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.
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.