401. In some cases of wounds of the intestine the continuity of the
bowel is not sufficiently re-established; the external wound remains
open, and becomes indurated and fistulous, giving passage to the fecal
matters, and rendering the sufferers very miserable. These cases are of
rare occurrence among the hardy natives of Great Britain and Ireland,
and comparatively little has been done or even recommended in this
country for the relief of this misfortune.
When an intestine has lost a more or less considerable part of its
substance at a particular spot, and an artificial anus is about to
be formed, it adheres to the peritoneum around the inside of the
external wound, although the adhesion is of little extent or width,
and forms but a narrow barrier for the protection of the cavity of
the abdomen. The upper end of the bowel is more open than the lower,
the caliber of which is contracted in size, and is sometimes even
difficult to find; while its opening is partially closed by a sort of
septum extending across, or from where the two portions of a divided
gut have come irregularly in contact with each other by their sides,
without uniting in the first instance in their length; or from the
falling in especially of the posterior part of the lower end, to which
the upper has become united. The projection thus formed in the tube is
called by the French _eperon_ or _promontoire_, valve or spur, ridge or
septum; it directs the fecal matter through the external wound, while
it obstructs its passage into the lower part of the bowel. There is
generally great difficulty in ascertaining the fact of the existence
and exact situation of this valve during life; in distinguishing the
upper from the lower end of the intestine, as well as the nature and
extent of the adhesions by which the injured intestine is retained in
its situation. If the absence of such a valve can be satisfactorily
made out--and it is sometimes wanting--the external opening may be
successfully closed by compression, or by operation. If the valve
should exist, its removal by a preliminary operation is necessary; it
has been attempted in France with various but somewhat doubtful success.
402. When a portion of small intestine has been lost by mortification
or otherwise, and the patient has recovered with an unnaturally
situated or artificial anus, the intestine, although at first in
contact with the wall of the abdomen, is gradually, in many cases
though not in all, retracted into the cavity--it has been supposed by
the dragging of the mesentery upon it at the point of union of the
divided extremities outside where the _eperon_ or valve is formed; and
it is said that this dragging has even led to the gradual disappearance
of the valve, admitting thereby of the contents passing more readily
from the upper part of the intestine into the lower, and consequently
laying the foundation for a cure. This dragging of the intestine,
or its movements under the different motions of the body, in some
cases cause an elongation of the membrane formed under the adhesive
process, by which the intestine is attached to the inside of the wall
of the abdomen in the same manner as adhesions are elongated between
the pleuræ, and a sac or pouch is thus formed between the cut ends
of the intestine and the fistulous external opening which Scarpa was
the first fully to demonstrate and explain, and which he called an
_entonnoir_, _infundibulum_, or funnel. If, then, in an old case, a
small portion of the wall of the abdomen be removed in the form of a
V, the internal opening at the apex of the V, if small, would be made
into a sort of funnel, while the outer incision would remove all the
hardened fistulous parts--an operation which is sometimes required to
be done when the external opening is not free, and fecal matters have
insinuated themselves between the aponeurotic parts, giving rise to
abscesses and other small fistulous openings in different directions.
It is necessary to bear the formation of this pouch in mind as well as
that of the valve, in order to understand the operations proposed for
the relief or cure of this complaint.
If simple compression fail in the first instance to prevent the passage
of the feces, which never can be thoroughly controlled from the want
of a sphincter and the uncertainty of pressure, the method of Desault
may be adopted. This consists in gradually dilating the external wound
so as to enable the operator to discover the open ends of the bowel,
when a tent is to be introduced into the lower end, and afterward
into the upper, being fastened by a thread passed around its middle.
A pyramidal-shaped pad is then to be placed over the opening, and
compression made by bandage upon it so as to press the whole inward.
The size of the tent is to be gradually enlarged until the contents of
the gut begin to pass downward with ease, when a well adjusted pressure
is to be made on the fistulous opening only, to prevent all oozing from
it until the internal parts have had time to close.
