Chapter XXV: Part 25

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.

LECTURE XXX.

WOUNDS OF THE PELVIS, ETC.

413. _Wounds of the pelvis_ from musket-balls injuring its contents are of common occurrence, and, although frequently fatal, often permit a considerable length of treatment before they destroy the sufferers or admit of their recovery. In many instances fistulous openings remain for years. The orifices of entrance and of exit of the ball lead to little information. It is only from the absence of paralysis or of hemorrhage, or of those signs which indicate the lesion of any of the organs contained within the pelvis, that the surgeon can form an estimate of the evil which has been committed; even when parts of the greatest importance are injured, such as the bladder or the rectum, the general symptoms are occasionally of little moment.

When paralysis occurs, which it rarely does unless the spinal marrow be injured, the functions of the bladder and of the rectum are implicated, and there is but little pain. When the nerves only are injured, the paralysis is not complete; it usually affects one side more than the other, is a numbness rather than a paralysis, and is accompanied by severe pain, sometimes at the seat of injury, but more usually extending to the thigh and to the extremities of the nerves in the foot. I was consulted in a case of wound from a pistol-shot, in the last dorsal or upper lumbar vertebra, of several years’ standing, in which the paralysis of both limbs was complete. The patient had a great desire to have the cicatrix opened, and the ball followed and extracted, and would willingly have submitted to such an operation, but he could not find any one in London or Paris willing to attempt it.

When a ball appears to cross or pass even from side to side of the pelvis, it is not always easy to say whether it has penetrated the cavity or not, until symptoms indicative of such injury appear; the less done to such wounds the better. When a ball enters, strikes a bone, and lodges, it is very desirable to ascertain its situation, in order that it may be at once removed, if it can possibly be done with but little comparative danger; for balls which lodge in these flat bones may often be removed, and the comfort of the patient assured by a timely operation, instead of proving the source of much torment and misery for many years by their being allowed to remain.

The late Colonel Wade, one of the most distinguished officers of his rank in Spain, was wounded at the battle of Albuhera, in 1811, by a musket-ball on the left side; it passed through the ilium, and was supposed to have narrowly avoided opening into the cavity of the abdomen. It could not be followed beyond the bone. The inflammatory symptoms were subdued in the usual time, and he gradually recovered his health, some pieces of bone coming away from time to time. A small fungous protrusion and discharge continued from the wound for several years, with a certain degree of pain, and of occasional lameness in the leg and thigh. The wound closed sometimes for a few months, and reopened after an attack of pain, with great lameness and swelling of the hip, and a discharge of matter from the original site. An abscess at last formed under the gluteus maximus, and was opened at its anterior and lower edge. This gave great relief and prevented the irritation of the upper and anterior original wound, the matter finding a more ready passage. I often assured him I could distinguish the ball very deeply seated; and in the summer of 1846, thirty-five years after the receipt of the injury, it had descended so far that I passed a probe under it at the distance of two inches and a half from the lower opening. He was to have come to London as early as his duties would possibly permit, in the spring of 1847, to have had it removed, when he was suddenly cut off by apoplexy, to the great regret of all who knew him.

The late General Sir Hercules Packenham, G.C.B., was wounded at the assault of Badajos by a musket-ball, April 6th, 1812, which deprived him of the use of the thumb and little finger, and partially of the hand; and by another which struck him on the right iliac region, passing in just below Poupart’s ligament and outwardly through the ilium. Eight pieces of bone came away at Elvas, and eleven more, in 1813, in London. He went to Baréges in 1814-15-16-17, with the hope that the ball might be loosened and removed, but in vain; it never could be found. A small quantity of inoffensive glutinous matter, sometimes streaked with blood, was discharged occasionally from the seat of the injury. At times the wound became painful and very troublesome for a week or ten days together, after which little inconvenience was felt in the limb.

