Chapter XV

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Rupture of the ureter is a very rare injury. Poland has collected the histories of four cases, one of which ended in recovery after the evacuation by puncture, at intervals, of about two gallons of fluid resembling urine. The other cases terminated in death during the first, fourth, and tenth weeks respectively. Peritonitis was apparently not present in any of the cases, the urinary extravasation having occurred into the cellular tissue behind the peritoneum.

There are a few recorded cases of uncomplicated wounds of the ureters. The only well authenticated case in which the ureter alone was divided is the historic injury of the Archbishop of Paris, who was wounded during the Revolution of 1848, by a ball entering the upper part of the lumbar region close to the spine. Unsuccessful attempts were made to extract the ball, and as there was no urine in the bladder, but a quantity escaping from the wound, a diagnosis of divided ureter was made. The Archbishop died in eighteen hours, and the autopsy showed that the ball had fractured the transverse process of the 3d lumbar vertebra, and divided the cauda equina just below its origin; it had then changed direction and passed up toward the left kidney, dividing the ureter near the pelvis, and finally lodged in the psoas muscle.

It occasionally happens that the ureter is wounded in the removal of uterine, ovarian, or other abdominal tumors. In such event, if it is impossible to transplant to the bladder, the divided or torn end should be brought to the surface of the loin or vagina, and sutured there. In cases of malignant growth, the ureter has been purposely divided and transplanted into the bladder. Penrose, assisted by Baldy, has performed this operation after excision of an inch of the left ureter for carcinomatous involvement. The distal end of the ureter was ligated, and the proximal end implanted in the bladder according to Van Hook's method, which consists in tying the lowered end of the ureter, then making a slit into it, and invaginating the upper end into the lower through this slit. A perfect cure followed. Similar cases have been reported by Kelly, Krug, and Bache Emmet. Reed reports a most interesting series in which he has successfully transplanted ureters into the rectum.

Ureterovaginal fistulae following total extirpation of the uterus, opening of pelvic abscesses, or ulcerations from foreign bodies, are repaired by an operation termed by Bazy of Paris ureterocystoneostomy, and suggested by him as a substitute for nephrectomy in those cases in which the renal organs are unaffected. In the repair of such a case after a vaginal hysterectomy Mayo reports a successful reimplantation of the ureter into the bladder.

Stricture of the ureter is also a very rare occurrence except as a result of compression of abdominal or pelvic new growths. Watson has, however, reported two cases of stricture, in both of which a ureter was nearly or quite obliterated by a dense mass of connective tissue. In one case there was a history of the passage of a renal calculus years previously. In both instances the condition was associated with pyonephrosis. Watson has collected the reports of four other cases from medical literature.

A remarkable procedure recently developed by gynecologists,

## particularly by Kelly of Baltimore, is catheterization and sounding of

the ureters. McClellan records a case of penetration of the ureter by the careless use of a catheter.

Injuries of the Bladder.--Rupture of the bladder may result from violence without any external wound (such as a fall or kick) applied to the abdomen. Jones reports a fatal case of rupture of the bladder by a horse falling on its rider. In this case there was but little extravasation of urine, as the vesical aperture was closed by omentum and bowel. Assmuth reports two cases of rupture of the bladder from muscular action. Morris cites the history of a case in which the bladder was twice ruptured: the first time by an injury, and the second time by the giving way of the cicatrix. The patient was a man of thirty-six who received a blow in the abdomen during a fight in a public house on June 6, 1879. At the hospital his condition was diagnosed and treated expectantly, but he recovered perfectly and left the hospital July 10, 1879. He was readmitted on August 4, 1886, over seven years later, with symptoms of rupture of the bladder, and died on the 6th. The postmortem showed a cicatrix of the bladder which had given way and caused the patient's death.

Rupture of the bladder is only likely to happen when the organ is distended, as when empty it sinks behind the pubic arch and is thus protected from external injury. The rupture usually occurs on the posterior wall, involving the peritoneal coat and allowing extravasation of urine into the peritoneal cavity, a condition that is almost inevitably fatal unless an operation is performed. Bartels collected the data of 98 such cases, only four recovering. When the rent is confined to the anterior wall of the bladder the urine escapes into the pelvic tissues, and the prognosis is much more favorable. Bartels collected 54 such cases, 12 terminating favorably. When celiotomy is performed for ruptured bladder, in a manner suggested by the elder Gross, the mortality is much less. Ashhurst collected the reports of 28 cases thus treated, ten of which recovered--a mortality of 64.2 per cent. Ashhurst remarks that he has seen an extraperitoneal rupture of the anterior wall of the bladder caused by improper use of instruments, in the case of retention of urine due to the presence of a tight urethral stricture.

