Part 56
An officer was wounded on the right side, on the 9th December, 1813, the ball being cut out behind; his case was considered hopeless. An hour afterward, on being moved to the fire, he desired to make water, and then passed what appeared to him to be a quantity of blood. Carried to the rear on a wagon for three leagues, he suffered beyond description, passed bloody water again, and on his arrival in quarters was bled and had an enema administered. He then became delirious, was bled several times, had blisters applied to the abdomen, suffered from pain at the top of the right shoulder, and took no other nourishment but tea for fourteen days. He gradually recovered, and at the end of seven weeks was sent to England. After remaining some time in London, he joined the depot of his regiment. In consequence of this exertion, he suffered an attack of fever and peritoneal inflammation; and a tumor formed in the site of the posterior wound, which was opened, and discharged several ounces of matter of a urinous odor. Another abscess formed, and was opened. During this time he suffered great pain and became greatly emaciated; the urine diminished in quantity with the frequent calls to pass it. He lingered in this state until the end of July. The flow of matter from the wound was great, and had a urinous smell. The desire to make water was incessant; but it passed only by drops, and brought him to a state of frenzy; the discharge from the wounds, which had been lessening for two days before, suddenly stopped; the pain and pressure of urine became intolerable; he remained at last in a state of the greatest torture for about three minutes, when, during an effort, a burst of urine took place, colored with blood, forcing out with it a hard lump, shaped like a short, thick shrimp, three-quarters of an inch long, which proved, when examined next day, to be the cloth which had been driven in by the ball. It must have passed from the pelvis of the kidney or the ureter into the bladder. It was hard, was covered by a black crust, and was thought to be a stone when passed. It could not, however, have been long in the bladder, or it would have been covered by the triple phosphates, and have formed the nucleus of a calculus requiring to be removed by operation.
Le Capitaine Negre, of the French Infantry of the Line, was struck on the left side above the hip, at the battle of Albuhera, by a musket-ball, which went through the upper part of the sigmoid flexure of the colon, and came out behind, injuring apparently the fourth and fifth lumbar vertebræ. As urine came through this opening, the ureter or lower part of the kidney must have been wounded; and, as he had lost the use of one leg and much of that of the other, the spinal marrow must also have been injured. He was left on the field of battle, supposed to be about to die, and was brought to me to the village of Valverde, three days afterward, in a most distressing state. The inflammatory symptoms had been and were severe; the pain he suffered on any attempt to move him was excessive; the discharge of feces from the anterior wound, and of urine from the posterior one and by the usual ways, rendered him miserable, and he at last implored me to allow the box of opium pills, of which one was given at night to each man who stood most in need of them, to be left within his reach, if I would not kindly do the act of a friend and give them to him myself. He died at the end of ten days, after great suffering, constantly regretting that our feelings as Christians caused their prolongation.
412. _Wounds of the spermatic cord_ are of infrequent occurrence, and rarely lead to fatal, although often to inconvenient consequences.
I have removed the bruised and shattered remains of a testis and epididymis to expedite the cure, and I have been obliged to do so at a later period in consequence of the wounded portion becoming enlarged and diseased. These occurrences are rare; the wound in the testis usually heals kindly; but the portion which remains, however, is probably of little use, although the patient does not like to lose it. A gentleman in perfect health was struck accidentally in the right testis by two shot, while out shooting partridges. The shot lodged, and gave rise to uneasiness, and after a time to an enlargement, which could not be distinguished from medullary sarcoma. I removed the testis, and the wound healed kindly. The lumbar glands had, however, taken on the disease, and he died of their great enlargement and the general mischief which ensued within the year. The preparation is in the museum of the College of Surgeons.
I have not had occasion to tie an artery, even when the penis has been as good as amputated. If bleeding should take place in the progress of the cure, a large catheter should be introduced into the urethra, as a point on which pressure may be made laterally; for I am not aware of any other use it can be, unless the urethra be also torn, when a moderate-sized catheter should be kept in it permanently, if it can be borne, to aid in the healing of the surrounding parts with as little contraction as possible of the canal. When the corpus spongiosum has been carried away or sloughs with the urethra, there is usually some injury done at the same time to the corpora cavernosa, and the part becomes contracted and curved when distended. I have not seen any of these cases since the introduction into practice of the methods which have been recommended by Dieffenbach and others for the formation of a new urethra by borrowing from the neighboring parts; but several might certainly have been benefited by such treatment.
A married soldier, of the 29th Regiment, was wounded on the heights of Roliça, in August, 1808, by a small musket-ball, which went through both corpora cavernosa from side to side. The man suffered very little inconvenience, and the wounds healed very well. He seemed to consider the injury as of no importance to himself, but had some idea there might be a difference of opinion in another party. There is usually a deficiency of substance at the part after such wounds, and sometimes on inconvenient curve or twist, such as often takes place when the corpora cavernosa and the corpus spongiosum are injured or ruptured from other causes.