403. Dupuytren invented a pair of forceps, consisting of a male and
female branch, to be applied separately, one on each side of the valve
or _eperon_, to the extent of an inch or an inch and a half at most,
when they were to be closed by a screw until they had compressed the
part between them sufficiently to destroy its life. The separation of
the valve included within the forceps would take place by the usual
processes of ulceration in its immediate proximity, and by adhesion
of the parts external to the bowels to those surrounding them. The
inflammation, however, did not always stop at the adhesive stage, and
death has been the result as well as a successful cure.
404. Mr. Trant has invented an instrument he calls a propeller, for
pressing back the eperon, an account of which is given in the _Dublin
Medical Press_, May 14th, 1845. He used this in one case with complete
success. The instrument by its formation admits of being passed
through the artificial anus, and of being placed on the _eperon_ at
the bottom of the wound, where it can be retained for a considerable
time without producing the slightest inconvenience. It does not, while
in the intestines, offer any obstruction to the passage of the fecal
matters flowing along the cavity of the tube. It acts as a forceps in
retaining the anterior wall of the intestine in close contact with the
posterior surface of the abdominal parietes, while the propeller is
pressing back the _eperon_ toward the spine; consequently the danger
of separating the delicate adhesions in this situation is prevented,
otherwise a fatal extravasation into the cavity of the abdomen might
ensue. The instrument was made by Mr. Reed, of Dublin, and merits
further trial, being apparently less dangerous than the other methods
recommended in similar cases. Whatever may be the method employed for
the cure of an artificial anus by operation, it cannot be doubted
that the patient must be exposed to all the dangers which may result
from inflammation, for which he must be prepared beforehand, and the
symptoms of which must be met and subdued as they arise; or, if this
cannot be accomplished, the mechanical means, if any be used that can
be taken away, must be removed, and quiet, if possible, restored by
their abstraction and by the treatment adopted. In successful cases,
a small aperture will frequently remain, constituting a fecal fistula
instead of an artificial anus. This will sometimes become irritable,
inflame, ulcerate, or burst, discharging the solid contents of the
bowel, although, on the subsidence of the irritation, the part under
pressure usually returns to its former state.
405. _Wounds and injuries of the liver_, whether incised or
penetrating, occurring from blows or from musket-balls, are very
serious, although not _necessarily_ fatal. Some few persons recover
altogether, some few with more or less of permanent disability. The
remainder die during the first or inflammatory stage, or in the
secondary one, which follows from the twelfth or fourteenth day after
the primary symptoms have in some measure subsided.
The symptoms which ensue after a wound of the liver are those common to
inflammation of the cavity of the abdomen, with the addition of those
peculiar to the organ--pulse often smaller and less perceptible than
in peritonitis; discoloration of the skin, eyes, and urine, amounting
even to jaundice, although this is not an immediate symptom, neither is
it always present. The pain is not confined to the part, but extends
to the umbilicus, while the pain symptomatic of inflammation of the
liver--viz., pain in the top of the right shoulder--is felt early, and
is often accompanied by cramps of the muscles of the arms and numbness
of the fingers. The usual symptoms of anxiety and depression are
present, and the stomach shows by its irritability that it has partaken
of the shock given to the system. The bowels are usually confined, but
I have known blood passed from them when it was not supposed that the
stomach or intestines had been wounded; the discharge from the wound is
either of blood or bile, or both, mixed with a serous effusion which
afterward becomes purulent. Wounds of the gall-bladder are, as far as
is known, fatal--the effusion of bile which immediately takes place
giving rise to inflammation which, with other causes, destroys the
sufferer at the end of a few days. If the gall-bladder be adherent to
the peritoneum from any previous inflammation, a wound in it need not
prove mortal, as the effusion would be avoided, and there is no reason
to believe that an injury to this part would be otherwise more vital
than that of any other of the viscera of the abdomen.
The late Lieut.-General Sir S. Barns, when Lieut.-Colonel of the
Royals, was wounded at the battle of Salamanca by a musket-ball,
which injured the cartilages of the false ribs, a portion of the rib
being removed and passed out through the liver. A bilious discharge
continued several weeks from the wound, and his life was saved with
great difficulty. He returned to his duties, although suffering from
a dragging pain and weight in the side, which any exertion increased.
