Contents

470

SECTION I

GENERAL SURGERY

CHAPTER XVI

WOUNDS OF THE GENITOURINARY TRACT

Shortly after the establishment of the American Expeditionary Forces a manual of urology a was prepared and distributed to the Medical Department, A. E. F., with the view of standardizing, among other activities, the work of those medical officers in whose hands would fall cases requiring operative treatment for injury to the genitourinary tract, incident to battle.¹

Since the text of this manual, in so far as the present subject is concerned, was based upon the existent literature, and since it proved of value in the work of medical officers, especially consulting urologists, it has been largely drawn upon in the preparation of this chapter.

It is unfortunate that analytical studies of series of injuries to the genito- urinary tract could not have been made on cases while these were in hospital. Lacking these, recourse has been had to clinical records, which, being variously prepared, frequently are silent as to features that would have present value.

WOUNDS OF THE KIDNEY

Wounds of the kidney in war are neither infrequent nor unimportant. It is true they are overshadowed in many instances by the more frequent and fatal lesions of adjacent viscera and so are frequently overlooked. But since they in themselves, though often fatal, are singularly amenable to intelligent treatment, the surgeon should not fail to focus his attention upon them. In 2,385 gunshot wounds of the abdomen in the American Expeditionary Forces, the kidney was involved in 129 instances, a percentage of 5.44.² To determine the relationship of the kidney injury with those of other organs, the clinical records of 66 members of the American Expeditionary Forces,³ showing injury to the kidney, were analyzed. In 38 instances no other viscus was involved. The association of lesions of other viscera was as follows: Liver, 11; spleen, 5; small intestine, 3; large intestine, 6. Thoracic viscera were injured in 11 instances in association, 2 of which are included above in connection with injuries of abdominal viscera.

As to the nature of the missile, in 61 of the cases this was given as follows: Rifle and machine gun, 41; shrapnel and high-explosive shell, 20.

PATHOLOGY

A gunshot wound of the kidney itself may involve only the parenchyma, one of the larger renal vessels, or the pelvis. If the parenchyma alone is injured and the pelvis scarcely opened, the resulting microscopic hematuria may pass

^a The Manual of urology for the Medical Department, A. E. F., was prepared by the author of this chapter in collaboration with Maj. Edward L. Keyes, Capts. M. L. Boyd, Everard L. Oliver, W. H. Mook, and D. M. Davis, and Lieuts. J. E. Moore and William Jack, M. C.

471

unnoticed and the renal injury either escape detection altogether or be disclosed by operation for other injuries or by a lumbar hematoma. If an artery is divided or so contused as to become obstructed by clot, the renal parenchyma supplied by this vessel will become gangrenous, for the arteries of the kidney are terminal; they do not anastomose. Division of one of the main branches of the renal artery, near the hilum, usually results in hemorrhage so severe as to demand operation, probably nephrectomy. Wounds of the renal pelvis of themselves imply only extravasation of urine, but, like those of the renal vessels, they are almost always associated with wounds of the renal artery and of the adjacent viscera as well.

The wound in the parenchyma may be perforating, tangential, or explosive. The edges of the wound are usually contused; adjacent parenchyma may become necrotic through arterial injury, but the more remote portions of the parenchyma suffer no more than temporary congestion, expressed by a brief anuria.

The later lesions are those of infection and extravasation, intraperitoneal or extraperitoneal. Destruction of fascial planes eliminates the usual anotomical restriction to their spread.

CLINICAL PICTURE

The patient arrives at the evacuation hospital labeled as a wound of the buttock, thigh, abdomen, or chest. The surgeon's immediate concern is with the state of shock, the amount of hemorrhage, the length of time since the patient was wounded, the general character of the wound itself, and symptoms pointing to perforation of the intraperitoneal viscera.

Unless the situation of the wound itself, the presence of hematoma in the loin, or of blood in the urine call his attention to the probable existence of a kidney injury, this does not usually enter the surgeon's calculations, since injuries to the other abdominal or the thoracic viscera are of much more immediate importance and are far more common, the decision to operate or not to operate is also reached with reference to the patient's general condition and the presence of a "penetrating" wound rather than with reference to a kidney injury.

SYMPTOMS

The immediate symptoms of renal wounds are due to hemorrhage. Thus hematuria is absent only if the ureter is completely divided or obstructed by clot, or if the wound does not invade the renal pelvis. This hematuria is total, but usually not so severe as to cause clotting in the bladder. Retention of urine is common. Shock is not so severe as that due to intraperitoneal injuries, unless the patient is exsanguinated. It is noteworthy that the hemorrhage from renal injuries, however severe, is rarely fatal. Hematoma in the loin develops rapidly in wounds that do not drain freely. It excites tenderness and rigidity of the overlying muscles, and forms an ill-defined mass. Hemorrhage from the wound is free. Intraperitoneal hemorrhage is obscured by the symptoms due to lesions of other organs. Gas gangrene, sepsis, extravasation, and secondary hemorrhage are the causes of death at the base. Secondary

472

hemorrhage may occur as late as two months after the wound. It is quite common in the second and third week. It is more to be feared than the primary bleeding because of its severity and its marked tendency to recur, from each of which recurrences the patient rallies less well than from its predecessor. Renal infection and stone are late complications.

DIAGNOSIS

All patients with abdominal injuries should he catheterized at the first opportunity, unless they can urinate freely. The urine obtained should be examined for blood.

Large wounds of the loin present no special diagnostic difficulties. The diagnosis is obscure under two conditions: (1) In the presence of hematuria. If the wound gives no clue as to the source of bleeding the diagnosis is made by cystoscopy, which discloses blood from the ureter, or by exploratory operation undertaken for the relief of other visceral lesions. (2) In the absence of hematuria. The renal injury is disclosed by cystoscopy and ureteral catheterization; operation for hematuria; retroperitoneal infection; lesions of other viscera.

Ureteral wounds seemingly do not occasion sufficient bleeding to permit an immediate diagnosis, except by surgical exploration.

TREATMENT

AT THE FRONT

When there is doubt as to whether or not to open the belly or the loin first, the loin should be opened. The loin incision should be transverse and extend approximately to the edge of the rectus. It may be enlarged by a vertical transrectus incision or by a vertical incision along the outer border of the erector spinte muscle long enough to permit division of all muscular and ligamentous attachments to the last rib. The twelfth dorsal nerve and artery may be avoided by placing the transverse incision a finger's breadth below the rib. Thus also one avoids the danger of inadvertently entering the pleura, through mistaking the eleventh for the twelfth rib.

If there is a wound of the loin and hematuria, or if the wound plainly leads to the kidneys, enlarge it transversely, deliver the kidney and examine the hilum for lesions of the renal vessels.

If the main artery or vein, or the upper main branch of the artery, are wounded, perform nephrectomy. If smaller arteries or the lower branch of the renal artery are wounded, or the renal wound is a relatively slight one, there are three procedures: (a) For wounds that are not very extensive or ragged and do not involve any great destruction of the arterial system of the kidney it may be wise to do nothing more than to pack the loin wound down to kidney.(b) But in case of persistent hemorrhage, extensive contusion, presence of foreign bodies, or division of arteries, the kidney demands the surgeon's attention; the renal wound may be packed or a portion of the parenchyma excised and sutured. (c) At the evacuation hospital, where such primary operations are usually performed, conditions are often such as to prohibit prolongation of the

473

operation for the purpose of resecting and suturing the kidney or searching for shell fragments or bullets. Resection is, however, the ideal operation for such cases--an ideal which has been realized in a few cases and one which the surgeon should always bear in mind. When partial nephrectony is performed the excised portion should include all that part of the kidney parenchyma which is deprived of circulation by division of its artery.