LECTURE XXX.
WOUNDS OF THE PELVIS, ETC.
413. _Wounds of the pelvis_ from musket-balls injuring its contents are of common occurrence, and, although frequently fatal, often permit a considerable length of treatment before they destroy the sufferers or admit of their recovery. In many instances fistulous openings remain for years. The orifices of entrance and of exit of the ball lead to little information. It is only from the absence of paralysis or of hemorrhage, or of those signs which indicate the lesion of any of the organs contained within the pelvis, that the surgeon can form an estimate of the evil which has been committed; even when parts of the greatest importance are injured, such as the bladder or the rectum, the general symptoms are occasionally of little moment.
When paralysis occurs, which it rarely does unless the spinal marrow be injured, the functions of the bladder and of the rectum are implicated, and there is but little pain. When the nerves only are injured, the paralysis is not complete; it usually affects one side more than the other, is a numbness rather than a paralysis, and is accompanied by severe pain, sometimes at the seat of injury, but more usually extending to the thigh and to the extremities of the nerves in the foot. I was consulted in a case of wound from a pistol-shot, in the last dorsal or upper lumbar vertebra, of several years’ standing, in which the paralysis of both limbs was complete. The patient had a great desire to have the cicatrix opened, and the ball followed and extracted, and would willingly have submitted to such an operation, but he could not find any one in London or Paris willing to attempt it.
When a ball appears to cross or pass even from side to side of the pelvis, it is not always easy to say whether it has penetrated the cavity or not, until symptoms indicative of such injury appear; the less done to such wounds the better. When a ball enters, strikes a bone, and lodges, it is very desirable to ascertain its situation, in order that it may be at once removed, if it can possibly be done with but little comparative danger; for balls which lodge in these flat bones may often be removed, and the comfort of the patient assured by a timely operation, instead of proving the source of much torment and misery for many years by their being allowed to remain.
The late Colonel Wade, one of the most distinguished officers of his rank in Spain, was wounded at the battle of Albuhera, in 1811, by a musket-ball on the left side; it passed through the ilium, and was supposed to have narrowly avoided opening into the cavity of the abdomen. It could not be followed beyond the bone. The inflammatory symptoms were subdued in the usual time, and he gradually recovered his health, some pieces of bone coming away from time to time. A small fungous protrusion and discharge continued from the wound for several years, with a certain degree of pain, and of occasional lameness in the leg and thigh. The wound closed sometimes for a few months, and reopened after an attack of pain, with great lameness and swelling of the hip, and a discharge of matter from the original site. An abscess at last formed under the gluteus maximus, and was opened at its anterior and lower edge. This gave great relief and prevented the irritation of the upper and anterior original wound, the matter finding a more ready passage. I often assured him I could distinguish the ball very deeply seated; and in the summer of 1846, thirty-five years after the receipt of the injury, it had descended so far that I passed a probe under it at the distance of two inches and a half from the lower opening. He was to have come to London as early as his duties would possibly permit, in the spring of 1847, to have had it removed, when he was suddenly cut off by apoplexy, to the great regret of all who knew him.
The late General Sir Hercules Packenham, G.C.B., was wounded at the assault of Badajos by a musket-ball, April 6th, 1812, which deprived him of the use of the thumb and little finger, and partially of the hand; and by another which struck him on the right iliac region, passing in just below Poupart’s ligament and outwardly through the ilium. Eight pieces of bone came away at Elvas, and eleven more, in 1813, in London. He went to Baréges in 1814-15-16-17, with the hope that the ball might be loosened and removed, but in vain; it never could be found. A small quantity of inoffensive glutinous matter, sometimes streaked with blood, was discharged occasionally from the seat of the injury. At times the wound became painful and very troublesome for a week or ten days together, after which little inconvenience was felt in the limb.
