bladder healed. The bladder was at first washed out 
through the drainage tube twice a day with a solution of boric acid. 
The iodoform tampon was changed at the end of the second, and 
permanently removed at end of the fourth day. The drain from 
the prevesical space two days following, and the bladder drain two 
weeks later. I attribute success in this case to a comparatively early 
operation and the open method of dealing with the infected perito- 
neum. 
I append a list of all the cases that could be tabulated up to 
date from a search made at the Library of the Surgeon-General's 
office here: INTRA-PERITONEAL RUPTURE OF THE BLADDER. 
3 
Operator. 
Date. 
Injury and Symptoms. 
Operation. 
Result. 
Reference. 
Blum, A. 
Brown, J. V. 
Bull, W. T. 
Duncan, J. 
Fox, J. M. 
May 15, 1887. 
April, 1887. 
October 27, 1884. 
May 5, 1886. 
August 16,1866. 
M., aged twenty eight, run over by 
a wagon; pain in thigh ; could 
not urinate; May 16, abdomen 
distended ; painful; catheter in- 
serted and urine drawn which 
was free of blood; vomiting; peri- 
tonitis. 
A. W-, fell on corner of doorstep ; 
when seen, patient in a state of 
collapse; vomiting; severe pain ; 
passed bloody urine. 
-, aged forty-six; fall into cellar; 
great shock; bloody urine; dull- 
ness half way to umbilicus; ca- 
theter went beyond bladder; also 
fracture of pelvis. 
W. E., aged thirty-eight; run over 
by cart; shock ; desire to urinate, 
but no power; bloody urine; peri- 
tonitis ; vomiting. 
E. M., aged forty-five; fell from a 
window; pain; unable t > uri- 
nate ; three ounces of bloody 
urine drawn by catheter; anxious 
expression; also fracture through 
neck of right femur. 
Forty hours after injury incision in 
linea alba; on opening perito- 
neum a large quantity of yellow 
fluid escaped; rupture on upper 
portion of bladder the size of a 
franc; rent closed by six Lem- 
bert sutures; vomiting ceased; 
peritonitis allayed. 
Laparotomy twenty-two hours 
after injury; blood-stained fluid 
found in peritoneal cavity; rent 
on posterior surface of bladder 
1% inches long: closed with Lem- 
bert sutures including peritoneal 
and muscular coats of viscus; 
no leakage when filled with 
Thiersch's solution; catheter 
tied in bladder. 
Laparotomy thirteen hours after 
injury; rent in posterior wall of 
bladder 3^ inches long: seven 
Lembert sutures; catheter tied 
in. 
Perineal cystotomy failed to dis- 
cover rent; abdominal section 
twenty-two hours after injury; 
blood and urine in cavity; rent 
in posterior vesical wall 2% 
inches; bladder wound was not 
sutured; glass drain introduced 
into bladder. 
Twenty hours after injury incision 
just above pubes; bloody urine 
and blood clots in cavity; supe- 
rior surface of bladder torn from 
side to side; fifteen Lembert 
sutures ; catheter passed through 
urethra and left in bladder; peri- 
tonitis. 
Entirely recovered 
June 20. 
Died sixteen hours 
after operation. 
Died in sevenhours. 
Died in fifty-five 
hours. 
Died August 18; 
forty-two hours 
after operation. 
Arch. Gen de Mede- 
cine, Paris, 1888, T. 
XXII, p. 22. 
Medical Record, New 
York, 1888, xxxiii, p. 
632. 
Annals of Surgery, 
1885,1, 67. 
Lancet, 1886,11, 399. 
Medical News, Phila- 
delphia, 1887, LI. p. 
673- 
Table of Cases of Laparotomy for Intra-peritoneal Rupture of Urinary Bladder. 4 
JAMES KERR. 
Operator. 
Date. 
Injury and Symptoms. 
Operation. 
Result. 
Reference. 
Heath, C. 
November 25, 1878. 
J. B., aged forty-seven; hit in the 
stomach; belly tense: bloody 
urine by catheter; water injected 
felt in abdomen by patient. 
J. D., aged twenty-eight; kicked 
by a horse in supra-pubic region ; 
severe pain ; bloody urine drawn 
by catheter; tympanitic; injec- 
tion of boric acia solution con- 
firmed rupture. 
Laparotomy forty hours after in- 
jury; extensive rupture of blad- 
der; continuous suture. 