If this has been opened, a small tube should be left in the pelvis of the kidney two days, in order to evacuate blood clots and to hasten the return of kidney function by removing intra pelvic pressure. Always open peritoneum in front of the colon in order to examine the adjacent viscera. Drain and suture the wound in the usual manner.

Complete nephrectomy should be performed when more than one-third of the kidney is contused. On the other hand, when less than one-third is contused resection may be considered.

If hematuria suggests renal injury, but the wound is remote from the loin. the decision in favor of or against immediate operation should be based on the following data: If the patient is going to die of primary renal hemorrhage, he is likely to do so before reaching the dressing station. Though exploration of renal wounds usually starts a fresh parenchymatous hemorrhage. it discloses the fact that the primary bleeding has already stopped. Therefore unless an external wound leads directly to the kidney region the presence of hematuria or of a retro peritoneal hematoma is no indication for immediate operation. A retro peritoneal hemorrhage discovered in the course of a laparotomy may be disregarded (it often does not arise from the renal vessels at all) unless it is of enormous size, in which event it should be evacuated extraperitoneally, before the intestines are much handled, for it has been found that immediate grave shock results from turning the patient over and operating upon his loin after laparotomy.

Transperitoneal nephrectomy is generally condemned.

AT THE BASE

All secondary operations should be preceded by cystoscopy, to ascertain the condition of the opposite kidney, and fluoroscopy to locate fragments of bone or missile. Large hematomata should be evacuated to forestall infection. Secondary hemorrhage calls for transfusion and, usually, for prompt nephrectomy unless other complications prohibit this, for the hemorrhage is likely to recur and the effect of each return of bleeding is cumulative. Sepsis is combated according to general principles of drainage and antisepsis. Persistent urinary fistulae in the loin should be treated by the insertion of a ureteral catheter up to the pelvis of the kidney. The catheter may be left in place for an indefinite period if changed every fourth or fifth day. If healing is to occur this may be expected within 10 days.

If the fistula fails to heal, the kidney may be explored for the purpose of reestablishing this urinary flow by plastic operation, or for nephrectomy, if the opposite kidney is proved sound.

474

MORTALITY

The mortality rate of injuries to the kidney, both complicated and uncomplicated, proved to be 55.81 among cases of the American Expeditionary Forces treated in hospital. ² The clinical record of 66 cases showed a mortality of 50.³

To shock and hemorrhage may be attributed a certain number of deaths in kidney injury at the front. However, with improvements in evacuation, so as to hasten the arrival of the wounded at hospital, and improvement in methods of treating shock, obviously danger from the above-mentioned causes of death was lessened. Thus, of 37 of the series of 66 cases mentioned above, 28 were operated upon on the day of injury; eight, on the second day; one, on the third day. In a series of 13 cases, in hospitals at the front, 3 died and 10 were evacuated to the base.⁴

When we consider the frequency of involvement of other important organs, the percentage of fatalities is not surprising. In the series of 66 cases, the intestines were involved in 14 percent; liver, 16 percent; chest, 16 percent; peritoneal cavity, 39 percent.³

CASE REPORTS

Case 1 R. H., sergeant, Company F., 355th Infantry, A. E. F. Gunshot wound of back, left kidney, received in action October 21, 1918. Evacuation Hospital No. 10: Through-and-through wound of back; wound of entrance, left post axillary line; wound of exit, right post axillary line. Urinary retention; catheter showed blood in urine. Base Hospital No. 15: During night of October 27, severe hemorrhage into bladder. Patient became pulseless. Salt solution infusion. Cystoscopy showed bleeding from left kidney. Left lumbar nephrectomy, suprapubic drainage of bladder. Base Hospital No. 6: December 15, 1918. Gun-shot wound of back, perforating left post axillary line to right back, nephrectomy wound, left loin, suprapubic wound, bed sore, paralysis below waist line, bladder satisfactorily drained by putting large catheter in place of suprapubic tube. Ultimate result, cure.

A. E. F. RECORDS

Case 2. J. E. H., 1204342, Company L, 105th Infantry. Wounded August 5, 1918. Gunshot wound of side, penetrating abdomen, causing tear of ascending colon and damage to lower pole of right kidney. Operation, Canadian casualty clearing station, several hours after injury: Suture of intra and extraperitoneal tear of ascending colon. Liver and kidney sutured. Removal of foreign body from liver. Drainage. Tedious convalescence. Ultimate recovery. Demobilized January 8, 1919, 10 percent disability.

Case 3. J. G., Company D, 120th Machine Gun Company, 273042. Wounded October 8, 1918. Gunshot wound entering right lumbar region, penetrating lower pole of kidney. Wound of colon. Operation, same day: Laparotomy, suture of colon and mesentery, drainage of right kidney, debridement. Foreign body removed. November 19, 1918, second operation for intestinal obstruction due to adhesions. January 29, 1919, cystoscopy, ureteral catheterization and functional tests negative. February 7, 1919, duty.  February18, 1919, demobilized; disability, 50 percent.

Case 4. H. C., 101333, Company G, 168th Infantry. Wounded September 12, 1918. Gunshot wound, abdomen, rupture of left kidney. Operation, 10 hours later: Laparotomy, nointestinal injury found; closure; dorsal incision; kidney delivered; 3 clamps applied; kidney removed. Recovery.  March 6, 1919, duty. March 13, 1919, demobilization, 50 percent disability.

Case 5. E. M. P., 76925, shrapnel wound. Gunshot wound, right lumbar region, hip, right kidney, and left shoulder. Resection of colon. Operation, same day: Débridement, foreign body removed, right kidney perforated, drainage. February 5, 1919, nephrectomy,

475

right. Pyonephrosis. Fistula connecting hepatic flexure of colon to pyonephritic sac. March 20, 1919, duty. April 22, 1919, demobilized, 75 percent disability.

Case 6. C. A. B., 57153, Company D, 28th Infantry. Wounded July 21, 1918. Gunshot wound, penetrating upper right abdomen; fracture of eleventh and twelfth ribs; injury to liver and kidney. Operation. Record of first operation lost. August 8, 1918, abdomen drained. November 30, 1918, nephrectomy, right; complications: Urinary fistula from right kidney, multiple abscesses, arthritis, sinus tract of abdominal wall. July 23, 1919, demobilized, disability 75 percent.

Case 7. H. J. K., Machine Gun Company, 356th Infantry, 3173056. Wounded September 12, 1918. Gunshot wound, chest, penetrating right back at eleventh rib, perforating kidney and liver. Operation, nephrectomy. January 30, 1919, demobilized, disability 40 percent.

Case 8. E. K., 2858609. Wounded September 12, 1918. Gunshot wound, right side, passing through diaphragm, liver, and kidney. Operation, laparotomy. Considerable blood found in cavity; small injury to kidney, inaccessible. Drainage of abdomen. Foreign body removed from back, subcutaneously. Complication: Bronchopneumonia. February 11, 1919, to duty, convalescent center. January 15, 1920, demobilized, 30 percent disability.

