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 RE-PKINTBD FROM THE "CANADA MEDICAL A SURQICAL JOURNAL," 
 
 MAY, 1888. 
 
 RARE FORMS OF URINARY EXTRAVASATION. 
 
 By James Bell, M.D., 
 
 • : V jv\ » Surgeon to the Montreal General HoBpitaL , : 
 
 {Read before the Medico-Chirurgieal Soeiety ctf Montreal.) 
 
 Mr. President and Gentlemen — I wish to bring before you 
 to-night the reports of two cases in which urine became extrava* 
 sated in unusual situations, and in each of which it pursued an 
 unusual course. (These cases have nothing in common beyond 
 the occurrence of this accidental condition.) 
 
 Case I. — H. R., aged 32, was admitted to hospital on the 3rd 
 of September last suffering from retention of urine. He was a 
 sailor and had suffered from stricture for fifteen years, and had 
 received treatment for it at different times in marine hospitals 
 in all parts of the world. For years he had carried with him 
 a No. 2 silver catheter and an ordinary wire stilette, with which 
 he relieved himself when retention occurred. When he appeared 
 at the hospital he stated that he had been four weeks in port 
 and had been drinking heavily all the time, and that he had been 
 obliged to relieve himself with his No. 2 catheter several times, 
 but that for twenty-four hours he had not been able to pass any 
 water, and had also failed to introduce either the catheter or the 
 stilette, both of which he had tried. The house surgeon, after 
 some difficulty, succeeded in passing a No. 2 catheter (English) 
 through a stricture situated in the penile urethra, just in front 
 of the scrotum, and emptied his bladder. The patient was very 
 ill at the time, however, and had a temperature of about 105^F. 
 On this account I postponed operating upon his stricture until 
 the 6th — three days later — and then, although his condition was 
 unchanged, I performed an internal urethrotomy and dilated the 
 
urethra to 34 (French). There was only the one stricture — 
 that at the root of the penis — and no difficulty was experienced 
 in the operation. As the stricture was so far forward, the rec- 
 tum was not examined before nor at the time of the operation, 
 although the patient complained of uneasiness about the neck of 
 the bladder, which was at the time attributed to the prolonged 
 retention. On the following day (the 7th) he was somewhat 
 better, but complained more of pain about the anus. From the 
 perineum there was considerable tenderness on pressure over 
 the region of the prostate, but no swelling nor sign of infiltration. 
 Urine passing freely. Temperature 102*'F. 
 
 Sept. Sth. — Patient complained of diarrhoea ; pain and fever 
 persisting. No further examination was made until the 12th, 
 six days after operation, when the rectum was explored, the 
 patient being anaesthetized for this purpose. The anus was red 
 and swollen, and on introducing the finger the rectum was found 
 to be surrounded by suppuration, which separated it from the 
 bony pelvis as far as the finger could reach and also from the 
 sphincter ani posteriorly and laterally, so that the finger could 
 be introduced between the bowel and the sacrum and ischia. 
 The sphincter was then cut through posteriorly so as to allow a 
 freer escape of inflammatory products and the cavity washed 
 out with a warm sublimated solution. The washing was con- 
 tinued daily, and three days later a large piece of the rectum 
 was found lying loose and completely separated, and was easily 
 withdrawn. This piece of gut measured four inches in length 
 and from an inch and three-quarters to two and a half in width, 
 and consisted of the posterior and lateral walls of the gut from 
 close upon the prostate on the left side around to the right side, 
 but not reaching to the prostate on the right. Much sloughy 
 cellular tissue also came away, and from this time the patient's 
 condition rapidly improved until the 24th of October, when he 
 left the hospital to join one of the outgoing vessels as an able 
 seaman. The wound seemed to be quite healed at this time, the 
 deficiency in the rectum being filled with cicatricial tissue. 
 Defecation and micturition were normally performed, and the 
 urethra admitted a No. 34 sound without difficulty. 
 
There can be little doubt, I think, but that this patient, in 
 passing the No. 2 catheter or stilette while drunk, must have 
 wounded the neck of the bladder in or about the point of the 
 prostate and behind the triangular ligament, and that the subse- 
 quent distension of the bladder forced a few drops of urine into 
 the peri-rectal cellular tissue, which produced the ordinary 
 results of urinary infiltration. 
 