Died in six days; 
autopsy; suture 
had given way. 
Medico-chirurgi- 
cal T ransactions, Vol. 
lx 11, 337. 
Herrick, J. B 
May 31, 1889, 
Twenty-three hours after injury in- 
cision from 1 inch above umbili- 
cus to symphysis pubis; on punc- 
ture reddish fluid escaped ; rent 
in bladder on posterior wall near 
fundus; Lembert sutures; ca- 
vity irrigated with boric acid so- 
lution ; glass drain. 
Died forty-nine 
hours after acci- 
dent. 
North American Prac- 
titioner, Chicago, 
1889, 1, 408. 
Hitchcock, H. 0. 
1888. 
Rupture of bladder. 
Laparotomy; rent six inches in 
length; sutures. 
Died. 
Pittsburgh Medical Re- 
view, 1888, 11. 55. 
Hofmokl. 
March, 29, 1886. 
K. L., aged twenty-seven; fell 
from a window ; symptoms prin- 
cipally those of extra-peritoneal 
rupture; also fracture of right 
forearm. 
Laparotomy ten hours after injury; 
intra- and extra-peritoneal rup- 
ture of bladder; great infiltration 
of tissues with blood; partial 
suture of bladder; upper portion 
left open and drained. 
Recovery. 
Wiener Medizinische 
Presse, 1886, p. 1228. 
Holmes. 
June 9, 1887. 
H. P , aged twenty-four; kicked in 
the abdomen; great pain ; unable 
to void urine; blood-stained 
urine drawn per catheter. 
Incision in median line six hours 
after injury; peritoneal cavity 
opened; rent in bladderabout two 
inches long; closed by eight su- 
tures ; cavity washed out; during 
next night voided urine naturally. 
Recovery. 
Lancet, London, July, 
1887. 
Hu Ike. 
January 14, 1892. 
C. E., aged thirty-three; butted in 
abdomen; great pain; anxious 
expression ; urgent desire to mic- 
turate ; urine mixed with blood, 
drawn repeatedly; vomiting. 
January 17, laparotomy; several 
ounces of grumous. bloody fluid 
escaped on opening peritoneum; 
rent in posterior wall of bladder 
214 inches long; closed with dou- 
ble row of sutures; peritoneal 
cavity flushed; vomiting returned; 
peritonitis. 
Died January 18. 
Lancet. London, 1892, 
n, p, 197- 
Keyes, E. 
December 1,1887. 
P K., aged twenty-two; run over 
by cart; scalp wound and lacer- 
ated wound of scrotum; abdo- 
men tympanitic; vomiting; col- 
lapse imminent. 
Laparotomy twenty-two hours 
after injury; bloody fluid gushed 
out; rent in bladder 1 % inches long 
in front of peritoneal reflection ; 
nine Lembert sutures; bladder 
distended with Thiersch's solu- 
tion found water-tight; no cathe- 
ter inserted. 
Diedeighteenhours 
after operation. 
Medical Record, New 
York, 1887, xxxii. 
781. 
Cases of Laparotomy for Intra-peritoneal Rupture of Urinary Bladder.-Continued. INTRA-PERITONEAL RUPTURE OF THE BLADDER. 
5 
Operator. 
Date. 
Injury and Symptoms. 
Operation. 
Result. 
Reference. 
Knight. 
October 15, 1888. 
G. H., aged forty-nine; fell against 
corner of a bench; great pain ; 
vomiting; inability to urinate; 
catheter passed without result; 
abdomen tender and distended. 
October 17, laparotomy; fluid welled 
up on opening peritoneum; 
ragged rent in fundus of bladder 
inches long, closed with con- 
tinuous sutures; peritoneal cavity 
washed; peritoneum brought to- 
gether with catgut, and abdomi- 
nal wall with wire suture; soft 
catheter tied in bladder. 
Recovery; dis- 
charged well, No- 
vember 25. 
New Zealand Medical 
Journal, Dunedin, 
1889-90, in, 158 
MacCormac, W. 
September 22, 1885. 
W. S., aged thirty-three; fell 
against iron post; no shock; 
ninety-five ounces of blood- 
stained urine withdrawn by cathe- 
ter ; great pain; vesical tenesmus. 
Had walked one mile to hospital 
day after injury. 
