Part 57
417. The urine, in most cases of injury below the peritoneum, flows readily through the wound of entrance, if not of exit, in the first instance, and care should be taken, by enlarging the posterior wound, that no obstacle within reach shall prevent it; but after inflammation has been established, the parts swell, and as the sloughs begin to separate, its passage is often obstructed; the elastic catheter, if not used before, will then render important service by allowing the sloughs to be separated without the healthy parts being irritated by the urine being retained. After a time the urine may be only drawn off in small quantities through the catheter, as frequently as circumstances may render advisable. The permanent use of the catheter in these cases will often prevent the urine from forming any devious paths as it proceeds outward, ending in abscesses and fistulous openings, causing much discomfort and even misery. It is not common for blood to be poured into the bladder in such a quantity as to cause much inconvenience; it coagulates with equal proportions of urine, and a silver catheter should be used, by which it may be broken up and rendered more easy of solution by injections of warm water. When the neck of the bladder or the prostatic part of the urethra has been divided so that a catheter cannot be efficiently used, surgery must come with more immediate aid to the assistance of the sufferer, by making a clear and free opening from the perineum for the evacuation of the urine and of the discharge from the wound. If a ball lodge in or near the bladder, or in the prostate, it must be removed by an operation in the perineum.
A soldier of the Light Division was wounded on the heights of Vera, in the Pyrenees. A musket-ball had entered behind near the sacrum and lodged. He was bled twice, in consequence of suffering pain in the part, but was not otherwise much disturbed. There was at first a difficulty in passing urine, but this gradually subsided, although he always suffered pain in micturition, which was frequent and distressing. He remained in this state until December, when he passed, with considerable effort and after much difficulty, a hard piece of his jacket about half an inch in length, larger than the orifice of the urethra, through which it was forced. As it was not incased by calcareous matter, it could not have been long in the bladder, but must have been lodged near it before it ulcerated its way in, giving rise to the constant desire and irritation which he had so long experienced. His symptoms then subsided, although they had not entirely disappeared when he left for England.
A French soldier was wounded by a musket-ball on the back part of the right hip, at Almaraz, on the Tagus, was taken prisoner, and sent to Lisbon in the autumn of 1813. The ball had lodged, but gave him little inconvenience at the time beyond some pain in the course of the sciatic nerve, subsequently followed by defect of motion on the right side. Four months after the injury pain came on about the region of the bladder, with great desire to pass urine, which he could not do when standing, but which dribbled away when lying down. When quiet he suffered little, but great pain followed any attempt at continued motion. A catheter could be introduced, but with great difficulty when it reached the prostate gland, which was exceedingly tender to the touch. After a time the instrument could not be passed, and the man was in great agony until something appeared to give way, and a discharge of matter took place, when the urine followed, and he was relieved. An abscess had formed, in all probability from the proximity of the ball, which still could not be felt. The man recovered, retaining, however, his former state of lameness and defect of power, although relieved from the vexatious irritation of the bladder.
A soldier of the Fourth Division of Infantry was wounded at the battle of Toulouse, while entering a redoubt, by a musket-ball, which entered at the left groin, and, crossing the pelvis, came out on the upper part of the opposite hip behind. The urine flowed from both wounds and from the rectum, indicating that the ball had passed between these parts, and a little feces came from the posterior wound for three weeks. The pain and suffering were not great, and principally arose from retention of urine, requiring the use of the catheter, which was left in, and changed from time to time, until the urine flowed by the side of it, instead of through the wounds, which it did occasionally for some weeks in drops, but not in any quantity; after which the wounds gradually closed, and the man was sent to England cured.
A soldier of the Cavalry of the King’s German Legion was struck, at the battle of Salamanca, by a musket-ball, which entered just above the pubes a little to the right side, and came out below on the opposite nates. The urine flowed readily through both wounds for the first three days, and he suffered afterward from great pain and distress about the region of the bladder, from which he could not expel any urine, neither would it pass by either wound. I immediately introduced a catheter, drew off a moderate quantity of urine, and then fixed it in the bladder, desiring him to draw off his urine every hour when awake. This he did, often leaving the stopper out at night. The urine flowed after a few days through the posterior wound, and then ceased. The catheter was washed from time to time, and was at last withdrawn, as the urine began to flow by the side of it, and the wound had finally closed when he left the San Domingo Hospital.