Case 9. M. F. B., Company E, Seventh Engineers. Wounded September 17, 1918. Gunshot wound, left lumbar region over left kidney, bullet lodging in kidney. Operation: Foreign body removed from left kidney through extraperitoneal incision. Recovery. December 25, 1918, duty.

Case 10. V. R., 1317456. Wounded September 29, 1918. Gunshot wound, back, penetrating right kidney. Operation: D ebridement, drainage. September 30, 1918, passing blood in urine. October 13, 1918. Operation: Eighth rib resected, liver drained; foreign body removed from right back. January 25, 1919, nephrectomy, right. June 16, 1919, demobilized, disability, 25 percent.

Case 11. J. McK., 1207623. Gunshot wound, left loin, penetrating kidney and diaphragm. Operation, same day: Foreign body removed from upper surface of diaphragm, which was sutured. Kidney drained. Recovery. March 6, 1919, demobilized, no disability.

Case 12. A. F., 3495499, Company D, 165th Infantry. Wounded October 16, 1918. Gunshot wound, penetrating peritoneum and injuring kidney. Operation: Débridement, drainage. Recovery. November 14, 1918, operation: Resection of rib for empyema. July 5, 1919, demobilized, disability, 30 percent, on account of old suppurative pleurisy and obliteration of lung.

WOUNDS OF THE URETER

The brief mention of wounds of the ureter in medical periodicals throws little light upon the subject. There are records of four gunshot wounds of the ureter in the American Expeditionary Forces.² Apparently the wound has always been associated with visceral injury requiring abdominal section. The ureteral lesion is disclosed by the watery quality and urinous odor of the intra or retro peritoneal drainage, or else by appearance of urine in the dressings after operation.

The treatment is expectant. Several such urinary fistulae have healed spontaneously. In brief, the treatment of ureteral wounds is the following:

Immediate repair by suture of the wound, if it is reparable and if the patient's condition permits.

If these conditions can not be fulfilled, adequate drainage will be provided for the urine. The upper end of a completely severed ureter which can not be repaired may be brought up and sutured to the parietes. Primary nephrectomy is not to be considered because of the added danger to life.

476

If the ureter is sutured the finest chromic gut should be employed, for plain catgut will not hold. But great care must be taken to catch the ureter at its very cut edges so that as little as possible of the suture remains within the lumen of the canal, for fear of secondary stone formation. A small drain should be led down to the ureteral wound.

If the completely divided ureter is dislocated and sutured to the parietes, no tension whatsoever should be made upon it for fear of angulation. A few strands of silkworm gut left in the ureter will greatly facilitate the urinary drainage.

If the ureter is known to be irreparably divided, nephrectomy is the operation of choice, after the patient has rallied from the immediate effects of his injury and catheterization of the ureter has proved the opposite kidney sound.

If the opposite kidney is not sound, a cup should be fitted over the ureteral fistula and permanent drainage established.

If the wound is not known to be irreparable, a precise diagnosis should be established by pyelography; if possible the kidney should be drained by the indwelling ureter catheter. The failure of ureter catheter drainage indicates the necessity for operative treatment. While it may be possible in certain instances to reestablish drainage by plastic operation, such procedures are notoriously inefficient in the treatment of infected kidneys, and the masses of scar resulting from the wound would doubtless still further diminish the probability of success. Nephrectomy will usually be required.

The following case, reported by Stevens, concerns a ureteral injury:⁵

Case 13. Gunshot wound, penetrating, of back; hematuria; bullet removed through perirectal incision. Patient was admitted with hematuria. Gunshot wound of the back above right costal margin; no wound of exit. Cystoscopy showed blood coming from the right ureter, but urethral catheter, which was passed up to the renal pelvis, gave clear urine, miscroscopically free from blood. Roentgen-ray examination showed machine-gun bullet lodged in the bony pelvis back of bladder in region of lower pole, right ureter. On rectal examination, missile could be felt high up in this region. Fluoroscopic and X-ray examinations with catheter in ureter showed that bullet had probably injured the ureter. Through apteral perirectal incision bullet was removed without difficulty.

WOUNDS OF THE BLADDER

In the experience of the American Expeditionary Forces, battle injuries to the bladder bore about the same ratio to abdominal wounds as did injuries to the kidney: that is to say, of 2,385 abdominal injuries, 127 involved the bladder, a percentage of 5.32.²

In a series of 57 cases,3 rifle and machine-gun missiles injured the bladder in 46 instances: shrapnel and high-explosive shell, in 11. There is no record of piercing instruments causing injury to the bladder in the American Expeditionary Forces.² In the series referred to, the abdomen was involved in 17 instances; the rectum, in 5; large intestine, in 4; small intestine, in 15.

CHARACTER OF INJURY

The size and shape of the bladder perforation depend upon the type of missile producing the wound. The perforation varies from the small slitlike hole of the rifle missile to the large laceration of the shell fragment. Small

477

missiles may destroy very little of the bladder substance, but larger ones may destroy a very considerable portion of the bladder wall.

The projectile may enter the bladder from any angle, and entrance wounds high up in the abdominal wall or back, and wounds of the buttocks, thighs, and hips, or of the perineum, may involve the bladder, and should always be viewed with suspicion, as it is often impossible from the position of the wound of entrance to tell whether or not the bladder has been injured. It is wise always to consider the possibility of vesical wounds in doubtful cases.

Foreign bodies, such as bits of clothing and spicules of bone have been carried into the bladder by the projectile, and the missile itself has sometimes lodged there. If not removed, these foreign bodies become nuclei on which stones may form.

Experience of the World War has gone far to eliminate the classic distinction of injuries to the bladder whereby they are divided into two groups, the intra and extraperitoneal. In the description of symptoms and treatment, however, the distinction of extra and intraperitoneal injuries must be maintained for the sake of clarity. But in the field the surgeon will find that most of the intraperitoneal bladder wounds are associated with extraperitoneal wounds and that the diagnosis of extraperitoneal injuries founded upon the absence of abdominal tenderness and rigidity may ultimately be belied by a fatal peritonitis. The following classification therefore simply represents the various combinations which may occur, and artificially dissociates the complex pathological conditions resulting from wounds of the pelvis or abdomen that involve the urinary bladder.

 I. Intraperitoneal injuries.
  (A) Wounds.
  I. Uncomplicated.
  II. Complicated by –
  (a) Perforations of other viscera.
  1. The small intestine.
  2.. The colon.
 (b) Fractures or injuries of bones.
 (c) Injury to large blood vessels.
 (B) Ruptures by concussion.
 I. Complicated.
 II. Uncomplicated.
 II. Extraperitoneal injuries.
 (A) Wounds.
 I. Uncomplicated.
 II. Complicated by - 
(a) Injury to rectum.
(b) Injury to deep urethra or prostate.
(c) Fractures of the bony pelvis or femur.
(d) Injury to important blood vessels.

478

INTRAPERITONEAL WOUNDS

Intraperitoneal wounds of the bladder are almost invariably associated with other intraperitoneal injuries, perforation of the small intestine being the most common. Owing to this frequent association no laparotony should be regarded as complete until the bladder has been inspected on the operating table.

SYMPTOMS

Symptoms vary according to the position and size of the lesion and they depend considerably on lesions to other organs, especially the small or large intestine.