Colonel Sir J. M. Wilson, now of Chelsea Hospital, was wounded in seven different places by three musket-balls on the left hip, at the Chippewa, near the Falls of Niagara, on the 5th of July, 1814. One, which struck him a little before the trochanter, passed upward through the ilium, (from which several pieces of bone came away on four or five different occasions,) and lodged against or in the spinal column, rendering the left leg quite powerless, and impairing the power of the right. He fell. Shortly after an Indian warrior came up, placed his foot on his neck, drew out his scalping-knife, seized his hair, and was in the act of beginning to scalp him, when a shot passed through his chest and laid him prostrate by the side of his intended victim, who thus happily escaped. The numbness and inability to put the limb to the ground continued from eighteen months to two years, during which time he was on crutches. After this he gradually recovered, always suffering more or less. The pain in the back is often most excruciating, coming on without any apparent cause, except perhaps from change of weather. He limps after walking a couple of miles, and if exercise be continued, pain ensues. He married in 1824, has several children, and is obliged to lead a very regular, quiet life, without which he breaks down. The great suffering he experiences, at the end of near forty years, is, however, from the pain in the back, sense of coldness in the left leg, and numbness accompanied by pain in the course of the nerves. He is equally sensible to heat in a close atmosphere, which he is obliged to avoid. The alvine and urinary secretions, etc. have always been impaired or deranged since the wound was received. He is troubled with painful affections and a train of nervous feelings of the whole system, attributable to the injury. The ball can of late be felt at the bottom of a soft swelling in the loins; but the colonel, since the affair of the Indian, has no predilection for cold steel, and protests as loudly against the scalpel of the surgeon as the scalping-knife of the Indian.
A soldier, of the Fourth Division of Infantry, was wounded at the battle of Salamanca by a musket-ball, which entered immediately above the right ilium, passed across, and made its exit nearly opposite on the left side, going nearer to the back than to the wall of the abdomen. He was supposed to be killed, but had recovered a little life when brought to me at the field hospital some hours afterward. The belly was swollen, generally tympanitic, and some hemorrhage had taken place from the wound of entrance, and he was unable to move the leg of that side. On reaction taking place, he was bled repeatedly, and treated antiphlogistically with the aid of calomel, opium, and antimony. He was removed to the San Domingo Hospital, and on the sixth day the bowels were relieved naturally. A small quantity of fecal matter was passed for several days with the discharge from the wound, but this gradually ceased, and the man ultimately recovered without any particular defect, except weakness and occasional pain and derangement of bowels, on any irregularity.
John Bryan, 1st Light Battalion of the King’s German Legion, was wounded on the 17th of June near Quatre Bras by a musket-ball, which entered at the groin, and made its exit behind. He was transported to Brussels, with his foot and leg in a state of mortification. Wine and other stimulants were freely given, and he rallied a little on the 23d and 24th. On the 25th, the stomach rejected everything except brandy and opium. On the 26th, a line of separation seemed to be about to form between the dead and the living parts, although he was evidently failing. He died on the 28th, eleven days after the receipt of the injury. On examination after death the ball was found to have completely divided the external iliac artery; about a pint of coagulated blood, mixed with some excessively fetid pus, was collected in the pelvis; the ends of the wounded artery had receded considerably from each other, and a coagulum had formed in each, which was easily squeezed out, the orifice of the upper end only being a little contracted. There were signs of some peritoneal inflammation having taken place; the intestines had not been wounded, and the ball, in passing out, had splintered the upper edge of the back part of the ilium.
General Sir Edward Packenham was killed instantaneously at New Orleans, by hemorrhage from a nearly similar wound, in which the common iliac artery was divided.
414. I have removed balls on different occasions which have lodged in the bones of the pelvis, and always with the greatest advantage, when done early. I have seen much evil result from their being allowed to remain, as they caused not only frequent distress, but at last gave rise to disease in the bone, derangement of the general health, and death. When the ball can be felt impacted in the bone, incisions through muscular parts of little consequence should not be spared to expose it. If an error exists at this moment, it is that too little is done, rather than too much. Too great reliance is placed on the efforts of nature, and not enough on the resources of art. The constant meddling with a wound is not recommended; nevertheless, much may be done by careful investigation from time to time, of which La Motte gives a good example in his fifty-first observation.
A grenadier was wounded at the battle of Dettingen, in 1743, by a musket-ball, which entered above Poupart’s ligament, near the opening of the external oblique muscle on the left side, and lodged. Thirteen days after his reception into the hospital at Landau, La Motte felt with the probe what he thought was the ball lying on the outside of the psoas muscle against the bone. He made the patient lie on his face, and touched the foreign body every day in order to loosen it. On the thirty-fifth day he was satisfied it was the ball, and on the forty-fifth, after many attempts, it was at last extracted. His fifty-second observation relates to a case as nearly similar as possible to those of Sir H. Packenham and Colonel Wade. He made several deep and long incisions in search of the ball, which he could not find; the wound became fistulous, and at the end of a year closed, in all probability to reopen from time to time.
The difference in practice between 1743 and 1855 ought to be, that in 1855 the ball should be found first, and the deep and long incisions made afterward for its extraction; which do not preclude any previous external openings that may be necessary to facilitate the first examination.