Captain Martin received a wound from a musket-ball at the siege of Ciudad Rodrigo; it entered just above the pubes, passed through the bladder and rectum, and came out behind, splintering the sacrum, the contents of both viscera being freely discharged through this opening. As he suffered but little inconvenience from the urine, very little of which passed by the urethra, that passage was not interfered with in the first instance. Inflammatory symptoms were kept within due bounds, the rectum was carefully washed out by emollient enemata, and his food rendered as light as possible. Under this treatment he gradually improved; the anterior wound first healed, and subsequently the posterior one, leaving him comparatively well when he left me for Lisbon on his way to England.
418. These cases give, however, a brighter view of the nature of these wounds than they frequently justify; extravasation of urine, inflammation, and death are not of infrequent occurrence in cases to which strict attention is not paid; and great misery is often caused from the irritation of the bladder and the discharge which follows, until the constitution is undermined and death ensues.
Captain Sleigh, of the 100th Regiment, was wounded at the battle of Chippewa, on the 5th of July, 1814, by a musket-ball, which entered the left groin immediately over Poupart’s ligament, by the side of the spermatic vessels, injuring in its course the anterior brim of the pelvis. It thence passed through the bladder obliquely across the pelvis, and terminated its course beneath the integuments in the right buttock, whence it was immediately extracted. Blood and urine flowed incessantly from the groin; the quantity of blood lost was considerable. He complained much of pain in the hypogastric region; the abdomen was tense and painful to the touch, and he had an almost continued inclination to micturate; but his attempts, after the most painful efforts, were entirely frustrated. The anxiety was great, the respiration hurried, and the pulse quick and fluttering. He was bled to the extent of thirty ounces; an enema was given; fomentations applied to the belly; and the catheter introduced--all which afforded him some relief. The next day he was removed to the rear, a distance of seventeen miles, in an open wagon, partly during the inclemency of the night, and was quite worn out by so long a journey. He was carried thence on board ship, and landed at York on the morning of the 9th of July, the fourth day after he received his wound.
July 9th.--Abdomen tense and painful to the touch; severe pain in the perineum; great inclination to void urine, but fruitlessly; wound in the groin sloughy, discharges urine and blood mixed with a small quantity of pus; posterior wound healthy, no discharge of urine from it; catheter attempted to be passed without success. Ordered an ounce and a half of castor-oil immediately.
10th.--Passed a restless night; had two copious stools; voided a few drops of urine by the urethra; still great inclination to pass urine. Ordered two grains of extract of opium made into a pill.
11th.--All the painful sensations much relieved; abdomen less tense; a small piece of bone extracted from the urethra about an inch in length, of the thickness of a crow-quill; a little urine followed more freely.
15th.--Complains of severe pain in the spermatic cord; discharge from groin more offensive; wound filled with large maggots; bowels open.
19th.--Wound of groin looks clean; a small piece of bone discharged by the urethra, and a piece of cloth extracted from the groin.
24th.--A small piece of bone extracted from the groin.
August 5th.--Passes a good deal of pus and urine by the urethra.
29th.--Posterior wound much inflamed and very painful upon pressure. A poultice to be frequently applied.
Sept. 1st.--An abscess has burst; a piece of cloth has been extracted; urine and pus are discharged by both wounds.
12th.--Doing well; wounds closing.
16th.--Bladder resuming its power; discharge of matter from groin very trivial.
Oct. 4th.--Posterior wound closed.
30th.--Wound of groin closed; urine, passed by the natural passage, mixed with pus.
At first it was supposed that only the fundus of the bladder was wounded; but when the collection of matter took place in the right buttock, and a piece of cloth was extracted from it, the urine following, it was evident that both sides of the bladder had been transfixed by the ball; and that, probably, the urine from the commencement had been prevented flowing posteriorly by the intervention of this foreign body. An elastic gum catheter could not be passed into the bladder on account of the piece of bone which had forced its way into the urethra, and from its being obstructed afterward by smaller pieces of bone.
When I saw this gentleman some time afterward, it appeared to me that the purulent discharge from the urethra was not from the inner membrane of the bladder, but was probably caused by some dead bone of the pelvis having a communication with the bladder by a fistulous opening.
A soldier, of the King’s German Legion, was struck, at Waterloo, by a musket-ball, which entered a little way above the pubes, and lodged. The symptoms which immediately followed were by no means severe, although he passed a little bloody urine at first; the external wound closed without difficulty. He complained of pain at the neck of the bladder, and had a great desire to pass urine, with other signs of stone in the bladder, which induced me to pass a sound, when I found that the ball was lying loose in that viscus. On his arrival at the York Hospital, at Chelsea, from Brussels, he became, with the French soldier, whose thigh had been amputated at the hip-joint, an object of great attention. I performed the operation for the removal of the ball in the presence of a large concourse of military and medical persons. It was done in less than two minutes; but the calculus, composed of the triple phosphates, which had formed around the ball, yielded, and broke under the forceps. The pieces were removed separately. The ball, being heavy, fell below the neck of the bladder, which, being healthy, yielded to the pressure, and allowed it to sink on the rectum, where it could not be caught by the forceps, until it had been raised by a finger in the bowel. The bladder was then well washed out, so as to remove all the pieces that might remain, and the man was placed in bed. He was bled once in consequence of some apprehension of pain; but he had not a bad symptom, and rapidly recovered.