There are a few cases on record in which the bladder has been ruptured by distention from the accumulation of urine, but the accident is a rare one, the urethra generally giving way first. Coats reports two cases of uncomplicated rupture of the bladder. In neither case was a history of injury obtainable. The first patient was a maniac; the second had been intoxicated previous to his admission to the hospital, with symptoms of acute peritonitis. The diagnosis was not made. The first patient died in five days and the second in two days after the onset of the illness. At the autopsies the rent was found to be in both instances in the posterior wall of the bladder a short distance from the fundus; the peritoneum was not inflamed, and there was absolutely no inflammatory reaction in the vesical wound. From the statistics of Ferraton and Rivington it seems that rupture of the bladder is more common in intoxicated persons than in others--a fact that is probably explained by a tendency to over-distention of the bladder which alcoholic liquors bring about. The liquor imbibed increases the amount of urine, and the state of blunted consciousness makes the call to empty the bladder less appreciated. The intoxicated person is also liable to falls, and is not so likely to protect himself in falling as a sober person.

Gunshot Wounds of the Bladder.--Jackson relates the remarkable recovery of a private in the 17th Tennessee Regiment who was shot in the pelvis at the battle of Mill Springs or Fishing Creek, Ky. He was left supposedly mortally wounded on the field, but was eventually picked up, and before receiving any treatment hauled 164 miles, over mountainous roads in the midst of winter and in a wagon without springs. His urine and excretions passed out through the wounds for several weeks and several pieces of bone came away. The two openings eventually healed, but for twenty-two months he passed pieces of bone by the natural channels.

Eve records the case of a private in the Fifth Tennessee Cavalry who was shot in the right gluteal region, the bullet penetrating the bladder and making its exit through the pubis. He rode 30 miles, during which the urine passed through the wound. Urine was afterward voided through the left pubic opening, and spicules of bone were discharged for two years afterward; ultimate recovery ensued.

Barkesdale relates the history of the case of a Confederate soldier who was shot at Fredericksburg in the median line of the body, 1 1/2 inches above the symphysis, the wound of exit being in the median line at the back, 1/2 inch lower down. Urine escaped from both wounds and through the urethra. There were no bad symptoms, and the wounds healed in four weeks.

The bladder is not always injured by penetration of the abdominal wall, but may be wounded by penetration through the anus or vagina, or even by an instrument entering the buttocks and passing through the smaller sacrosciatic notch. Camper records the case of a sailor who fell from a mast and struck upon some fragments of wood, one of which entered the anus and penetrated the bladder, the result being a rectovesical fistula. About a year later the man consulted Camper, who unsuccessfully attempted to extract the piece of wood; but by incising the fistula it was found that two calculi had formed about the wooden pieces, and when these were extracted the patient recovered. Perrin gives the history of a man of forty who, while adjusting curtains, fell and struck an overturned chair; one of the chair-legs penetrated the anus. Its extraction was followed by a gush of urine, and for several days the man suffered from incontinence of urine and feces. By the tenth day he was passing urine from the urethra, and on the twenty-fifth day there was a complete cicatrix of the parts; fifteen days later he suffered from an attack of retention of urine lasting five days; this was completely relieved after the expulsion of a small piece of trouser-cloth which had been pushed into the bladder at the time of the accident. Post reports the case of a young man who, in jumping over a broomstick, was impaled upon it, the stick entering the anus without causing any external wound, and penetrating the bladder, thus allowing the escape of urine through the anus. A peculiar sequela was that the man suffered from a calculus, the nucleus of which was a piece of the seat of his pantaloons which the stick had carried in.

Couper reports a fatal case of stab-wound of the buttocks, in which the knife passed through the lesser sacrosciatic notch and entered the bladder close to the trigone. The patient was a man of twenty-three, a seaman, and in a quarrel had been stabbed in the buttocks with a long sailor's knife, with resultant symptoms of peritonitis which proved fatal. At the autopsy it was found that the knife had passed through the gluteal muscles and divided part of the great sacrosciatic ligament. It then passed through the small sacrosciatic notch, completely dividing the pudic artery and nerve, and one vein, each end being closed by a clot. The knife entered the bladder close to the trigone, making an opening large enough to admit the index finger. There were well-marked evidences of peritonitis and cellulitis.