Captain Campbell was wounded by a pistol-ball, on the 5th of September, 1805; it penetrated the abdomen on the middle of the right side, and was extracted from nearly the same situation on the left; from its irregular denticulated shape, it would appear to have impinged against a vertebra. He complained of violent pain in the loins and belly, with numbness and pain of the left leg and thigh, and suffered also from the greatest oppression, anxiety, and sickness. An enema was administered, and twenty-four ounces of blood were taken from the arm; lower extremities nearly paralyzed; anxiety and oppression great at night. Blood-letting to ten ounces. Cannot pass his urine; hot fomentations; and at twelve at night sixteen more ounces of blood were drawn. At three P.M., had three motions, the two last containing apparently a pint of pure blood. Pain and other symptoms being urgent, eight ounces more blood were taken away. At six P.M., passed urine for the first time, highly tinged with blood; has had two motions, also mixed with blood. Pain continuing, ten ounces of blood were abstracted, although occasionally almost fainting on any movement; belly fomented. At eight at night, sixty drops of laudanum. At ten, being very restless, twenty drops more, which procured some sleep, although he vomited frequently; belly relieved by the fomentation; three stools mixed with blood.
Sept. 6th.--All the symptoms relieved; passes blood with his urine; sickness and vomiting troublesome; pulse 90, rather firm than feeble. One o’clock.--Complains of violent pain in the left leg and thigh, belly, and loins; pulse 116, full and strong. Blood-letting to sixteen ounces. Barley-water with niter for common drink. Six P.M.--Pulse 96; bowels open, with discharge of blood; symptoms generally relieved. Tincture of opium, twelve drops at night.
8th.--Slept better; less pain; paralysis continues. In the evening symptoms aggravated; lost twelve ounces of blood; enema, etc. repeated; pulse 120.
9th, 10th, 11th, 12th.--Pulse 96; bowels open; urine bloody; is generally better.
15th.--Wound of exit healed; urine bloody; bowels open. Chicken-broth for the first time.
20th.--The opening of entrance having nearly closed was enlarged, and a free exit allowed for the matter.
Oct. 20th.--Wounds quite closed; is free from pain, is able to move about the house on crutches; warm, stimulating applications to the limbs seem to have given most relief.
Nov. 20th.--Paralytic affection gone; he can now mount his horse, and has only a feeling of numbness and torpor in the left leg and thigh.
415. The general opinion which formerly prevailed, that _wounds of the bladder_, by musket-balls, were for the most part mortal, is now known to be erroneous. When the bladder is wounded below, where it is not covered by the peritoneum, persons do sometimes recover by what may be considered the almost unaided efforts of nature. A large number of cases came under my observation at Brussels and at Antwerp, and many had already died. Persons rarely recover in whom urine has found its way into the general cavity of the abdomen. They generally die of inflammation in from three to six days.
When the bladder is wounded where it is covered by the peritoneum, and the opening or openings do not by some accident permit the urine to flow into the cavity of the abdomen, the patient may be free from immediate danger for a short time, although very anxious and greatly depressed in countenance and manner, and even sick to vomiting. The pain is not commonly severe at first, and if he can make water, which in all such cases it is desirable to prevent by having recourse to the catheter, it is more or less colored or mixed with blood. If the urine should not escape into the cavity of the abdomen, the ordinary inflammation which must necessarily ensue takes place and affects the internal surface of the bladder. The desire to pass urine becomes greater, and is frequently insupportable, while it can in some cases be only passed by drops. In others these symptoms are less urgent. Nevertheless, the natural action of the bladder, or, in those severe cases, the additional efforts which are made for its expulsion by the abdominal muscles, may cause the urine to be forced through the wound into the cavity of the abdomen, whence the advantage to be obtained from the early use of the elastic catheter. When the orifices of entrance and of exit are free, and low down in the pelvis, the urine may run out without much immediate mischief ensuing. But as this cannot always be known, an elastic gum catheter should be introduced from the first and fixed in the bladder, in every case where the nature of the injury is doubtful, until the urine ceases to flow through the wounds. It must, however, be recollected that in some cases in which it has caused great irritation, by being introduced too early, while the bladder was very sensitive, the patients have been much relieved by its removal. The principle is nevertheless incontrovertible in all doubtful cases; the urine should be allowed to drop out of the catheter nearly as fast as it passes into the bladder, when this organ is very irritable; great pains should also be taken that the end of the instrument should be within, but not too far within the bladder, so as to excite irritation by rubbing against its sides, or to allow its end rising above the urine which might in this way collect below it, and at last escape through the wounds.
416. The inflammatory actions are to be subdued by general bleeding, the application of leeches, the administration of diluent drinks in moderate quantity, the exhibition of gentle aperients, such as castor-oil, and by enemata. Opium in all these cases is an important remedy, principally in the shape of morphia. Opium in substance, when introduced into the rectum in the shape of a suppository, or dissolved in half an ounce or an ounce of water as an enema, should be repeated in such quantities, beginning with two grains, as will procure ease.