Laparotomy nineteen hours after 
injury; vertical rent in posterior 
wall of bladder 4 inches long; 
sixteen Lembert sutures; perito- 
neum divided at sides to relax 
bladder walls; abdominal drain- 
age tubes. 
Rapid recovery. 
Lancet, London, 1886, 
11, 1118. 
MacCormac, W. 
November 17, 1886. 
C. F., aged thirty-seven; fall from 
scaffold; no symptoms of intia- 
peritoneal injury; no shock; next 
day fluid present in abdomen; 
vesical tenesmus ; signs of inci- 
pient peritonitis; nausea. 
Laparotomy twenty-seven hours 
after injury; large amount of 
bloody fluid in abdomen; rent 3 
inches long in upper part of pos- 
terior bladder wall; twelve Lem- 
bert sutures; urine passed volun- 
tarily: no abdominal drainage. 
Recovered. 
Lancet. London. 18S6, 
11, 1118. 
McGill, A. F. 
October 20, 1886. 
M. B., aged fifty-four; run against 
iron gate; insensible for some 
time; pain; bloody urine; could 
not urinate; peritonitis. 
Laparotomy sixty-eight hours after 
injury; pint of urine in cavity ; 4 
inch rent in apex and fundus of 
bladder; nine chromic sutures : 
autopsy: bladder wound firm; no 
fluid in cavity. 
Died in seventeen 
hours 
Lancet, London, 1886, 
xxi, 972. 
Robson, A. W. M. 
-, aged sixty-eight; desire but in- 
ability to micturate; bloody urine 
drawn by catheter; fracture of 
right side of pelvis. 
Membranous urethra opened and 
tube introduced into the bladder; 
laparotomy three hours after in- 
jury, in median line, but as no 
urine or rupture into peritoneal 
cavity was found, the external 
wound was closed. 
Died in a few hours 
from shock. At 
autopsy it was 
found that a frag- 
ment of the pel- 
vis had penetra- 
ted anterior wall 
of bladder. 
MacCormac on Abdom- 
inal Section, London, 
1887, P- 53 
Scion. 
1887. 
-, aged twenty; retention of urine; 
bloody fluid drawn off; hiccough; 
pain above pubes. 
Laparotomy; rent in front of blad- 
der admitted tip of index finger 
(extra-peritoneal); woundstitched 
to abdominal wall; drainage tube 
nine days. 
Recovered. It is 
doubtful whether 
peritoneal cavity 
was opened or 
not. 
Annals of Surgery, 
February, 1887. 
Cases of Laparotomy for Intra-peritoneal Rupture of Urinary Bladder.-Continued. 6 
JAMES KERR. 
Operator. 
Date. 
Injury and Symptoms. 
Operation. 
Result. 
Reference. 
Sonnenburg. 
1885. 
No peritonitis for twenty-four 
hours; 1000 grams clear urine 
dtawn off. 
Laparotomy two days after injury; 
rent from vertex to neck along 
posterior wall of bladder; no 
sutures; drainage tube ; infiltra- 
tion of urine and intense perito- 
nitis, 
Died on fourth day. 
CentralblattfiirChirur- 
gie, 1885, p. 838. 
Symonds, C J. 
18SS. 
Girl, aged seven; fell from a 
bridge into a passing barge: ex- 
treme collapse; catheter inserted 
six hours after accident, and dark 
blood drawn off. 
Laparotomy seven hours after in- 
jury; dark fluid, with urinous 
odor escaped; rent 1% inches in 
bladder closed with twelve Lem- 
bert sutures; catheter tied into 
bladder, which irritated patient. 
Died on eighth day. 
Lancet, London, 1888, 
L 977- 
Teale, T. P. 
December, 6,1883. 
F. S., aged twenty-five; kicked in 
abdomen: unable to urinate: ab- 
domen distended and tender; only 
one ounce fluid drawn by cathe- 
ter; no shock. 
Laparotomy two hours after injury; 
rent in posterior surface of blad- 
der near apex, closed by six su- 
tures ; unusual oozing of blood 
from abdominal wound. 
Died in about 
twenty hours. 
Lancet, London, 1887, 
I, ii33- 
Rose, P Edward. 
1892. 