 Case II. — In this case extravasation occurred into the pelvis 
 from the reopening of a wound in the bladder which had been 
 accidentally inflicted during the performance of an ovariotomy. 
 
 Mrs. L., aged 42, was admitted to the Montreal General Hos- 
 pital on the 20th of September last suffering from an abdominal 
 tumor which had been growing for twelve years, but which had 
 increased rapidly in size during the last four months. Her 
 general health was excellent. She had never had any pain, 
 and suffered only from the inconvenience of the rapidly enlarg- 
 ing growth. Menstruation was regular and normal. On exami- 
 nation, the abdomen was seen to be enlarged to about the size 
 of a full-term pregnancy. The tumor had evidently grown from 
 the left side, and was round, smooth, painless on pressure, and 
 only very indistinctly fluctuating at its most prominent point. 
 Per vaginam, the uterus was freely movable. The diagnosis 
 was a left parovarian tumor. The operation was performed in 
 the usual way four days after admission, the patient being cathc- 
 torized by the nurse before being brought into the operating- 
 room. On tapping the tumor only a few ounces of fluid could 
 be withdrawn, and it was seen to be a dermoid cyst containing 
 the usual semi-solid sebaceous-looking material. The abdominal 
 wound was enlarged and the tumor delivered entire. There 
 were no adhesions except about the left broad ligament, from 
 between the layers of which it had to be enucleated. When this 
 process was being accomplished a broad vascular mass of adhe- 
 sion was encountered, which it was thought wise to ligature in 
 sections and out with the scissors. This mass was to the left 
 and partly in front of the tumor, and, unknown to the operator, 
 contained a portion of the fundus of the bladder, which had been 
 
carried high up into the abdomen by the growth of the tumor. 
 In this way, therefore, the bladder was wounded, an incision 
 about an inch long having been made into its upper and posterior 
 surface with the scissors. This was immediately sutured with 
 catgut after Lembert's method and the tumor removed. The 
 operation was concluded, the wound closed and a dressing applied, 
 and the patient made uninterrupted progress until the twelfth 
 day. For the first four days a soft rubber catheter was tied 
 into the urethra ; from this time it was removed and passed 
 every two hours. On the twelfth day the nurse (a new one) 
 complained that she " could not get the catheter in far enough," 
 and that the urine withdrawn had been bloody. The patient 
 also complained that the passage of the catheter pained her. It 
 was then ordered to be passed every four hours, and the bladder 
 was washed out daily with a weak solution of salicylic acid dis- 
 solved with borax. Next day a small hard mass about as large 
 as a marble was observed at the lower end of the abdominal in- 
 cision, which was painful on manipulation. This mass remained 
 without much change, and irritability of the bladder with foetid 
 bloody urine persisted. On the eighteenth day after operation 
 the mass was found to have suddenly disappeared, but the patient 
 complained of pain and tenderness over the left inguinal region 
 and in the left loin. These symptoms, together with a marked 
 diminution in the amount of urine withdrawn by the catheter 
 made it clear that a general extravasation of urine had occurred 
 into the left side of the pelvis. The patient was therefore anaes- 
 thetized and the abdomen opened through the lower inch of the 
 original incision (over the site of the little hard mass which had 
 first appeared). Urine flowed from this incision, and on explor- 
 ing with the finger an opening could be felt in the fundus of the 
 bladder which would almost admit the point of the little finger, 
 while a larger sinus led down into the left. side of the pelvis. 
 Through this last a pair of long forceps was introduced and pro- 
 truded into the left side of Douglass' fossa, when an incision was 
 made into the vagina. A large drainage-tube was then drawn 
 from the vagina through this opening and up through the ab- 
 dominal wound and a large soft catheter tied into the urethra. 
 