Old-time surgeons had considerable difficulty in extracting arrow-heads from persons who had received their injuries while on horseback. Conrad Gesner records an ingenious device of an old surgeon who succeeded in extracting an arrow which had resisted all previous attempts, by placing the subject in the very position in which he was at the time of reception of the wound. The following noteworthy case shows that the bladder may be penetrated by an arrow or bullet entering the buttocks of a person on horseback. Forwood describes the removal of a vesical calculus, the nucleus of which was an iron arrow-head, as follows: "Sitimore, a wild Indian, Chief of the Kiowas, aged forty-two, applied to me at Fort Sill, Indian Territory, August, 1869, with symptoms of stone in the bladder. The following history was elicited: In the fall of 1862 he led a band of Kiowas against the Pawnee Indians, and was wounded in a fight near Fort Larned, Kansas. Being mounted and leaning over his horse, a Pawnee, on foot and within a few paces, drove an arrow deep into his right buttock. The stick was withdrawn by his companions, but the iron point remained in his body. He passed bloody urine immediately after the injury, but the wound soon healed, and in a few weeks he was able to hunt the buffalo without inconvenience. For more than six years he continued at the head of his band, and traveled on horseback, from camp to camp, over hundreds of miles every summer. A long time after the injury he began to feel distress in micturating, which steadily increased until he was forced to reveal this sacred secret (as it is regarded by these Indians), and to apply for medical aid. His urine had often stopped for hours, at which times he had learned to obtain relief by elevating his hips, or lying in different positions. The urine was loaded with blood and mucus and with a few pus globules, and the introduction of a sound indicated a large, hard calculus in the bladder. The Indians advised me approximately of the depth to which the shaft had penetrated and the direction it took, and judging from the situation of the cicatrix and all the circumstances it was apparent that the arrow-head had passed through the glutei muscles and the obturator foremen and entered the cavity of the bladder, where it remained and formed the nucleus of a stone. Stone in the bladder is extremely rare among the wild Indians, owing, no doubt, to their almost exclusive meat diet and the very healthy condition of their digestive organs, and this fact, in connection with the age of the patient and the unobstructed condition of his urethra, went very far to sustain this conclusion. On August 23d I removed the stone without difficulty by the lateral operation through the perineum. The lobe of the prostate was enlarged, which seemed to favor the extent of the incision beyond what would otherwise have been safe. The perineum was deep and the tuberosities of the ischii unnaturally approximated. The calculus of the mixed ammoniaco-magnesian variety was egg-shaped, and weighed 19 drams. The arrow-point was completely covered and imbedded near the center of the stone. It was of iron, and had been originally about 2 1/2 inches long, by 7/8 inch at its widest part, somewhat reduced at the point and edges by oxidation. The removal of the stone was facilitated by the use of two pairs of forceps,--one with broad blades, by which I succeeded in bringing the small end of the stone to the opening in the prostate, while the other, long and narrow, seized and held it until the former was withdrawn. In this way the forceps did not occupy a part of the opening while the large end of the stone was passing through it. The capacity of the bladder was reduced, and its inner walls were in a state of chronic inflammation. The patient quickly recovered from the effects of the chloroform and felt great relief, both in body and mind, after the operation, and up to the eighth day did not present a single unfavorable symptom. The urine began to pass by the natural channel by the third day, and continued more or less until, on the seventh day, it had nearly ceased to flow at the wound. But the restless spirit of the patient's friends could no longer be restrained. Open hostility with the whites was expected to begin at every moment, and they insisted on his removal. He needed purgative medicine on the eighth day, which they refused to allow him to take. They assumed entire charge of the case, and the following day started with him to their camps 60 miles away. Nineteen days after he is reported to have died; but his immediate relatives have since assured me that his wound was well and that no trouble arose from it. They described his symptoms as those of bilious remittent fever, a severe epidemic of which was prevailing at the time, and from which several white men and many Indians died in that vicinity." The calculus was deposited in the Army Medical Museum at Washington, and is represented in the accompanying photograph, showing a cross-section of the calculus with the arrow-head in situ.

