Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE XXIX.

ABNORMAL OR ARTIFICIAL ANUS, ETC.

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.