419. Surgery in such, or in nearly similar cases, requires a catheter or staff to be passed down the urethra as far as it will go; an incision should then be made upon it, from the center or across the perineum, and the urethra divided on the staff until the finger rests upon the wounded parts, when, in all probability, a straight catheter, with the aid of the forefinger in the rectum, can be carried through them into the bladder. The urine will then have a direct passage outward, instead of coming indirectly from the bladder by the wounds. If the straight catheter cannot be passed, which can scarcely occur, the central incision is to be continued from the point of obstruction into the bladder, guided by the finger in the rectum. A free opening from the bladder offers the only hope of safety.
420. The rectum may be wounded without any other organ being injured within the pelvis; of this I have seen several instances. Captain Gordon, of the navy, was struck by a rifle-ball toward the lower part of one side of the sacrum, after being knocked down by one he had received on the head, and by another in the neck and back. The ball, which passed into the rectum, made its exit on the opposite side of the sacrum, and stercoraceous matters were evacuated by both wounds. The pain was severe; the limbs were deprived of much of their power of motion, and the next day the bladder was incapable of expelling its contents. This was relieved by the catheter, and the rectum was kept clear by warm, mild enemata, while the inflammatory symptoms were subdued by bleeding, opium, starvation, and rest. At the end of three months he was able to walk, but with some difficulty, on account of defective power in one leg. Some small pieces of bone came away and the wounds closed, although he was subject to an occasional slight opening of the orifice of entrance, from which a little matter was discharged, when it again closed. He remained more or less lame until his death, which took place with the loss of the ship he commanded, in a hurricane, on the coast of North America.
A French soldier was wounded at the battle of Salamanca by a ball, which entered by the side of the sacrum, and lodged. Having been rode over and bruised, he was taken prisoner, and brought to me on the field of battle. From this wound he suffered comparatively little, except from a difficulty of passing urine. On the third day after his arrival at the San Carlos Hospital, or the sixth from the receipt of the injury, he passed the ball per anum. The wound quickly closed, and he aided his comrades as an orderly in the hospital afterward.
CONCLUSIONS.
421.—1. Severe blows on the abdomen give rise to the absorption of the muscular structures, and the formation of ventral hernia, in many instances; this may, in some measure, be prevented during the treatment, by quietude, by the local abstraction of blood, and by the early use of retaining bandages.
2. Abscesses in the muscular wall of the abdomen, from whatever cause they arise, should be opened early; for although the peritoneum is essentially strong by its outer surface, it is but a thin membrane, and should be aided surgically as much as possible.
3. Severe blows, attended by general concussion, frequently give rise to rupture of the solid viscera, such as the liver and the spleen, causing death by hemorrhage. When the hollow viscera are ruptured, such as the intestines or the bladder, death ensues from inflammation.
4. Incised wounds of the wall of the abdomen to any extent rarely unite so perfectly (except, perhaps, in the linea alba) as not to give rise to ventral protrusions of a greater or less extent.
5. As the muscular parts rarely unite in the first instance after being divided, sutures should never be introduced into these structures.