As quoted by Chelius, both Hennen and Cline relate cases in which men have been shot through the skirts of the jacket, the ball penetrating the abdomen above the tuberosity of the ischium, and entering the bladder, and the men have afterward urinated pieces of clothing, threads, etc., taken in by the ball. In similar cases the bullet itself may remain in the bladder and cause the formation of a calculus about itself as a nucleus, as in three cases mentioned by McGuire of Richmond, or the remnants of cloth or spicules of bone may give rise to similar formation. McGuire mentions the case of a man of twenty-three who was wounded at the Battle of McDowell, May 8, 1862. The ball struck him on the horizontal ramus of the left pubic bone, about an inch from the symphysis, passed through the bladder and rectum, and came out just below the right sacrosciatic notch, near the sacrum. The day after the battle the man was sent to the general hospital at Staunton, Va., where he remained under treatment for four months. During the first month urine passed freely through the wounds made by the entrance and exit of the ball, and was generally mixed with pus and blood. Fecal matter was frequently discharged through the posterior wound. Some time during the third week he passed several small pieces of bone by the rectum. At the end of the fifth week the wound of exit healed, and for the first time after his injury urine was discharged through the urethra. The wound of entrance gradually closed after five months, but opened again in a few weeks and continued, at varying intervals, alternately closed and open until September, 1865. At this time, on sounding the man, it was found that he had stone; this was removed by lateral operation, and was found to weigh 2 1/4 ounces, having for its nucleus a piece of bone about 1/2 inch long. Dougherty reports the operation of lithotomy, in which the calculus removed was formed by incrustations about an iron bullet.

In cases in which there is a fistula of the bladder the subject may live for some time, in some cases passing excrement through the urethra, in others, urine by the anus. These cases seem to have been of

## particular interest to the older writers, and we find the literature of

the last century full of examples. Benivenius, Borellus, the Ephemerides, Tulpius, Zacutus Lusitanus, and others speak of excrement passing through the penis; and there are many cases of vaginal anus recorded. Langlet cites an instance in which the intestine terminated in the bladder. Arand mentions recovery after atresia of the anus with passage of excrement from the vulva. Bartholinus, the Ephemerides, Fothergill, de la Croix, Riedlin, Weber, and Zacutus Lusitanus mention instances in which gas was passed by the penis and urethra. Camper records such a case from ulcer of the neighboring or connecting intestine; Frank, from cohesion and suppuration of the rectum; Marcellus Donatus, from penetrating ulcer of the rectum; and Petit, from communication of the rectum and bladder in which a cure was effected by the continued use of the catheter for the evacuation of urine.

Flatus through the vagina, vulva, and from the uterus is mentioned by Bartholinus, the Ephemerides, Meckel, Mauriceau, Paullini, Riedlin, Trnka, and many others in the older literature. Dickinson mentions a Burmese male child, four years old, who had an imperforate anus and urethra, but who passed feces and urine successfully through an opening at the base of the glans penis. Dickinson eventually performed a successful operation on this case. Modern literature has many similar instances.

In the older literature it was not uncommon to find accounts of persons passing worms from the bladder, no explanations being given to account for their presence in this organ. Some of these cases were doubtless instances of echinococcus, trichinae, or the result of rectovesical fistula, but Riverius mentions an instance in which, after drinking water containing worms, a person passed worms in the urine. In the old Journal de physique de Rozier is an account of a man of forty-five who enjoyed good health, but who periodically urinated small worms from the bladder. They were described as being about 1 1/2 lines long, and caused no inconvenience. There is also mentioned the case of a woman who voided worms from the bladder. Tupper describes a curious case of a woman of sixty-nine who complained of a severe, stinging pain that completely overcame her after micturition. An ulceration of the neck of the bladder was suspected, and the usual remedies were applied, but without effect. An examination of the urine was negative. On recommendation of her friends the patient, before going to bed, steeped and drank a decoction of knot-grass. During the night she urinated freely, and claimed that she had passed a worm about ten inches long and of the size of a knitting-needle. It exhibited motions like those of a snake, and was quite lively, living five or six days in water. The case seems quite unaccountable, but there is, of course, a possibility that the animal had already been in the chamber, or that it was passed by the bowel. A rectovaginal or vesical fistula could account for the presence of this worm had it been voided from the bowel; nevertheless the woman adhered to her statement that she had urinated the worm, and, as confirmatory evidence, never complained of pain after passing the animal.

Foreign bodies in the bladder, other than calculi (which will be spoken of in