The outstanding subjective symptom of a bladder injury is a desire to void urine and an inability to do so. Often the patient is able only to expel a small amount of bloody urine. Frequently, however, no urine can be passed, since a large part of it is escaping into the abdominal cavity. Hematuria is always present. The amount of blood in the urine varies greatly. Usually it is present in considerable amount, though sometimes it is only visible as a smoky cloud. In case bleeding is profuse large intravesical clots form. Intestinal contents, especially in cases associated with rectal wounds, have often been noted in the urine drawn by catheter.

Symptoms referable to the abdomen are often very indefinite. There are signs of slowly developing peritonitis, namely, tenderness, rigidity, and dullness, at first limited to the lower abdomen. Later, this becomes general and the whole abdomen is tender and rigid. At this state there is usually nausea and vomiting. As the urinary collection in the peritoneal cavity increases, signs of intra-abdominal fluid appear; i. e., there is shifting dullness in the flanks and marked general abdominal distension.

DIAGNOSIS

Preoperative diagnosis can not usually include a cystoscopy and therefore can be but approximate. The hematuria indicates an injury to the urinary organs. The wounds of entrance and exit, the presence or absence of abdominal rigidity and tenderness, and the signs of injury to other viscera will suggest the location of this injury; that is, whether of the bladder or kidney, or whether intraperitoneal, extraperitoneal, or both. Under no circumstances should fluid be forced into a bladder through a catheter to determine whether or not it is ruptured. The consensus of surgical opinion is that such a procedure is both deceptive and dangerous.

TREATMENT

The peritoneal cavity is opened by a vertical incision through the rectus muscle and intestinal injuries are located and repaired. With the patient in the Trendelenberg position a finger is introduced through the perforation into the bladder to search for blood clot and foreign bodies, which if present are removed, and to locate the presence and position of any extraperitoneal tears. The hole in the bladder may be punctiform and easily closed by a purse-string

479

suture. The tear may be of considerable size and the method employed in repairing it will depend upon its position in the bladder wall. Wounds of the summit or anterior surface of the bladder are usually readily accessible. The edges of the bladder wound should be excised so that fresh surfaces may be brought together by a continuous suture of catgut approximating the muscular walls. A retention catheter should then be introduced. If the wound is situated at the base of the bladder it may be quite impossible to suture it. In such instances the best one can do is to convert the intraperitoneal wound into an extraperitoneal one by closing the peritoneum and carrying out suprapubic cystotomy.

Suprapubic cystotomy should not be done as a routine in these cases, as practically all authorities state that tight closure of the bladder and catheterization is preferable. Catheterization is usually necessary for only four or five days.

PROGNOSIS

The mortality of intraperitoneal wounds of the bladder varies between 50 and 70 percent. Peritonitis secondary to intestinal perforation is an important cause of death. Perforations of the posterior bladder wall have been overlooked and a urinary extravasation into the peritoneum has led to subsequent peritonitis and death. Unquestionably the immediate mortality cases where large blood vessels have been severed by the missile, has been very high.

EXTRAPERITONEAL WOUNDS

Wounds of the buttocks, thighs, or hips, with little or no evidence of any abdominal disturbance or discomfort, frequently invade the bladder extraperitoneally and should always be carefully investigated. Sacral and perineal wounds involving the rectum have often an associated bladder injury of this type, while wounds of the lower abdominal wall or flanks may obviously cause an extraperitoneal bladder perforation. These wounds of the bladder rarely exist independently.

In a series of 35 cases of extraperitoneal injury to the bladder,³ there was an associated involvement, in 8, of either the bony pelvis or the femur. In three instances, the rectum was injured; in one, the prostate was injured.

Intraperitoneal perforations are frequently produced by a missile entering the bladder extraperitoneally. Thus, in a series of 44 such cases, 3 the small intestine was injured in 8 instances, the large, in 1.

SYMPTOMS

An uncomplicated extraperitoneal wound of the bladder produces hematuria and difficult urination; the signs of urinary extravasation are present. In these cases the urinary extravasation usually follows the path of least resistance, which is along the most damaged fascial planes. The wound of entrance may be of sufficient size adequately to drain the bladder and in these instances no extravasation into the tissues takes place. Severe cellulitis and sepsis follow in the wake of the urinary extravasation and often prove fatal.

480

DIAGNOSIS

The diagnosis without cystoscopy can not be absolute. All patients with wounds of the buttocks or thighs should be catheterized. Hematuria will give a valuable hint as to the presence of bladder injury. Urine and blood maybe draining from the wound of entrance. There may be associated intraabdominal lesions and the signs and symptoms of intestinal injury should always be looked for. In cases where the rectum and bladder have both been injured the urine will usually contain feces as well as blood.

TREATMENT

Urinary drainage must be provided for these cases, and the wound of the bladder wall repaired if accessible.

Urinary drainage may be provided by (1) cystotomy, (2) interval catheterization, (3) retention catheter, or (4) enlargement of the wound of entrance and drainage of the bladder through it. Some surgeons believe that cystotomy should be done for all bladder perforations. Others, however, believe that in many extraperitoneal bladder wounds satisfactory drainage can be obtained through the wound of entrance. Whereas, in 45 cases in the series of 57 bladder wounds were drained, cystotomy was done on but 14.

In general, it may be said that if the tract of the missile is short and fairly large the bladder can be properly drained through it and there is no need for suprapubic cystotomy. In cases where the missile has produced a long tract, satisfactory drainage can not be obtained through it. In wounds of the bladder complicated by compound fracture of the pelvis or femur, cystotomy should be employed as a routine. If urine is allowed to drain over these open fractures serious cellulitis results and sepsis develops, often leading to a fatal outcome.

MORTALITY

There were 68 deaths in the 127 cases of gunshot wounds of the bladder, American Expeditionary Forces. ² The individual records 3 of but 57 cases have been discoverable. Among these, 35 deaths are recorded; 25 give no cause; 2 were from hemorrhage; 3 from shock; 3 from septicemia; 2 from pneumonia.

CASE REPORTS

Case 14. A. S., :3489070, Company G, 47th Infantry. Wounded October 12, 1918. Gunshot wound, penetrating right buttock, pelvis, and bladder. Shrapnel. Operation: Sulpraplubic eystotony; foreign body not removed. Debridemenit and drainage of buttock. Ligation of sciatic artery. D bridement of wounds of arm. Complications: Gas gangrene of arm, necessitating amputation below shoulder. August 15, 1919, demobilized, 80 percent disability, because of amputated arm. Healed scars, suprapubic and gluteal.

Case 15. M. C. G., 102628, Company M, 167th Infantry. Wounded July 28, 1918. Gunshot wound of abdomen between umbilicus and pubis, perforation of intestine and of bladder. Operation, July 29. Wound, debrided, two perforations in small intestine closed. Bladder wound closed with drainage. Recovery. February 27, 1919, operation to cure postoperative hernia. May 15, 1919, demobilized, 20 percent disability, because of weak- ness of abdominal wall.

Case 16. E. D., 184581, Headquarters Company, 101st Engineers. Wounded November 9, 1918. Gunshot wound, penetrating abdomen in right lower quadrant, perforating

481

bladder and intestine. Operation, foreign body removed; bladder drained; perforation of intestine and bladder closed by suture. Details of operation lost. May 7, 1919, cystoscopy, small stone in bladder. July 14, 1919, demobilized, 30 percent disability, because of hernia in abdominal wound.

