A Case of Fractured Pelvis with Rupture of the Bladder in an Infant under Two Years, with Recovery

Robert W. Angevine
1918 Boston Medical and Surgical Journal  
bladder was included in the tear. A supravaginal hysterectomy was done. After the uterus had been amputated, the patient was given intravenous salt solution as her condition was desperate. The wound was then closed with drainage, and the patient returned to bed. She responded to stimulants, and in a few days was out of danger. Incontinence of urine, of course, resulted. Cystoscopy eight days after operation revealed a transverse tear behind the inter-ureteral ridge, about 5x2 cm. The urine
more » ... cm. The urine escaped through the torn cervix, the anterior lips of which were widely separated. It was planned to close the fistula on the tenth day, but the patient developed an adynamic ileus, which delayed operation for a week. Through a suprapubic incision the bladder was opened. The fistula was closed without tension on the right; but as the left side was approached it was found necessary to divide the bladder down to the tear, for the relief of tension. The wound was closed with drainage to the bladder, and a retention catheter placed in the urethra. There was no leakage until the seventh day, when urine again escaped through the vagina. Examination two days later showed that the sutures on the left side near the ureter had broken down. Silk stitches, used in ligating the uterine arteries at the former operation, could be seen through the opening in the bladder. The patient could prevent continuous leaking by lying on her abdomen and having a bed pan placed under her when she turned on her back. It was thought best for the patient to go home for Christmas, and return later for closure of the fistula. In January, 1918, she returned, but there was so little leaking that she preferred to wait longer. In March, 1918, the opening in the bladder had contracted to 1 cm. in diameter. At this time the silk stitches previously noted were removed. They could be pulled down into the vagina through the cervix, and were divided with scissors. In April, 1918, five months after the bladder was ruptured, a second attempt was made to close the fistula. T tried this by the perineal route, using Schuchardt's para-rectal incision, so graphically described by Dr. George Gray Ward, Jr., in Surgery, Gynecology and Obstetrics, August, 1917. Without this procedure it would have been impossible to operate from below, as the opening in the bladder communicated with the cervix just below the peritoneal covering. The anterior vaginal wall was incised longitudinally, the incision beginning 5 or 6 cm. anterior to the cervix, and extending back to it. The bladder was dissected as wide as necessary to prevent tension on the sutures. A female metal catheter in the bladder served ,as a guide to expose the fistula. The cervix was circumscribed and dissected as far as possible, especial effort being made to remove the mucosa. Lembert sutures of chromic catgut closed the bladder. A second row, including whatever remained of cervical tissue, reinforced the first. These last sutures did not approximate the tissues completely, for fear that too much tension might be put on the bladder. The vaginal mucosa was then closed, and a retention catheter inserted into the bladder. It was very little trouble to close the para-rectal incision. A small drain was left in this wound. The patient made a good recovery. The catheter was removed on the 7th day, and the patient left the hospital on the 14th day. There has been no leakage up to the present timeone month after operation. Aside from the recovery of the patient, the interesting feature of this case is the successful closure of the vesico-cervical fistula by the para-rectal incision of Schuchardt. The incision is simple, injures no important structures, and provides an excellent exposure. General Hospital, suffering from injuries received in an automobile accident. According Lo the history, a rear wheel of a five-passenger automobile passed over the child's pelvis and lower abdomen. The baby presented but few symptoms of shock, but was restless. Pain apparently was not great. Few physical signs were present. There were several superficial abrasions marking the line of passage of the wheel across the pelvis. The abdomen was slightly more tense. than normal. There was no spasm or rigidity of abdominal muscles. No fluid wave could be made out, but flatness in the lower flank could be noted when the child was placed on either side. An x-ray, taken immediately, indicated an oblique fracture of the left ramus of the pubis within 3-4 inch of the symphysis. Catheterization gave an ounce of fluid, containing a large proportion of fresh blood. An hour after the accident, a small catheter was passed and six ounces of sterile salt solution were injected into the bladder. Subsequent catheterization within five minutes yielded only two and one-half ounces of fluid, containing blood. Under ether anesthesia, a mid-line incision one and one-half inches long was made just
doi:10.1056/nejm191807181790305 fatcat:m44me6fyx5cujba24jstru25lu