In the autumn of 1819 he was attacked by acute inflammation; the pain
in the right side, extending over the stomach and umbilicus, was
constant and acute, and increased on pressure; the pulse small, indeed
scarcely perceptible; the extremities cold; the countenance depressed
and anxious; bowels confined; stomach rather irritable. A number of
leeches were applied, and other remedies administered. The constant
pain, which was increased by pressure, could only be relieved by loss
of blood, although every other symptom seemed to forbid depletion.
Twenty ounces of blood were taken from the arm, which caused a
diminution of the pain, and gave relief for an hour; the pain then
returned, and twelve ounces more blood were taken away, with the most
beneficial effect; a blister was applied over the part, and a dose of
calomel and opium was repeated. Shortly afterward he became tranquil;
the extremities lost their coldness; and, although the pain continued
in a slight degree for several hours, and much soreness remained for
many days, he quickly recovered. Two months afterward he had another
and equally severe attack, in consequence of walking about two miles
rather hastily; from that he was relieved in a similar manner. Whenever
he bent his body, a portion of the rib appeared to press in upon the
liver, and often gave him acute, darting pain; and one day, on pulling
on his boot in haste with some bodily exertion, a third attack ensued.
In order to prevent the bending of the body forward, and to confine the
motion of the liver, which seemed liable to injury from the irregular
points of bone which could be readily distinguished above it, stays,
made with iron plates instead of whalebone, were adapted to his body,
and from these he derived great comfort.
Corporal Macdonald, first battalion, 79th Regiment, was wounded on
the 16th of June at Quatre Bras, by a musket-ball, which entered the
abdomen, splintered the eighth rib on the right side, passed through
the liver, and was supposed to have lodged on the opposite side, as he
says he felt the ball strike the left side, on which he was not able
to lie for a long time. Lost but little blood at the time; was dressed
superficially, and arrived in Brussels on the 19th, laboring under
considerable fever. Bleeding to thirty-six ounces. For seven successive
days the bleeding was repeated, to from twelve to sixteen ounces each
day, when a large, bilious, and purulent discharge took place from the
wound, on which the inflammatory symptoms appeared to subside, until
the 30th of June, when bleeding took place from the wound during the
night to the extent of twenty ounces, and then ceased spontaneously.
On the 15th of July the hemorrhage recurred with so much fever as to
warrant twenty ounces of blood being taken from the arm, and this was
repeated the next day. The bilious discharge ceased in the middle of
August, and on the 2d of September he was discharged convalescent.
Lieutenant Edward Hooper, first battalion, 38th Regiment, was wounded
by a musket-ball on the 9th of December, 1812. It passed through the
anterior edge of the liver, and, glancing round the ribs, was cut out
about two inches from the spine.
On his being wounded, he could scarcely believe his shoulder was
not the part affected. His pulse was intermitting; the breathing
hurried and laborious, and in a short time the tunicæ conjunctivæ
became yellow. He was _very largely_ bled, and warm fomentations were
applied to the abdomen, from which, and the bleeding, he received some
temporary relief; but, in consequence of his removal that night to the
rear, the symptoms were much aggravated on the morning of the 10th. He
complained of acute pain over the whole abdomen, increased on pressure;
vomiting; quick, hard, and wiry pulse, (no pain referred to the wound.)
The bleeding was repeated ad deliquium, warm fomentations and an
enema also repeated, and a saline mixture, with a _very few_ drops of
tincture of opium, to allay the irritability of the stomach. On the
following evening the vomiting had ceased; his pulse was less frequent
and hard; pain less. On the 11th, after passing a very restless night,
the pulse again rose; the abdomen became tense but not very painful,
and he made ineffectual efforts to stool. He was again bled, a large
blister was applied over the abdomen, and an ounce of castor-oil was
given immediately. The blister acted well, and the purgative gave him
three copious stools of dark and fetid feces. On the 12th he complained
of twitching pains, referred to the right shoulder, and was ordered one
grain of calomel, with two of antimonial powder, three times a day.
Jan. 13th.--Was free from pain; pulse fuller and less frequent; urine
clear; tension of abdomen subsided. The calomel and antimony were
continued, and some light nourishment was allowed. From this day a
gradual amendment took place. The calomel was continued until his mouth
became slightly affected; and, as his bowels were in general torpid,
from the deficient secretion of bile, a mild purgative was given every
two or three days, as occasion required, and an ounce of the infusion
of calumba, with quassia, three or four times daily.