Colonel Sir J. M. Wilson, now of Chelsea Hospital, was wounded in seven different places by three musket-balls on the left hip, at the Chippewa, near the Falls of Niagara, on the 5th of July, 1814. One, which struck him a little before the trochanter, passed upward through the ilium, (from which several pieces of bone came away on four or five different occasions,) and lodged against or in the spinal column, rendering the left leg quite powerless, and impairing the power of the right. He fell. Shortly after an Indian warrior came up, placed his foot on his neck, drew out his scalping-knife, seized his hair, and was in the act of beginning to scalp him, when a shot passed through his chest and laid him prostrate by the side of his intended victim, who thus happily escaped. The numbness and inability to put the limb to the ground continued from eighteen months to two years, during which time he was on crutches. After this he gradually recovered, always suffering more or less. The pain in the back is often most excruciating, coming on without any apparent cause, except perhaps from change of weather. He limps after walking a couple of miles, and if exercise be continued, pain ensues. He married in 1824, has several children, and is obliged to lead a very regular, quiet life, without which he breaks down. The great suffering he experiences, at the end of near forty years, is, however, from the pain in the back, sense of coldness in the left leg, and numbness accompanied by pain in the course of the nerves. He is equally sensible to heat in a close atmosphere, which he is obliged to avoid. The alvine and urinary secretions, etc. have always been impaired or deranged since the wound was received. He is troubled with painful affections and a train of nervous feelings of the whole system, attributable to the injury. The ball can of late be felt at the bottom of a soft swelling in the loins; but the colonel, since the affair of the Indian, has no predilection for cold steel, and protests as loudly against the scalpel of the surgeon as the scalping-knife of the Indian.

A soldier, of the Fourth Division of Infantry, was wounded at the battle of Salamanca by a musket-ball, which entered immediately above the right ilium, passed across, and made its exit nearly opposite on the left side, going nearer to the back than to the wall of the abdomen. He was supposed to be killed, but had recovered a little life when brought to me at the field hospital some hours afterward. The belly was swollen, generally tympanitic, and some hemorrhage had taken place from the wound of entrance, and he was unable to move the leg of that side. On reaction taking place, he was bled repeatedly, and treated antiphlogistically with the aid of calomel, opium, and antimony. He was removed to the San Domingo Hospital, and on the sixth day the bowels were relieved naturally. A small quantity of fecal matter was passed for several days with the discharge from the wound, but this gradually ceased, and the man ultimately recovered without any particular defect, except weakness and occasional pain and derangement of bowels, on any irregularity.

John Bryan, 1st Light Battalion of the King’s German Legion, was wounded on the 17th of June near Quatre Bras by a musket-ball, which entered at the groin, and made its exit behind. He was transported to Brussels, with his foot and leg in a state of mortification. Wine and other stimulants were freely given, and he rallied a little on the 23d and 24th. On the 25th, the stomach rejected everything except brandy and opium. On the 26th, a line of separation seemed to be about to form between the dead and the living parts, although he was evidently failing. He died on the 28th, eleven days after the receipt of the injury. On examination after death the ball was found to have completely divided the external iliac artery; about a pint of coagulated blood, mixed with some excessively fetid pus, was collected in the pelvis; the ends of the wounded artery had receded considerably from each other, and a coagulum had formed in each, which was easily squeezed out, the orifice of the upper end only being a little contracted. There were signs of some peritoneal inflammation having taken place; the intestines had not been wounded, and the ball, in passing out, had splintered the upper edge of the back part of the ilium.

General Sir Edward Packenham was killed instantaneously at New Orleans, by hemorrhage from a nearly similar wound, in which the common iliac artery was divided.

414. I have removed balls on different occasions which have lodged in the bones of the pelvis, and always with the greatest advantage, when done early. I have seen much evil result from their being allowed to remain, as they caused not only frequent distress, but at last gave rise to disease in the bone, derangement of the general health, and death. When the ball can be felt impacted in the bone, incisions through muscular parts of little consequence should not be spared to expose it. If an error exists at this moment, it is that too little is done, rather than too much. Too great reliance is placed on the efforts of nature, and not enough on the resources of art. The constant meddling with a wound is not recommended; nevertheless, much may be done by careful investigation from time to time, of which La Motte gives a good example in his fifty-first observation.

A grenadier was wounded at the battle of Dettingen, in 1743, by a musket-ball, which entered above Poupart’s ligament, near the opening of the external oblique muscle on the left side, and lodged. Thirteen days after his reception into the hospital at Landau, La Motte felt with the probe what he thought was the ball lying on the outside of the psoas muscle against the bone. He made the patient lie on his face, and touched the foreign body every day in order to loosen it. On the thirty-fifth day he was satisfied it was the ball, and on the forty-fifth, after many attempts, it was at last extracted. His fifty-second observation relates to a case as nearly similar as possible to those of Sir H. Packenham and Colonel Wade. He made several deep and long incisions in search of the ball, which he could not find; the wound became fistulous, and at the end of a year closed, in all probability to reopen from time to time.

The difference in practice between 1743 and 1855 ought to be, that in 1855 the ball should be found first, and the deep and long incisions made afterward for its extraction; which do not preclude any previous external openings that may be necessary to facilitate the first examination.