Case 17. McK. G., 1380683. Gunshot wound entering left buttock, passing through intestine and bladder. Operation same day. Resection and end-to-end anastomosis of injured small intestine. Suture of wound in bladder. Recovery. October 6, 1918, removal of foreign body. December 25, 1918, returned to duty.

Case 18. J. H., 1415627, Company F, 165th Infantry. Gunshot wound, through and through, of sacrum, lower abdomen, bladder, right anterior abdominal wall, 7 cm. below umbilicus. Operation, incision; insertion of drainage tubes in front and behind. August 1, 1918, tube removed from lower abdominal incision, urine escapes. Able to void urine through urethra. October 5, 1918, wound healed, scars firm. November 10, 1918, return to duty.

Case 19. L. V. G., 1417607, Company D, 102d Infantry. Gunshot wound entrance, right buttock, passing through ilium, perforating bladder and left groin. Pubic bones fractured. Operation, November 18, 1918, median line abdominal incision. Omentum in hernial canal ligated and excised. No intestinal perforation found. Abdominal wound closed without drainage. Hernial sac excised. Wound closed. Drainage tube in bladder through tract of bullet. Recovery. November 10, 1918, a suprapubic drain inserted. November 21, 1918, external urethrotomy. Suprapubic fistula closed. December 20, 1918, No. 20 sound passes without difficulty. Wounds healing. Complications: Periurethral abscess, urinary fistula of lower abdomen. January 26, 1919, wounds healed. Demobilized, 50 percent disability, because of wound of abdomen perforating bladder.

Case 20. W. J. D., 1456617, Company E, 139th Infantry. Wounded September 27, 1918. Gunshot wound penetrating the abdomen just above and to the right of the symphysis pubis, perforating bladder and rectum, the exit being through the center of the left buttock. Followed by a discharge of urine through wound of entrance and feces through wound of buttock. Operation, insertion of drainage tube into the bladder through the wound of entrance. November 7, 1918, urethral drainage provided. November 14, 1918, no leakage from abdominal wound. Slight discharge from sinus in buttock, but not of fecal character. January 20, 1919, culture from bladder urine showed no growth. May 17, 1919, demobilized, 1.5 percent disability because of cicatrices and weakened abdominal muscles. No fistulae.

Case 21. R. K., 106426, Company D, 3d Machine-Gun Battalion. Wounded August 18, 1918. Gunshot wound, right thigh, entering bladder. Operation, incision of wound of thigh, evacuation of hematoma of right buttock; suprapubic cystotomy, removal of foreign body in bladder; drainage. Recovery. Complications: Indirect inguinal hernia; operation therefor April 22, 1919. May 23, 1919, returned to duty.

Case 22. D. N., 2239852. Gunshot wound, through and through, of abdomen, perforating intestine and bladder; exit, right buttock. Urine and feces escaped through the wound. Operation. Wound of entrance debrided to peritoneum; closed with external drain of rubber tissue. Wound of exit d ebrided with cigarette drain inserted through the sacrum. Dakin tubes inserted in buttock wound. Laparotomy, median incision. Examination showed bullet had not passed through adbomen. Wound closed in layers. October 6, 1918, urine escaped from drainage incision in lower abdominal incision and fecal matter from right buttock wound. December 19, 1918, examination of fecal fistula showed opening into rectum 2 inches above internal sphincter. December 31, 1918, pelvic abscess pointed just to the inner side of the anterior superior spine, incised and drained. November 19, 1919, abdominal exploration, removal of Beek's paste from fistulous tract. Tube drainage provided. No further record.

Case 23. F. H. C., 2715115, Company D, 315th Infantry. Gunshot wound, penetrating, left thigh, pelvis, and bladder. At operation, laparotomy, the foreign body was removed from the pelvis, and perforation of bladder closed. Suprapubic drainage afforded. Complications: Left foot drop from injured sciatic nerve; urinary fistula, which finally healed. February 16, 1920, demobilized, 40 percent disability because of paralysis of extensor muscles of left leg.

482

Case 24. R. B., 2846210, Company K, 355th Infantry. Gunshot wound, through and through, lower abdomen, perforating pubic hone and bladder; exit, right buttock. Laparotomy was performed the day of injury; examination showed perforation of bladder; no other viscera injured. Pubis was fractured; fragments removed. Bladder wound closed, rubber drainage tube inserted through wounds at entrance and exit. Subsequently vesicorectal fistula was discovered and on February 25, 1919, operation was done for this, successfully. May 27, 1919, demobilized, 15 percent disability because of scars; no fistulae present.

WOUNDS OF THE POSTERIOR URETHRA AND PROSTATE

Wounds of posterior urethra and prostate, like those of the bladder, are usually one element in an extensive wound of the pelvis or the thigh. The usual injury is an extensive laceration of the urethra by a bullet or shell fragment. The missile in traversing the pelvis may fracture this or the femur, and lacerations of the rectum and bladder and pelvic vessels are common complications.

The usual symptoms of wound of the urethra is retention of urine, though if the wound is a large one, carrying away the neck of the bladder, there may be incontinence of urine.

Urethrorrhagia is an almost constant symptom. If the wound is transverse and does not lacerate the superficial tissues of the perineum, the injury to the urethra is disclosed by a perineal hematoma and confirmed by the passage of a catheter. If the urethral wound is neglected, the retention is soon exchanged for incontinence by overflow of the bladder, with resulting urinary infiltration and infection of the perineum, the ischiorectal fossae, and the whole pelvis. Only the mildest injuries escape this fate.

The associated shock, hemorrhage, fracture of the pelvis, and wounds of rectum, bladder, or other viscera should not distract the surgeon's mind from the urethral condition. Whenever there is a fracture of the pelvis, or a bullet wound of pelvis, buttock, or thigh, a catheter should be passed into the bladder. If the urethra is ruptured the catheter may pass well up into the pelvis, but it will not draw urine, and if there is any doubt as to injuries about the perineum the extravesical course of the catheter may be readily identified by palpating it with the finger introduced into the rectum.

A slight injury to the prostatic urethra may produce only a hemorrhage into the bladder, which may be overlooked, may result in infiltration of urine, or may leave a urinary fistula. Shock and the associated injuries to viscera, vessels, and bone constitute the immediate dangers; but if the passage of a catheter reveals rupture of the urethra, provision must be made by perineal or suprapubic section for drainage of the bladder, unless this is assured by the character of the wound. Lacking this, the patient will probably die of urinary infiltration.

The ultimate prognosis as to restoration of the urinary function and the occurrence and extent of traumatic stricture depends upon the nature of the injury and the thoroughness of treatment.

The diagnosis is made by passage of a catheter. The shock and the wound are treated in the usual manner.

If the catheter will not pass, the bladder is to be drained by suprapubicor perineal section, a tube being left in the wound for drainage.

483

No immediate attempt at restoration of the urethra is warrantable, beyond attaching the two ends of the natural roof to each other and to the surrounding fascia, if this is possible. The perineal wound should always be left widely open, and if there is a perineal hematoma this should be opened by a median incision and the clots evacuated, even though the bladder is drained suprapubically.

Immediate closure of a rectal tear may, however, be successful and this should always be attempted, using fine chromic catgut and protecting the suture line as well as possible by suturing the levator and across it. The propriety of immediate colostomy may be considered.