The symptoms of irritation did not, however, entirely pass away, as could have been wished, and I began to fear that some small pieces of calculus had been overlooked; when, one morning, after considerable effort, he passed a ring of sandy calcareous matter, which had formed around the orifice of the bladder, and which, being dislodged, had fortunately entered the urethra, along which it was forced by the urine. It was evidently formed of the phosphates in minute portions, which had become agglutinated together, around the meatus of the bladder. This he took with him to Hanover, where it, himself, and the cicatrixes of his wound, and of his operation, attracted great notice. The ball, which was flattened on one side, I kept in a small box, together with the pieces of calculus which were extracted, and showed them annually at my lecture on this subject for many years. One evening, however, I unfortunately left my little box on the table after lecture; and when I recollected, and returned for it, I found that some gentleman had borrowed it, and has not yet returned it. At the battle of Chillianwallah a similar wound took place; the ball formed the nucleus of a calculus, and was removed successfully by a gentleman in the service of the East India Company, whose name I have not been able to learn.
The following case, from Baron Percy, is in point: A young man was wounded by a pistol-shot, which entered just above the os pubis, through the linea alba, wounded the bladder, and lodged. The belly swelled; a tumor formed in the perineum; no urine passed; the bowels were confined, and fever ran high, with a tendency to delirium. Believing that the tumor in the perineum, and the fluctuation he thought he perceived, might be caused by extravasated urine, he punctured it with a trocar, and evacuated a large quantity of bloody urine. This induced him to enlarge the opening, and carry it on to the bladder, through which he brought out the ball, some shirt, and several clots of blood. The man was bled nine times in all; the urine after a time passed in the ordinary way, and the patient slowly recovered.
An officer was wounded near Bayonne, by a musket-ball, on the left side; it passed through the ilium across the pubes, and made its exit through the gluteus maximus of the opposite side, but lower down. Urine flowed through both wounds at first very readily, but none of any moment came by the urethra, from which some blood occasionally oozed. The attempt to pass a catheter failed, although the desire to make water was urgent and painful. After a few days the passage of urine by the external wounds became obstructed, apparently by the sloughs; great pain and misery were experienced; fever ran high; rigors and delirium followed extravasation of urine, and death closed the scene. The mischief here arose from the catheter not having been passed into the bladder, which could not be effected, from the prostatic part of the urethra or the neck of the bladder having been injured.
419. Surgery in such, or in nearly similar cases, requires a catheter or staff to be passed down the urethra as far as it will go; an incision should then be made upon it, from the center or across the perineum, and the urethra divided on the staff until the finger rests upon the wounded parts, when, in all probability, a straight catheter, with the aid of the forefinger in the rectum, can be carried through them into the bladder. The urine will then have a direct passage outward, instead of coming indirectly from the bladder by the wounds. If the straight catheter cannot be passed, which can scarcely occur, the central incision is to be continued from the point of obstruction into the bladder, guided by the finger in the rectum. A free opening from the bladder offers the only hope of safety.
420. The _rectum_ may be wounded without any other organ being injured within the pelvis; of this I have seen several instances. Captain Gordon, of the navy, was struck by a rifle-ball toward the lower part of one side of the sacrum, after being knocked down by one he had received on the head, and by another in the neck and back. The ball, which passed into the rectum, made its exit on the opposite side of the sacrum, and stercoraceous matters were evacuated by both wounds. The pain was severe; the limbs were deprived of much of their power of motion, and the next day the bladder was incapable of expelling its contents. This was relieved by the catheter, and the rectum was kept clear by warm, mild enemata, while the inflammatory symptoms were subdued by bleeding, opium, starvation, and rest. At the end of three months he was able to walk, but with some difficulty, on account of defective power in one leg. Some small pieces of bone came away and the wounds closed, although he was subject to an occasional slight opening of the orifice of entrance, from which a little matter was discharged, when it again closed. He remained more or less lame until his death, which took place with the loss of the ship he commanded, in a hurricane, on the coast of North America.
