anomalies and curiosities of medicine-第169部分

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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　recovereda　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　othersa　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