Boy. seven years old; admitted to 
hospital two days after accident: 
abdomen distended and tender; 
dullness in lumbar regions and 
echymosed; vomiting; constipa- 
tion ; passing only few drops of 
bloody urine 
Laparotomy; bladder contracted 
and stellate rent on upper surface; 
not sutured; drains on either side 
and packed with iodoform gauze 
and catheter left in bladder. 
Recovered. 
Deutsche Zeitschrif t fiir 
Chirurgie, Bd. xxxi, 
Heft 3 and 4. 
Walsham. W. J. 
March 1, 1887. 
C. H., aged twenty-two; butted in 
abdomen: great pain, but little 
shock; next day on passing ca- 
theter no urine flowed. 
Laparotomy thirteen hours after 
injury; intra-peritoneal rent in 
posterior wall of bladder sewed 
up with nine Lembert sutures: 
bladder injected with boric acid 
solution found tight; peritoneum 
irrigated; abdomen closed as in 
ovariotomy. 
Recovered. 
Lancet, London, 1888, 
1. 173- 
Walter. 
-, aged twenty-two years ; hit in 
the abdomen; signs of active peri- 
tonitis. 
Laparotomy ten hours after injury: 
much blood and urine; extensive 
tear at base of bladder 2 inches 
long; no sutures into bladder; 
drainage tube; catheter in blad- 
der ; opium treatment. 
Recovered. 
MacCormac on Ab- 
dominalSection, Lon- 
don, 1887, p. 54. 
Willet, A. 
June 11, 1876. 
T. F , aged forty-eight; kicked over 
pubes; shock and pain; bloody 
urine by catheter; symptoms of 
j peritonitis. 
Laparotomy twenty-nine hours 
after injury; rent 3% inches 
across fundus of bladder; inter- 
rupted sutures. 
Died in twenty- 
three hours. At 
autopsy, portion 
of bladder wound 
found open. 
St. Bartholomew Hos- 
pital Reports, 1876, p. 
209. 
Cases of Laparotomy for Intra-peritoneal Rupture of Urinary Bladder.-Continued. INTRA-PERI1 ONE AL RUPTURE OE THE BLADDER. 
7 
Operator. 
Date. 
Injury and Symptoms. 
I 
Operation Result. Reference. 
.. 
Schlange. H. 
1892 
Man, aged thirty-four; injured by 
heav y wagon; laparotomy twenty- 
four hours after; an intra- and 
extra-peritoneal rupture: intra 
sutured extra packed with iodo- 
form gauze. 
Urine mopped out of peritoneal Recovered. Arch, fiir Klin. Chirur- 
cavity, not flushed. gie, Bd. xliii, Heft 1. 
Page. 
February 6 1892. 
Injured by man falling on him; 
next day patient anxious expres- 
sion; thready pulse and dis- 
tended abdomen. 
Laparotomy found collapsed blad-Died beforecomple-Lancet, London, Feb- 
der with stellate wound on back tion of operation, ruary 6, 1892. 
and upper part of fundus sutured. 
Kerr, J. 
May 13, 1892. 
Man, aged thirty-three: fell thirty- 
five feet; fracture of pelvis; on 
opening prevesical space injected 
fluid not returning through 
wound or filling bladder; lapar- 
otomy performed and combined 
intra- and extra peritoneal rup- 
ture made out. 
Operation eight hours after injury; Recovery. Annals of Surgery, 
side of bladder stiched to pubes December, 1893 
and pelvis tamponed with iodo- 
form gauze; bladder and Retzius 
space drained 
Pilcher, L. S. 
July 26, 1S93. 
Man. aged twenty-three; fell from 
second story of a dwelling house 
while drunk: no apparent injury 
at time; gradual supervention of 
symptoms of internal haemor- 
rhage; six hours later found in 
profound collapse, with empty 
bladder and slight bloody dis- 
charge from urethra ; rallied by 
stimulants and intravenous saline 
infusion of forty fluid ounces. 
Laparotomy twelve hours after in- Death two hours Personal Communica- 
jury; abdomen filled with blood after close of tion. 
and urine; longitudinal rent 1% operation from 
inches long, at apex of bladder; shock and anae- 
bleeding from torn superior vesi- mia. 
cal veins: abdominal cavity 
sponged out and irrigated; blad- 
der tear sutured: abdominal 
wound closed 
Cases of Laparotomy for Intra-peritoneal Rupture of Urinary Bladder.-Continued. 
Twenty-nine cases. 11 recoveries; 18 deaths.