HE following case of intraperitoneal rup-T ture of the urinary bladder is reported because it illustrates most of the textbook features of the condition and some of the difficulties in its diagnosis.
Case ReportA 33 years-old labourer was admitted at 4.30 p m . on 16 Oct. 1957. On the previous day he had indulged in a beer drinking session, lasting ffom 5.30 p m . to 9.30 pm., and later that night had become involved in a fight. He was unable to remember details of the incident, but knew that, at one stage, he had received either a blow or a kick in the abdomen. He reached h i s room and slept well that night. At 11.30 a.m. next day he awoke with abdominal pain. He was not sure of its initial site, but it gradually became more severe, was of a constant nature, was aggravated by coughing, and did not radiate. There was no pain in his shoulders. A few ounces of heavily blood-stained urine were passed on two Dccasions that morning.There were no gastro-intestinal symptoms, except that he had vomited once en route to the hospital.There were no relevant features in the family or previous history.On examination, the man was found to be sweating and in scverc pain. He was breathing rapidly and shortly in an effort to minimize his pain. His face was flushed and rather plethoric. He had a "black eye" and a subconjunctival haemorrhage on the left side. There was a laceration over the left side of his forehead. No bruises or other signs of contusion were seen in the abdomen or over the perineum. The abdomen was rigid and tender all over. One observer thought that the maximum tenderness was in the suprapubic area. Bowel sounds were absent and shifting dullness could be demonstrated; this latter with some difficulty. Rectal examination revealed no abnormality. The respiratory, cardio-vascuIar and central nervous systems all appeared normal. Temperature 99.2" F. Pulse 84/m. Respirations 26/m. Blood pressure 140/80 mm. of Mercury. Haemoglobin (by Sahli method) was 100 per cent.X-ray films of the chest, lumbo-sacral spine and pelvis were all normal. Supine and erect films of the abdomen showed no abnormality; no free gas was seen within the peritoneal cavity. Intravenous excretory urography was undertaken. The dye was Hospital, Launceston excreted well on both sides. The calyceal systems and pelves of the kidneys and the ureters all appeared normal. The shadow of the bladder was also interpreted as being normal (Fig. I).The patient had been unable to void since admission and it was decided to postpone catheterization until he was taken to the operating theatre.There, after the induction of anaesthesia, a soft urethral catheter was passed. A few drops of macroscopically clear urine were obtained, and this amount was increased by suprapubic manual compression. Later, the urine was found microscopically to contain many red blood cells.Despite the normal cystogram and the apparently clear urine, the surgeon still thought a ruptured bladder the most likely diagnosis.
OperationA right lower paramedian incision was made.When the periton...