The whole cavity, as well as the bladder, was then thoroughly 
 washed out with a solution of salicylic acid and borax, the wound 
 freely dusted with iodoform, and a gauze dressing applied. The 
 drainage was very satisfactory and the patient's condition imme- 
 diately improved. The wound was irrigated and dusted with 
 iodoform and dressed as above described daily. Four days after 
 the incision sloughs of cellular tissue began to come away in 
 enormous masses, and an incision into the loin was found to be 
 necessary on account of a collection of sloughy tissue in that 
 region. The sloughs were soon all removed, and about this time 
 (fourteen days after incision) a dark jelly-like, fermenting sub- 
 stance came away from the wound in considerable quantity for 
 a few days. It was odorless, and a careful microscopical and 
 chemical examination failed to determine its exact nature. The 
 bowels acted normally throughout. During the separation of the 
 sloughs the patient suffered from severe sciatic pain and hyper- 
 sesthesia of both legs. These symptoms began on the left side, 
 and were more severe and lasted longer on that side. By the 
 20th of October all these symptoms had disappeared, the wounds 
 wero looking healthy, the bladder wound was nearly closed, the 
 use of iodoform, which had been of late greatly lessened, was 
 now entirely discontinued, and the prospects of recovery were 
 most encouraging. It is worthy of note here that until the 
 sloughs began to separate there was no elevation of temperature 
 whatever, and at no time was the temperatu f high or con- 
 tinuous, but from the onset of the bladder sympr* ma the pulse 
 remained rapid — from 100-120. About the 1st of November 
 an acute mania developed, and from this time, although 
 the local conditions continued to improve, the patient had to be 
 forcibly restrained. She refused food, and was in a state of 
 maniacal excitement day and night, without sleep and with fre- 
 quent involuntary evacuations, gradually and perceptibly sinking 
 until the 9th of November, when she died ; at the end of the 
 eighth week after operation. Slight delirium at night and a 
 peevish, nervous condition of the patient, especially while being 
 dressed, had been observed for a few days before the violent 
 maniacal symptoms set in. These latter lasted about eight days, 
 
6 
 
 and were accompanied by very rapid emaciation. Unfortunately 
 an autopsy could not be obtained. 
 
 This case presents many points of interest, and illustrates 
 a chapter of accidents such as it fortunately seldom falls to the 
 lot of the surgeon to report in any individual case. 
 
 (1) It emphasizes the necessity for instrumental exploration 
 of the bladder by the surgeon before operating. It had here- 
 tofore been my practice to allow the nurse to catheterize the 
 patient before bringing her into the operating room. This was 
 done with the double object of shortening the period of ansea- 
 thesia and to avoid soiling the hands after having cleansed them 
 for operation. Important as these matters are, however, they 
 are not to be compared with the risk of wounding the bladder, 
 which is occasionally carried high up into the abdomen on the 
 surface of the tumor. 
 
 (2) It strengthens the evidence already existing to show that 
 catgut is not to be relied upon as a suture to retain the contents 
 of a hollow viscus. I may say here that from past experience 
 I would not have used catgut, but that no suitable silk was at 
 hand at the moment. 
 
 (3) The necessity for careful and thorough catheterization 
 for at least two weeks after an accident of this kind is here 
 shown. 
 
 Finally, with regard to the acute maniacal condition, which 
 was the immediate cause of death, and which supervened when 
 to all appearances the other difficulties had been overcome, I 
 have two suggestions to make, viz., that it was due cither to the 
 toxic effects of iodoform or to the absorption of ptomaines or 
 leucomaines from the urine retained and decomposing in the 
 cellular tissue of the pelvis ? The patient was a healthy, 
 vigorous woman, with an excellent family history, and who had 
 never suffered from any form of nervous derangement in her life. 
 On the other hand, the use of iodoform bad been practically dis- 
 continued for several days before the maniacal symptoms ap- 
 peared, and the cavity had been thoroughly irrigated every day 
 with a solution of salicylic acid and borax. 
 
 I need only mention here a third case, in which, during the 
 
performance of an ovariotomj, a strong fibrous band connecting 
 the surface of the tumor with the base of the bladder was stripped 
 off from the latter tearing away its peritoneal covering over a 
 small area. Nothing iivas thought of this at the time, and the 
 patient made an excellent recovery ; but two weeks after opera- 
 tion a small inilammatory mass appeared at the lower angle of 
 the abdominal wound. This was thought to be a stitch-hole 
 abscess, but on pressing it an amber-colored fluid exuded. A 
 large soft catheter retained in the urethra for ten days not only 
 gave immediate relief to tho symptoms, but effected a complete 
 cure. 
 
 The history of these cases shows that the necessity for early 
 surgical interference where extravasation of urine has occurred 
 within the pelvis, no matter how slightly or how gradually occur- 
 ring, is as great or greater than for extravasation into the perineal 
 tissues. Had I recognized the condition sufficiently early in 
 case No. 2 of this series, I have no doubt but that I would have 
 saved my patient. 
 
 I..