Bladder, Rectum.

Wounds of the Soft Parts.-Ordinary characteristics and treatment are the same as those we see and employ in bullet lesions. The furrows and culs-de-sac produced by shell splinters are often large. The tracks made in the gluteal region expose the patient to grave haemorrhage (gluteal and ischiatic vessels and their branches); temporary plugging, ligature after relieving constriction by free incisions. The plugging should not be left in situ for long, as so doing would render extremely grave putrid suppuration liable to occur, and, as we have lately seen in a German wounded man, haemorrhagic suffusion of the pelvis, of the pelvic, iliac, and Retzian regions, with possible diffuse aneurysms.

Lesions of the Sciatic - Nothing special in the treatment.

Lesions of the Pelvic Bones - They are the same as lesions of flat or spongy bones : oval or oblique perforations, either quite clean or with a few short splinters from the internal table, sometimes indentations or excoriations. Contusion is possible.

Pelvis.-Penetration of the pelvis by bullets With SOLUTION OF CONTINUITY does not exist (twenty bullets have passed through the pelvis without causing fracture- Delorme).

Immobilization of the pelvis, therefore, by a special apparatus is an inexplicable procedure.

Nothing particular with regard to treatment.

The pelvic organs are struck in their intra- or extraperitoneal portions, or simultaneously in both. This division should be remembered.

The track is generally antero-posterior, and corresponds

(i) to the hypogastrium, to the floor of the perinaeum, to the notches;

(2) to the pelvis.

A transverse or oblique course is more uncommon.

Wounds of the Bladder - Contusions, excoriations, cul-de-sac wounds, are exceptional; total perforations habitual. Orifices equal or inferior to the size of the bullet, generally narrow. The perforation of the serous coat is small, that of the muscular coat more extensive, and that of the mucous coat intermediate as regards dimensions. Hernia of the mucous membrane. Bursting is rare (explosive projectiles).

Tearing and puncture are possible by splinters.

Diagnosis. -The diagnosis is generally not difficult; it is anticipated by the relations of the track with the bladder, and would be confirmed by the escape of urine through the wound and by haematuria, either in spontaneous micturition or after the use of the catheter. These last signs in conjunction with the first are pathognomonic, but they are often absent.

Let us call attention to some functional signs : Radiating pain in the hypogastrium, in the perinaeum, the loins, the genital organs; an overwhelming desire to pass water, to defaecate ; retention of urine; finally, when there are complications, signs of peritonitis, infiltration of urine, urinary reabsorption.

Prognosis.-Some wounds heal easily, especially narrow wounds that are not complicated by a lesion of the rectum Too often, however, we see peritonitis, urinary infiltration the formation of simple or urinary abscesses, which develop in the cavity of Retzius and in the ischio-rectal fossa, and which manifest their presence by a hard, oedematous, sometimes crepitant, hypogastric or iliac tumefaction, and by grave general symptoms (perivesical cellular tissue), or by a perineal abscess.

Immediate death is rare; rapid death in a few days is frequent (superacute peritonitis); delayed death takes place from the eighth to the twentieth day. It follows infiltration of urine or pelvic abscesses.

These wounds are rather often complicated by foreign bodies, shreds of clothing, pubic hairs, splinters, bullets, which may be the starting-point of stone in the bladder.

What is the proportion between deaths and recoveries ? It is impossible to give it correctly. Bartels gives a mortality of from 45 to 50 per cent. The wounded in the Transvaal, where bullets of small calibre were employed, rarely recovered. According to Makins, the extraperitoneal wounds would hardly be less grave than the intraperitoneal. A concomitant rectal lesion is a very serious complication.

Treatment - The treatment comprises two indications: Prevent the effusion of urine; contend against infection (peritonitis, pelvic or perinaeal infiltration).

The first transport of the patient is to be carried out very cautiously, preferably in the sitting position; nothing whatever should be given to drink - this is capital; decubitus facilitates the outflow of urine; wide dressing often renewed - these are the first indications to fulfil. The wounded man should expressly be treated on the spot where he fell.