After infection has been controlled and the complete diagnosis made by radiograph, and if necessary, by cystography the urethral wound is attacked according to the following principles:

1. An uncomplicated complete division of the posterior urethra may sometimes be healed by suprapubic cystotomy followed by suture of the urethra over a catheter, any defects in the urethral channel being pieced out by transplanted flaps of skin or mucous membrane. If the loss of tissue in the perineum is great this had better be filled in by a skin flap swung over from an adjoining portion of the thigh. Otherwise the dense perineal scar will obliterate the urethra.
2. If there is considerable loss of tissue, after suprapubic drainage has been established, a graft of skin or mucous membrane is sutured in place between the divided ends so as to form the roof of the urethra. The wound is then packed and after a slow healing and probably one or two accessory plastic operations the urethra lumen may be reestablished.
3. If complicated by a wound of the rectum a preliminary colostomy should be done rather early. This alone may be sufficient to cause healing of the wound in the bowel, or it may be necessary to freshen the cut edges and suture them or even bring the bowel down to form a new anus. Not until the rectal wound has been closed should any attempts be made to close the urethra. Thereafter the colostomy wound may be closed.
4. Wounds of the prostatic urethra have usually been associated with so great a loss of tissue as to defy closure by operation.

WOUNDS OF THE BULBOUS URETHRA

Wounds of the bulbous urethra like those of the posterior urethra, are usually but a part of grave injuries of the adjoining structures. The chief interest attached to them relates to the various plastic operations which may be performed for the restoration of the urethra in the perineum.

CASE RECORDS

In detailing his experiences in France with wounds of the genitourinary tract, as consulting surgeon to a base center, Stevens⁵ cites the following interesting case:

Case 25. Machine-gun bullet wound, the entrance being in the left buttock and the exit in the right wall of the scrotum. The patient had not tried to urinate. Nevertheless, it seemed extraordinary that no swelling, induration, or ecchymosis was present in the perineum.

484

The urethral lesion was diagnosed by the patient's inability to urinate and the physician's inability to pass a catheter. In its course the bullet had completely divided the bulbous urethra, and perforated an old right-sided hernia; this explained the presence of a mass of omentum protruding from the scrotal wall. The cord and testicle were uninjured. Operation was performed eight hours after the wound was received. The injured omentum was excised and the hernia repaired. Then, through a perineal incision, an end-to-end suture of the urethra was done, and perncial drainage established proximal to the suture line. The subsequent course was entirely satisfactory up to the fifth day, when the patient was evacuated to the base.

Case 26. P. H. G., private, 23d Infantry. Wounded June 14, 1918, at 2 p. m. Shell fragment entered posterior aspect of right thigh, passed just posterior to femur, exit wound being on the inner aspect of the thigh close to the perineum. Projectile then entered perineum, severed the urethra close to the bulb, divided the left spermatic cord, and tore its way out through the abdominal wall in the left inguinal region without entering the peritoneal cavity. Operation 10 p. m., same date. De bridement of the thigh wound, left castration, and suprapubic cystostomy. Evacuated June 22, to Base Hospital No. 18, where, on June 23, examination revealed a large sloughing wound of hypergastric region involving the recti muscles; suprapubic drainage wound; wound of thigh; incisions in left groin, scrotum, and dorsal surface of penis. Dakin's solution applied continuously with frequent dressings. June 28, wounds were cleaner and condition better, but suddenly patient began to have clonic spasms, slight strismus present, and his reflexes were hyperactive. Diagnosis: Tetanus. Antitetanic serum, 20,000 units administered; general condition, worse the next day. A lumbar puncture withdrew fluid under tension. Patient received antitetanic serum 10,000 units subcutaneously each day. On July 3 a second lumbar puncture was done and 20,000 units given intraspinally. Steady improvement now began. July 6, external urethrotomy, suprapubic tube removed. The good effect of dependent drainage afforded by external urethrotomy was soon demonstrated in the condition of all the wounds. Several large sloughings separated from the suprapubic wound and the thigh wound filled in rapidly. Owing to the fact that this hospital was functioning as an evacuation hospital it was necessary to evacuate on account of the exigencies of the service. Again seen June, 1919. General condition excellent, all wounds healed, perfect urinary control, urine passed entirely through perineal fistula.

Case 27. W. B., sergeant, 30th Infantry. Wounded by a rifle bullet, June 20, 1918.The missile entered left side of scrotum, severing urethra at penoscrotal junction, entering inner aspect of left thigh and making its exit at gluteal fold of left thigh. Patient reached Field Hospital No. 27, where a paralysis of the left leg, retention of urine, and inability to pass catheter were noted. Suprapubic cystotomy was done and patient evacuated. At Evacuation Hospital No. 7 it was impossible to introduce a catheter (either anterior or retrograde). Admitted to Base Hospital No. 18 June 23, where thigh wounds were opened and pus evacuated-Dakin's solution. Found impossible to pass catheter. July 8, external urethrotomy and operative attempt made to approximate torn ends of the urethra. Tube was placed in bladder through perineal wound and suprapubic tube removed. July 13,catheter was passed through meatus up into the perineal wound where it was introduced into the bladder; perineal wound closed over it; small protective drain to take care of any leakage. July 20, catheter withdrawn but subsequently had to be reintroduced. August 10, necessary to evacuate the patient; all wounds granulating well, patient voiding, at normal intervals, clear uninfected urine, No. 24 F sound could be introduced into the bladder through small perineal fistula present but rapidly closing.

Case 28. E. G., private, 39th Infantry. Wounded August 5, 1918, by machine-gunmissile which passed through left leg, upper inner portion of right thigh into perineum, severing membranous urethra and causing fracture of ischium and extravasation of urine. Operation, Field Hospital No. 19, wounds débrided, external urethrotomy with plastic reconstruction of the urethra, suprapubic cystotomy done. August 9, admitted to Base Hospital No. 18; bladder was draining well through suprapubic and perineal tubes; suture would of perineum badly infected; three stitches removed, pus evacuated. All wounds treated by continuous Dakin's solution. August 14, all wounds cleaner. Suprapubic tube

485

had been removed and all urine was passed by perineal tube. It was planned to treat this case like the preceding one, but in order to prepare for fresh convoys of casualties it was necessary to evacuate patient. This case illustrates the inadvisability of attempting any plastic procedure for the repair of the urethra at the first operation; resulting sear will seriously hamper future operative procedure for repair of urethra.

The following case report has been taken from clinical records of members of the American Expeditionary Forces.³

Case 29. R. F. S., 105796, Company D, 2d Machine-Gun Battalion. Wounded July18, 1918. Gunshot wound, entrance right buttock, exit left pubis, perforation of urethra and fracture of pubis. No record of operation, which was done in a French military hospital. Complications: Traumatic stricture of urethra and three urinary inguinal fistulae. August 14, 1918, operation, A. R. C., Military Hospital No. 1. Incision from wound in left groin to perineum. Fracture of superior ramus of pubis discovered. Evacuation of large abscess cavity beneath pubis extending to prostatic region of bladder. Urethra found completely severed in front of prostate. Catheters were inserted through penis into bladder and out suprapubic wound; bladder irrigation; Carrel tubes for other wounds. January 1,1919, impassable stricture. Perineal urethrotomy; stricture divided; suprapubic opening enlarged and opening into bladder through sphincter determined; rubber tube passed through perineal wound into bladder and suprapubic wound closed. January 30, 1919, secondary hemorrhage, packing of perineal wound. September 27, 1919, demobilized, 30 percent disability, on account of traumatic stricture of urethra, maximum improvement attained.