A soldier of the 48th Regiment was struck by a musket-ball at Albuhera,
on the upper part of the right hypochondrium, over the liver; it
came out behind, at a point immediately corresponding to that in
front. Blood and bile were discharged from the wounds in considerable
quantity, and his case was considered to be hopeless. Brought to me at
Valverde, the next day, he was bled largely several times; the wounds
were dressed simply, and he was kept perfectly quiet, and his bowels
gently open. The skin became of a yellow color, his strength failed
under the treatment, and he became thin, and looked ill. At the end of
three weeks he was sent to Elvas, where he gradually improved, and was
forwarded thence to Lisbon and to England, with his wounds healed.
An officer was wounded in one of the battles in the Pyrenees,
by a musket-ball, which penetrated the outer part of the right
hypochondrium, at the edge of the false ribs, and lodged. Blood and
bile flowed in considerable quantity; the skin became yellow, the pain
and swelling of the abdomen were considerable, and he was given over as
lost. Under a vigorous and careful treatment he gradually recovered,
so as to be sent to England, with a fistulous opening at the orifice
of entrance. I examined the wound in 1817, three years afterward, and
found that a large blunt probe passed inward toward the stomach and
liver for the distance of five inches, where it ended apparently in a
sort of sac. Purulent and bilious matters were constantly discharged
from the wound; his countenance was sallow; his digestion bad; he
suffered from constant uneasiness, if not pain, and was altogether out
of health. I saw him once annually for several years, and found that
I could sometimes strike the ball with the probe; that he frequently,
after an attack of pain and derangement, passed matter by stool,
after which the pain and uneasiness about the wound ceased. I had
hopes the ball would some day pass through the opening thus made, and
had thoughts of enlarging the external wound, and of endeavoring to
extract the ball with a long pair of forceps. He ceased at last to pay
his annual visit, and I suspect he died in one of the attacks I have
alluded to. This ball must have passed very close to, if it did not
penetrate, the gall-bladder.
I have never had an opportunity of extracting a ball from the liver
during life, although I have seen persons live many weeks into whose
livers balls had penetrated; and I have been acquainted with three
persons who had been wounded through the liver, to whom little
subsequent inconvenience was occasioned.
406. Portions of the liver have been removed in some instances; in
one case, related by Blanchard, a small piece of liver was removed
with the forceps. The patient dying of fever three years afterward, a
small piece of the liver near the external wound was found wanting.
Dieffenbach gives a case in which a small protruded portion was cut
off with scissors, without any bad consequence. Dr. Macpherson, in the
‘_London Medical Gazette_’ for January, 1846, has related the case of
a Hindoo, a large piece of whose liver protruded through a wound an
inch in length, made by a spear in the right hypochondriac region. A
ligature was applied tightly around its base, and the piece cut off,
rather than make such an enlargement of the wound as might allow the
restoration of the protruded liver. The arteries bled from the cut
surface, and required to be tied, and a double ligature was put through
the stump of liver and tied on each side. The part was not pushed back
into the abdomen, but allowed to remain in the wound. The symptoms were
mild, the ligatures came away on the ninth day, and the man returned to
his home in three weeks.
These cases may be considered exceptions to the general rule, which
directs the return of all protruded parts. The retention of the part
from which the piece was cut off within the divided parts of the wound
was agreeable to the principles I have inculcated with respect to
wounds of all the cavities.
407. _Wounds of the stomach_ are usually fatal, although some persons
escape when these injuries are confined to its anterior and upper
surface, and do not penetrate both sides, in which case effusion into
the cavity of the abdomen, and consequent inflammation, can scarcely
fail to ensue. It is fortunate for the patient, when they occur, that
the stomach should be empty. If it should not be so, the contents may
possibly be ejected shortly after the receipt of the wound, but it is
not advisable to excite vomiting by remedies, or by means adapted for
that purpose. In a perfectly quiescent state, the general compression
of the contents of the abdomen by its walls may prevent effusion under
ordinary circumstances, and this state should be maintained as rigidly
as possible. The apparent course of the wound indicates the probable
mischief, which is especially confirmed by vomiting of blood, great
anxiety, depression of countenance, a cold, clammy skin, pain in the
part, hiccough, and by the discharge of the contents of the stomach,
if the wound be sufficiently open to allow it; pulse low and sometimes
intermittent. If effusion of the contents of the stomach should not
occur, the external wound, if an incised one, should be closed by
suture, and the patient kept in the utmost state of quietude, in a
somewhat elevated position, the abdominal muscles being relaxed.