A French soldier was wounded at the battle of Salamanca by a ball, which entered by the side of the sacrum, and lodged. Having been rode over and bruised, he was taken prisoner, and brought to me on the field of battle. From this wound he suffered comparatively little, except from a difficulty of passing urine. On the third day after his arrival at the San Carlos Hospital, or the sixth from the receipt of the injury, he passed the ball per anum. The wound quickly closed, and he aided his comrades as an orderly in the hospital afterward.
CONCLUSIONS.
421.--1. Severe blows on the abdomen give rise to the absorption of the muscular structures, and the formation of ventral hernia, in many instances; this may, in some measure, be prevented during the treatment, by quietude, by the local abstraction of blood, and by the early use of retaining bandages.
2. Abscesses in the muscular wall of the abdomen, from whatever cause they arise, should be opened early; for although the peritoneum is essentially strong by its outer surface, it is but a thin membrane, and should be aided surgically as much as possible.
3. Severe blows, attended by general concussion, frequently give rise to rupture of the solid viscera, such as the liver and the spleen, causing death by hemorrhage. When the hollow viscera are ruptured, such as the intestines or the bladder, death ensues from inflammation.
4. Incised wounds of the wall of the abdomen to any extent rarely unite so perfectly (except, perhaps, in the linea alba) as not to give rise to ventral protrusions of a greater or less extent.
5. As the muscular parts rarely unite in the first instance after being divided, sutures should never be introduced into these structures.
6. Muscular parts are to be brought into apposition, and so retained principally by position, aided by a continuous suture through the integuments only, together with long strips of adhesive plaster, moderate compression, and sometimes a retaining bandage.
7. Sutures should never be inserted through the whole wall of the abdomen, and their use in muscular parts under any circumstances is forbidden; unless the wound, from its very great extent, cannot be otherwise sufficiently approximated to restrain the protrusion of the contents of the cavity. The occurrence of such a case is very rare.
8. Purgatives should be eschewed in the early part of the treatment of penetrating wounds of the abdomen. Enemata are to be preferred.
9. The omentum, when protruded, is to be returned by enlarging the wound through its aponeurotic parts if necessary, but not through the peritoneum, in preference to allowing it to remain protruded, or to be cut off.
10. A punctured intestine requires no immediate treatment. An intestine, when incised to an extent exceeding the third part of an inch, should be sewn up by the continuous suture in the manner recommended, _Aph._ 391.
11. The position of the patient should be inclined toward the wounded side, to allow the omentum or intestine being closely applied to the cut edges of the peritoneum. Absolute rest, without the slightest motion, should be observed. Food and drink should be restricted, when not entirely forbidden.
12. If the belly swell, and the propriety of allowing extravasated or effused matters to be evacuated seem to be manifest, the continuous suture or stitches should be cut across to a certain extent, for the purpose of giving this relief.
13. If the punctured or incised wound be small, and the extravasation or effusion within the cavity seem to be great, the wound should be carefully enlarged, and the offending matter evacuated.
14. A wound should not be closed until it has ceased to bleed, or until the bleeding vessel has been secured, if it be possible to do so. When it is not possible so to do, the wound should be closed, and the result awaited.
15. A gunshot wound penetrating the cavity can never unite, and must suppurate. If a wounded intestine can be seen or felt, its torn edges may be cut off, and the clean surfaces united by suture. If the wound can neither be seen nor felt, it will be sufficient for the moment to provide for the free discharge of any extravasated or effused matters which may require removal.
16. A dilatation or enlargement of a wound in the abdomen should never take place, unless in connection with something within the cavity rendering it necessary.
17. If the epigastric, circumflexa ilii, or other artery in the wall of the abdomen, be injured and bleed, the wound should be enlarged, and the bleeding vessel secured by ligature. If the main trunk or the external iliac artery be sought for and tied, the patient will in all probability die.
18. When balls lodge in the bones of the pelvis, they should be carefully sought for and removed, if it can be done with propriety and safety.
19. In a wound of the bladder, an elastic gum catheter should be kept in the urethra, frequently without a stopper, until the wound is presumed to be healed--unless its presence should prove injurious, from excess of irritation, not removed by allowing the urine to pass through it by drops as it is brought into the bladder.
20. In all cases in which a catheter cannot be introduced, in consequence of the back part of the urethra or the neck of the bladder being injured, an opening for the discharge of the urine should be made from the perineum into the bladder. It is essential to the preservation of life.
21. The treatment of all these injuries must be eminently antiphlogistic, principally depending on general and local blood-letting, absolute rest, abstinence from food, and in some cases almost even from drink, the frequent administration of enemata, and the early exhibition of mercury, and especially of opium, in the different ways usually recommended, with reference to the part injured.