FISTULA OF THE URETHRA

Urethroperineal fistulae are usually irregular and embedded in dense scar. They may heal even after remaining open for months. If healing is despaired of, they may be closed by a plastic operation; but before this is attempted several specimens of tissue, excised from the region of the orifice of the fistula should be stained and examined for tuberculosis, as a persistent perineal fistula is often due to this disease. If acid-fast bacilli are found, the treatment should be conservative, consisting of a thorough curettage of the fistulous tract with excision of all pockets and followed by cauterization of the wound down to its urethra orifice. This operation produces surprisingly good results both in reducing the size and complications of the stricture and in some cases even closing it.

In the absence of tuberculosis the following operation should be performed: A sound should be introduced into the urethra and the whole of the perineal scar excised, the structured urethra being dealt with according to the requirements of the case. Drainage is procured by a small tube introduced into the bladder through the suprapubic opening. The perineal urethra is then closed by fine chromic gut sutures, the perineal muscles carried over this line of suture and ample drainage left in the superficial tissues.

FISTULA OF THE PENILE URETHRA

A fistula of the penile urethra, if small, may be encouraged to heal by touching lightly with the actual cautery.

If the loss of tissue is considerable the urethra may best be closed by the following operation: 1. Drainage of the bladder by suprapubic tube. 2. The skin or scar about the fistulous orifice is divided at a point far enough away from this orifice to permit a flap to be lifted and turned in, so that the skin

486

surface will form the floor of the urethra. This incision will usually have tobe made about 1 cm. from the orifice. It is convenient to keep a sound in theurethra while making it. The flaps may be rectangular or the incision maybe an ovoidal one surrounding the fistulous opening. In lifting up the flap, great care should be taken not to puncture the underlying urethral mucosa an to retain a fair blood supply for the flap itself. The tissues will usually beso thin about the edges of the fistula that the flap can not be dissected upanrv nearer than about 0.5 cm. from its orifice. The flap edges are then turnedin by one of two methods; viz, either the edges themselves are sutured togetherwith plain catgut or else the whole cuff or flap is caught up in a purse-stringsuture, the ends of which are drawn into the urethra through the fistula, broughtout at the external meatus and tied rather tightly over a small piece of gauzeacross the meatus. If the latter procedure is employed it is wise to insert a split tube of a few strands of silkworm gut through the external meatus intothe urethra to provide for the exit of the secretions which accumulate in it.The superficial skin and fascia are then dissected free in a lateral direction halfway around the penis on each side and brought together by mattress sutures of heavy catgut.

URETHRORECTAL FISTULA

This condition results frequently from wounds by missiles, or from abscessesinvolving the prostate and posterior urethra.

The escape of urine into the rectum and of gas and feces into the urethra lead to great discomfort. As a rule the condition is not associated with in-continence of urine, but if the internal sphincter has been injured urine mayflow constantly from the bladder into the rectum, and if the external sphincteris impaired incontinence of urine and frequent escape of gas and liquid fecesthrough the penile urethra may occur.

Not infrequently a previous perineal operation upon the prostate, or the incision of a prostatic abscess through the rectum, may be responsible forthe rectourethral fistula.

TREATMENT

When it is discovered that the wound involves both the rectum and urethra, its spontaneous closure should be encouraged by providing suprapubic drainageto divert the flow of urine, and by dilating the sphincter ani widely to facilitate the passage of feces.

No attempt at primary closure of the rectal and urethral openings should be made unless, in the removal of the missle, the rectal opening is small and the wound conditions are such as to justify attempt at primary closure.

During the convalescence examination for urethral stricture should he made, and if present it should be dilated with filiforms, followers, and sounds, controlled by finger in rectum.

In many cases, especially where suprapubic drainage has been maintained,spontaneous closure of the fistula occurs, but where this does not occur, after many weeks, operation should usually be undertaken.

487

OPERATION TO CLOSE FISTULA

The many procedures which have been advocated attest to the great difficulty which has been encountered in curing urethrorectal fistulae. A method which has shown almost invariable success is as follows: ⁷

First, suprapubic drainage of the bladder is established, with the patient in dorsal posture. The patient is then shifted to the exaggerated lithotomy position. A racquet-shaped incision, beginning in the midline of the perineum about 3 cm. anterior to the anal margin, is carried backward to this margin, and then encircles it at the mucocutaneous junction. Through the circular part of this incision the mucosa of the rectum is dissected free all round until a cylinder of the membrane is stripped from its attachments well above the point at which the rectal orifice of the fistula opens, the fistulous tract being divided transversely in this process. This dissection of the bowel is carried upward until sufficient mucous membrane is loosened to permit the pulling of the segment containing the fistulous orifice well out of the anus. The orifice and a small margin of normal mucosa above it, and all that below it, lying outside of the skin level are excised later. This procedure may be described as an exaggeration of the Whitehead principle in operating for hemorrhoids. The Young long urethral tractor is often very useful in drawing down the prostate and in facilitating the separation of rectum and prostate.

A minor point of some practical importance consists in beginning the dissection of the mucosa at the posterior or dorsal part of the circle. By so doing, not only is it easier to find normal planes of cleavage here, where there is no scarring but also the field is rendered less obscure by hemorrhage than would be the case if the anterior side be first attacked, as blood then runs down over the posterior half of the anus.

The structures of the perineal body are next divided through the straight incision in the midline (the handle of the racquet) so as to expose thoroughly the urethral orifice of the fistula. If the sphincter ani previously has been cut, the ends should be dissected free from scar tissue. In many cases the sphincter ani may be left intact, being pulled out of the way with a retractor as required. In some cases it may be advisable to divide it. The edges of the urethral fistulous opening then exposed are freshened and brought together with catgut sutures over a sound which has been previously passed through the urethra. These sutures do not penetrate the surface of the urethral mucous membrane. The levators, fascia, and smaller muscles are then brought together by interrupted catgut sutures across the midline of the perineum in several layers, reconstructing the perineal body much as is done in gynecological operations for relaxed vaginal outlet. Finally, the sphincter ani, if it has been cut, is restored by uniting its ends with a mattress suture of catgut, and the midline incision is closed with interrupted sutures. The last stage in the operation consists in the excision of the protruding cuff of rectal mucosa in which the fistulous opening lies, and the union of the lower end of the rectum to the anal skin margin. This is done by interrupted silk sutures after four submucous-subcutaneous sutures of catgut have been placed at quadrant points to help anchor the bowel in place.

488

It will be seen that there are four essential principles in this procedure. The first is the protection of the repair from leakage and muscle spasm by diverting urine from the urethra through suprapubic drainage. The second principle is the complete ablation of the damaged portion of rectal wall and the reposition of perfectly sound mucosa quite to the skin edge. The third element in the operation is the closure of the urethral orifice; and the final essential is the interposition between rectum and urethra of a solidly built up perineal body.

WOUNDS OF THE EXTERNAL GENITALIA

Gunshot wounds of the external genitalia occurred in the American Expeditionary Forces as follows: ² Penis, 171; scrotum, 499; testicle, 237.