Neither food nor drink should enter the stomach, although thirst should
be allayed by wetting the tongue and mouth. The bowels should be
relieved by enemata, and the belly fomented. Bleeding and leeching, as
frequently repeated as the symptoms appear to require, must be carried
to the greatest extent that can be permitted with safety.
When the external wound is so large as to enable the wounded stomach to
be seen, the cut edges of the wound in it should be brought together
by the continuous suture, as in the intestines; and the external
wound should be closed in a similar manner, the end of the ligature
on the wound of the stomach being cut off close to the viscus, that
organ being left perfectly free, with the hope that the thread will be
carried into its cavity, while the outside adheres to the peritoneum
opposed to it.
When the stomach pours its contents through an external opening, too
small to allow its being examined, it is desirable that the wound
should be enlarged, if a doubt be entertained of the passage being
free. It is a sufficient reason for such an operation to allow the
opening in the stomach to be seen. It is very probable that effusion
will take place into the cavity of the abdomen if it be not done, and
the death of the patient will follow. It is very probable he will
die if it be done, and therefore in such cases little has hitherto
been attempted. I am of opinion, however, that in the case I have
last alluded to, a blunt hook may be sometimes introduced through the
wound into the stomach, so as to keep it stationary while the external
opening is carefully enlarged, and that it ought to be done in such
cases, and the wound in the stomach closed in the manner recommended.
I have never had a case under my care in which I could have done this;
but I have seen some die in whom it might have been done; and it
deserves to be considered when surgeons shall be in sufficient numbers
on the field of battle to attend to such recommendations, and to the
after-treatment these cases require.
When the stomach is injured by a musket-ball, and its contents are
discharged externally, the edges of the wound, not being in a condition
to unite, must remain open for several days. The person should be
placed in the mean time in the most easy and comfortable position
which may enable the contents of the stomach to be readily passed
out externally, if they show any disposition to be thus evacuated.
The external wound should be dilated as far as the peritoneum, if it
should be required, so as to admit of the passage being direct, and
symptoms must be awaited and treated as they arise. If the patient
should survive the first or inflammatory stage, he should be supported
by clysters composed of strong beef-tea or veal broth, given five
or six times during the twenty-four hours. When it may be expected
that the wound in the stomach has closed, or that the injured portion
has adhered to the neighboring parts, warm jellies and light broths
may be frequently given in small quantities, but solid food should
be forbidden until complete recovery has taken place. I have seen
inattention to this precaution in more than one instance prove fatal.
408. Fistulous openings have been known to follow wounds of the
stomach, and to continue for years. The case related by Dr. Beaumont of
the American army, of St. Martin, who, in 1822, received an extensive
wound in the stomach, which became fistulous, admitting of a variety of
most interesting inquiries being made into the process of digestion, is
remarkable.
Hevin has related some of the most interesting cases of those who had
swallowed knives, etc., by design or by accident, and whose stomachs
were opened for their removal. The most ridiculous story of the whole
is an instructive one, however. Some young students, desirous of
punishing a young woman who had offended them, cut short the hair of
the tail of a large pig, and when frozen hard, forcibly pushed it up
her anus, leaving a couple of inches only hanging out of the small
end or tip. The hairs having been cut short caught in the gut when
attempts were made to draw out the tail, and gave her inexpressible
pain. The most serious symptoms followed during six days, and every
attempt having failed, Marchetti was applied to. He prepared a hollow
tube two feet long, large enough to receive the thickest part of the
pig’s tail, to the end of which he fastened a strong waxed cord, which
he drew through the tube. This he carefully introduced into the anus,
pushing it over the pig’s tail, until he drew the whole of it into the
tube, which he then brought away, including the tail, to the great
relief of the sufferer.