Catheterism, which was extolled by Larrey, is still the easiest and safest primary therapeutic measure; it is also the one most capable of generalization. We all know its incidental difficulties, its occasional inadequacy.

We must also make use of catheterism with the instrument tied in and changed every third day, of intermittent catheterism if the tied-in catheter is not tolerated. Deep drainage of the wound is advisable when the lesion is large.

The button-hole median perinaeal incision, which was recommended formerly when the catheter was badly tolerated, is replaced nowadays by suprapubic cystotomy - an excellent operation, but not capable of being generalized.

In cases of peritonitis, Murphy's incision. Experience will show up to what point it may be employed primarily.

Free laparotomy, with suture of the bladder, will be exceptional.

Wounds of the Rectum - Isolated or concomitant with wounds of the bladder, lesions of the rectum present the same characteristics as wounds of the remainder of the intestine or of the bladder. They are either sub- or intraperitoneal. We may consider it a case of the latter when the lesion lies at 5 or 6 centimetres from the anus; but generally the wound is both intra- and extra-peritoneal.

Escape of faecal matter from the aperture of exit is the pathognomonic sign of rectal wounds, but it is often absent on account of their narrowness. Escape of flatus and of blood through the anus are other characteristic signs, but they also may be absent.

We must abstain from injections if, when given through the wound, they return through the anus. Rectoscopic examination very rarely can be utilized. Rectal exploration with the finger sometimes enables us to discover the wound (tactile sensation and blood at the end of the finger) The length of the index is about that of the extraperitoneal portion of the rectum.

Simultaneous lesions of the bladder and rectum may be recognized by the signs of a wound of both of them.

To prevent perirectal infection is the principal indication of the treatment. Dilatation of the sphincter is a practice that is often employed, owing to its simplicity. Intrarectal dressing with vaseline and iodoform is preferable to th introduction of gauze. In the event of the latter bein used, a large drainage-tube should be placed in the centre

Of the dressing. Enemata are dangerous. Once a faecal abscess has formed, or is threatening, posterior rectotomy.

Perirectal and presacral abscesses should be opened by a perinaeal incision, followed or not by precoccygeal separation; iliac abscesses by the incision used for tying the external iliac; abscesses of the space of Retzius by a supraubic incision.

No food at first, then alimentation consisting only of meat; opium must be given. These are the principal measures that help the treatment.

Wounds of the Prostate and of the Urethra.

In a perinaeal or abdomino-perinaeal track the prostate and the deep part of the urethra may be injured. The treatment of the former is included in that of the other wounded parts.

These wounds are recognized by the urethrorrhagia and by the escape of urine through the wound, sometimes, however, by direct examination.

Delicate catheterism, though dangerous, is a last resource. De visu we must judge of the. feasibility of suturing the urethra. Puncture of the bladder may be necessary. With regard to retention of urine and urinary abscess, which may complicate the urethral lesion, they necessitate a button hole, perinaeal incision.

Wounds of the Genital Organs.

Wounds of the genital organs are often concomitant with lesions of the thighs or of the pelvis.

They are not rare. We have seen a complete series of these cases in the hospitals of Nancy, and more particularly those of Bordeaux.

Perforations of the scrotum give rise to a haematic swelling, someetimes of a considerable size; the clots it contains must be cleared away. Extensive tearing with escape of the testicle would necessitate immediate reduction with a few fixation sutures (Delorme).

The testicle, owing to its mobility and elasticity, often escapes the bullets that go through the scrotum. On other occasions it is excoriated or perforated. The treatment is to reunite the edges of the wound after reduction of the herniated testicular tissue.

The penis may be notched or perforated in its cavernous, or urethral portions. With the old bullets division of the urethra was scarcely ever noticed. Catheter to be tied in.

The haemorrhage that follows wounding of the cavernous bodies is not so grave as one might suppose. The consecutive curvature of the penis, which is quite possible, can be treated by later intervention.

Chapter 19

Wounds of the Vertebral column and Spinal Cord