In a series of 42 cases of injury to the penis, involving the penile urethra or the penis alone, rifle and machine-gun missiles were the cause of 27; shrapnel and high-explosive shell, 14; indirect injury, 1. The entrance wound involved the penis in 29 instances; the thigh in 9; buttock, 1; hip, 1; abdomen, 1. Secondary injuries numbered 20.

In a series of 164 cases of injury to the scrotum and testicles,3 95 of the wounds were due to rifle or machine-gun missiles; 58 to shrapnel and high-explosive shells; 5 to grenade fragments; 2 to revolver missiles. In 83 cases of scrotal injury the testicles were not involved, or at least not sufficiently involved to require operative treatment. There were 81 cases in which injury to the testicles was recorded, necessitating a right orchidectomy in 31 instances, a left orchidectomy 23 times, and a bilateral orchidectomy twice. Among the 81 cases with testicular injury, there were 10 deaths, but among the 83 cases in which the scrotum was involved, 5 deaths occurred.

WOUNDS OF THE SCROTUM, TESTICLES, PENIS, AND ANTERIOR URETHRA

Gunshot wounds of the external genitals often involve both scrotum and penis, producing extensive laceration. The primary indications are the following: (1) Control hemorrhage. (2) Carefully excise all contused tissue so as to forestall infection. (3) Do not remove a testicle unless its blood supply is irreparably damaged. Even if the tunica albuginea is split open the wound edges in may be freshened and sutured with chromic catgut. (4) No attempt should be made at this time to replace the testicle in the scrotum. (5) A catheter should be tied into the urethra, both to prevent cicatrical contraction of its orifice and to insure the patient against retention of urine. If the urethra is completely divided this catheter will issue from the wound and a second section of catheter should be inserted into the anterior portion of the urethra so as to prevent cicatricial contraction of its cut end. (6) The penile wound should be dressed wide open. If the penis is partially divided, even though the slip of tissue by which it adheres is insignificant, every effort should he made to pre-serve the end of the organ while dressing the wound wide open and awaiting the opportunity for secondary plastic operation.

489

RUPTURE AND TRAUMATIC STRICTURE OF THE URETHRA

Traumatic stricture following wound or rupture of the urethra has the following characteristics: (1) The gravest type of stricture may result from an injury so slight as to cause but little hematuria and no important disturbance of urination. (2) Traumatic stricture usually appears, and recurs after operation, with great rapidity. Stricture resulting from even the slightest injuries may contract so rapidly as to cause complete retention of urine within a few weeks, and, following simple external urethrotomy without resection of the urethra, such a stricture may recur and cause retention before the patient leaves the hospital.(3) Traumatic stricture is usually extremely resistant, rebellious to treatment by sounds and, as stated above, to the simple forms of operation.

PROPHYLACTIC TREATMENT

The most important feature in the treatment of traumatic stricture is its prophylaxis. Wounds of the urethra that do not completely sever the canal are not likely to result in severe strictures, but all wounds severing the canal and all contusions or ruptures of the urethra, be they ever so slight, should be regarded with grave apprehension and serious efforts made to prevent the formation of residual traumatic strictures, as follows: The indwelling catheter should not be employed, since it only encourages infiltration and scar formation in the wound. Stricture of the prostatic urethra may be prevented by the bladder drainage which the wound itself required. Rupture of the membranous urethra (usually caused by the so-called straddle injury) calls for immediate perineal section and drainage with a large tube for three or four days in order to estab-lish the lumen of the urethra and prevent infiltration of urine and subsequent stricture. This rule applies even to those cases whose only symptom is a slight urethral hemorrhage. Perineal section is likewise required to prevent stricture of the bulbous urethra. No special measures need be taken to prevent stricture following injuries to the pendulous urethra, excepting the use of the indwelling catheter in order to keep the cut ends from contracting during the first week after injury, and the frequent passage of sounds after reconstruction of the canal. Stricture will surely ensue, but it is readily controllable.

OPERATIVE TREATMENT

Stricture of the prostatic urethra usually occurs at the bladder neck and may be cured by the use of Young's prostatic punch. If the stricture is so tight as not to admit this instrument, it may be attached by the suprapubic route, the pin-point urethral opening being first divulsed and then the whole floor of the urethra at the bladder neck being removed by rongeur forceps, scalpel, or scissors.

Traumatic stricture of the bulbous or membranous urethra requires excision. Through a median or curved incision the perineal urethra is laid bare, and the precise location of the stricture identified by the passage of urethral instruments. The stricture is then divided longitudinally and one of three procedures follows:

490

(a) If the scar is relatively narrow, especially upon the roof of the canal, the urethra is resected by Cator's method. The bulbous portion of the canal is freed for at least 3 cm. from its attachment to the corpora cavernosa. The scar tissue is split open on the floor of the urethra in the direction of the long axis of this canal and any dense masses of scar tissue are excised. A small sound is placed in the urethra as a guide and the gap in the urethral wall is closed about this by fine transverse chromic catgut sutures, beginning at the lateral angles of the wound and inserted alternately on each side, finishing at the median line. None of these sutures is tied until the last one has been inserted. Then a small puncture is made, upon a staff, in the urethra behind the suture line, and through this an 18 F soft rubber catheter is introduced into the bladder for drainage. The sound is then reintroduced and the sutures tied in the same order as they were inserted. The mobilized urethra is thus drawn down into the perineum and the urethral wound tightly closed. The bulbo cavernosus muscle is now drawn across the line of suture and the dislocated bulbous urethra by a few catgut sutures, the anterior end of the skin wound closed, but a wide opening left in the superficial tissues about the catheter in the perineum, so as to prevent infiltration. The catheter is retained for 10 days. (b) If resection of the roof of the urethra is required, a transverse section of the urethra is excised, suprapubic drainage established, the cut edges of the urethra drawn together by a few fine chromic gut sutures, and the urethral stumps carefully supported by three or four heavier chromic sutures so as to take the strain off the cut edges. The deep tissues of the perineum are fully closed, but the superficial tissues are drained. (c) If the gap is so wide that no reconstruction is possible, the scar is excised and the two cut ends of the urethra brought out into the perineum for subsequent reconstruction of the urethra. Traumatic strictures of the pendulous urethra are controllable by internal urethrotomy. The rapidity with which the stricture contracts makes the Maisoneuve urethrotome the instrument of choice.

REFERENCES

(1) Manual of Military Urology, including Venereal Diseases, Skin Diseases and Wounds of the Genito-Urinary Organs. Masson et Cie. Paris, 1919. (2d ed. Published for the American Expeditionary Forces by the American Red Cross.)
(2) Based on sick and wounded reports to the Surgeon General.
(3) Clinical records, American Expeditionary Forces. On file, A. G. O., World War Division, Medical Records Section.
(4) Surgical reports made to the chief consultant, surgical services, A. E. F. On file, Historical Division, S. G. O.
(5) Stevens, A. R.: Experiences in France with Surgery of the Genitourinary Tract. Journal of the American Medical Association, Chicago, 1919, lxxii, 1589.
(6) Colston, J. A. C.: Observations on Gun-shot Wounds of the Urethra. Journal of Urology, Baltimore, 1920, iv, 185. (7) Young, Hugh H., and Stone, Harvey B.: The Operative Treatment of Urethro-Rectal Fistula (Presentation of a Method of Radical Cure). Journal of Urology, Baltimore, 1917, i, 289.