409. The necessity for an operation so grave as that of opening the
stomach must be shown by the presumed impossibility of the foreign
substances being dissolved, or of their passing out of it by any other
means, while the continued distress they occasion more than equals the
risk which is likely to be incurred. The offending substance ought
to be felt through the wall of the abdomen, and the incision for its
removal should be made between the recti muscles in the linea alba,
unless the foreign body have actually pierced the stomach, and can be
felt to the outside of the rectus muscle, at which part the incision
ought to be made obliquely in the direction of the fibers of the
external oblique muscle, all bleeding vessels being secured before the
peritoneum is opened. This having been accomplished, the protruding
body should be extracted by such an enlargement of the opening in the
stomach as may be actually necessary. When the substance does not
protrude, although it can be felt through the wall of the stomach,
it will be advisable, if possible, to draw it toward the upper or
smaller curvature of the stomach rather than to the lower, avoiding
the coronary vessels, and taking a medium distance for the opening
from the cardiac orifice, and thereby such advantage as may be derived
from gravitation. The wound in the stomach should be united by the
continuous suture, and the external wound should be closed in a similar
manner. The patient ought to be kept in bed in an easy erect position.
410. _Injuries of the spleen_ have been usually fatal, from hemorrhage
filling the general cavity of the abdomen, especially when they have
arisen from rupture of that organ, which I have several times seen
occur in consequence of falls, or from blows from cannon-shot, which
have not opened into the cavity or exposed the viscus. Wounds from
musket-balls have for the most part destroyed the sufferers, either
from hemorrhage or from inflammation. I have not seen nor heard, during
the Peninsular war, of a wound in the abdomen through which the spleen
protruded, the patient recovering. Instances have occurred in which
this part has been removed in man after its exposure by injury. A case
is said to have taken place after the battle of Dettingen, in which
the spleen, covered with dirt, was cut off, and the patient recovered.
In another case the spleen, found without the wound at the end of
twenty-four hours, was cold, black, and mortified. The surgeon placed
a ligature above this part, and cut off three inches and a half of
the spleen; a large artery was tied, and the remaining portion of the
viscus was returned into the cavity of the belly, the ligature hanging
to it, and the patient got well.
Wounds from stabs with a bayonet, or a sabre, or long-pointed sword
are frequently fatal, either from hemorrhage or from inflammation;
but I have seen accidentally, after death, cicatrixes in the spleen
corresponding to external marks, indicative of a former wound. The
treatment, in all such cases, should be to encourage the discharge of
blood from the part, in the first instance; then to close the external
wound if an incised one, to place the patient on the injured side, and
to subdue all unnecessary inflammation by bleeding, leeching, absolute
rest, and starvation. The application of warm fomentations where an
oozing of blood may be expected to take place cannot be recommended,
and cold should be substituted if agreeable to the feelings of the
patient. When the blow or wound does not cause the death of the
individual by hemorrhage or acute inflammation, a chronic state of
disease may supervene, which, if not duly combated, will ultimately
destroy him. The early administration of calomel and opium, and the
repeated application of blisters, will, in these cases, as well as in
those of wounds of the liver, be of the greatest service. Effusion or
suppuration may take place as well as in those cases which have been
noticed, when other viscera have been injured; although instances of
such terminations are not recorded, it does not follow that they have
not taken place.
411. _Wounds affecting the kidney_ have been less fatal than those
of the spleen, although they are scarcely less dangerous, from the
complications by which they are attended; the successful cases on
record are not numerous, and the practice to be pursued can only be
general. The results, when not fatal, have been for the most part
unknown, from the patients either lingering on or recovering after they
have been discharged from the service. I saw two cases of this nature
after the battle of Waterloo. In one, the ball had passed through the
abdomen, entering a little below and to the left of the umbilicus, and
coming out behind nearly opposite and close to the spine. No fecal
matter was discharged from the front wound, but some came through the
posterior one, accompanied by a small quantity of urine, indicating a
lesion of the kidney or of the ureter at its upper part. The symptoms,
at first severe, had subsided under proper treatment, and there was
every probability that the sufferer would eventually recover, although
I was unable to trace the case after the man left Brussels. In the
other, pain was principally felt in the testis and the spermatic cord
of the side injured.
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.