Captain Campbell was wounded by a pistol-ball, on the 5th of September, 1805; it penetrated the abdomen on the middle of the right side, and was extracted from nearly the same situation on the left; from its irregular denticulated shape, it would appear to have impinged against a vertebra. He complained of violent pain in the loins and belly, with numbness and pain of the left leg and thigh, and suffered also from the greatest oppression, anxiety, and sickness. An enema was administered, and twenty-four ounces of blood were taken from the arm; lower extremities nearly paralyzed; anxiety and oppression great at night. Blood-letting to ten ounces. Cannot pass his urine; hot fomentations; and at twelve at night sixteen more ounces of blood were drawn. At three P.M., had three motions, the two last containing apparently a pint of pure blood. Pain and other symptoms being urgent, eight ounces more blood were taken away. At six P.M., passed urine for the first time, highly tinged with blood; has had two motions, also mixed with blood. Pain continuing, ten ounces of blood were abstracted, although occasionally almost fainting on any movement; belly fomented. At eight at night, sixty drops of laudanum. At ten, being very restless, twenty drops more, which procured some sleep, although he vomited frequently; belly relieved by the fomentation; three stools mixed with blood.

Sept. 6th.--All the symptoms relieved; passes blood with his urine; sickness and vomiting troublesome; pulse 90, rather firm than feeble. One o’clock.--Complains of violent pain in the left leg and thigh, belly, and loins; pulse 116, full and strong. Blood-letting to sixteen ounces. Barley-water with niter for common drink. Six P.M.--Pulse 96; bowels open, with discharge of blood; symptoms generally relieved. Tincture of opium, twelve drops at night.

8th.--Slept better; less pain; paralysis continues. In the evening symptoms aggravated; lost twelve ounces of blood; enema, etc. repeated; pulse 120.

9th, 10th, 11th, 12th.--Pulse 96; bowels open; urine bloody; is generally better.

15th.--Wound of exit healed; urine bloody; bowels open. Chicken-broth for the first time.

20th.--The opening of entrance having nearly closed was enlarged, and a free exit allowed for the matter.

Oct. 20th.--Wounds quite closed; is free from pain, is able to move about the house on crutches; warm, stimulating applications to the limbs seem to have given most relief.

Nov. 20th.--Paralytic affection gone; he can now mount his horse, and has only a feeling of numbness and torpor in the left leg and thigh.

415. The general opinion which formerly prevailed, that _wounds of the bladder_, by musket-balls, were for the most part mortal, is now known to be erroneous. When the bladder is wounded below, where it is not covered by the peritoneum, persons do sometimes recover by what may be considered the almost unaided efforts of nature. A large number of cases came under my observation at Brussels and at Antwerp, and many had already died. Persons rarely recover in whom urine has found its way into the general cavity of the abdomen. They generally die of inflammation in from three to six days.

When the bladder is wounded where it is covered by the peritoneum, and the opening or openings do not by some accident permit the urine to flow into the cavity of the abdomen, the patient may be free from immediate danger for a short time, although very anxious and greatly depressed in countenance and manner, and even sick to vomiting. The pain is not commonly severe at first, and if he can make water, which in all such cases it is desirable to prevent by having recourse to the catheter, it is more or less colored or mixed with blood. If the urine should not escape into the cavity of the abdomen, the ordinary inflammation which must necessarily ensue takes place and affects the internal surface of the bladder. The desire to pass urine becomes greater, and is frequently insupportable, while it can in some cases be only passed by drops. In others these symptoms are less urgent. Nevertheless, the natural action of the bladder, or, in those severe cases, the additional efforts which are made for its expulsion by the abdominal muscles, may cause the urine to be forced through the wound into the cavity of the abdomen, whence the advantage to be obtained from the early use of the elastic catheter. When the orifices of entrance and of exit are free, and low down in the pelvis, the urine may run out without much immediate mischief ensuing. But as this cannot always be known, an elastic gum catheter should be introduced from the first and fixed in the bladder, in every case where the nature of the injury is doubtful, until the urine ceases to flow through the wounds. It must, however, be recollected that in some cases in which it has caused great irritation, by being introduced too early, while the bladder was very sensitive, the patients have been much relieved by its removal. The principle is nevertheless incontrovertible in all doubtful cases; the urine should be allowed to drop out of the catheter nearly as fast as it passes into the bladder, when this organ is very irritable; great pains should also be taken that the end of the instrument should be within, but not too far within the bladder, so as to excite irritation by rubbing against its sides, or to allow its end rising above the urine which might in this way collect below it, and at last escape through the wounds.