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.