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War Wounds of the Urogenital Tract1
WAR WOUNDS OF THE UROGENITAL TRACT1 JAMES C. KIMBROUGH, COL. (MC) USA
The scope of this paper is three-fold: to present a preliminary report of the management of wounds of the genito-urinary tract observed in the operations on the continent from June 6, 1944 to October 6, 1944; to report a study of the wounds of the urogenital tract found in one hundred forty-seven killed in action in air crew casualties during a period of 5 months; and to discuss the treatment of neurogenic bladder of 193 patients due to injury of the central nervous system during the first three months of combat on the continent. N eurogenic bladder is not essentially a war wound of the genito-urinary tract, but because of the fact that the care of the genito-urinary tract in such injuries so often determines the ultimate results of the treatment, it is believed permissible to include these cases in the report. The information regarding the wounds of the genito-urinary tract was obtained from reports rendered by the urologists on duty in the general hospitals receiving patients from the mobile hospitals of the Army. In some cases these hospitals were located so close to the front line that patients were evacuated direct to them from the division dressing stations. In these hospitals it was necessary to evacuate the patients rapidly so that definitive treatment in many cases was not completely carried out. The reports were made by individual urologists working under the stress of caring for large numbers of casualties and do not assume the thoroughness of information which may later be obtained from a review of the completed clinical records. REPORT OF KILLED IN ACTION CASUALTIES
The genito-urinary tract injuries of 147 soldiers of air crews killed in action were compiled from the records of the operational research section of the Chief Surgeon's office during the 5 months period, June to October 1944. These bodies were examined immediately on removal from the aircraft and data were assembled regarding the character of the wounds, the type of missiles causing the wounds and the conditions under which the injuries were received. In the 147 bodies, 14 or 9.5 per cent had injuries of the genito-urinary system in addition to the other fatal wounds. The tabulation of these wounds is as follows: cases
Kidney: Laceration of both kidneys.............................. Laceration of right kidney .......................................... Laceration of left kidney. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bladder: Perforation or rupture of the bladder ................................ Scrotum and testicles: Perforation wounds ................................... Traumatic amputation ................................
2 4 3 3 1 1 14
1
Read at meeting of Royal Medical Society, Edinburgh, Scotland, Feb. 16, 1945.
179
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JAMES C. KIMBROUGH
Wound distribution of killed in action casualties with genito-urinary tract injuries CASES
PER CENT WOUNDS
NO. WOUNDS
Head and neck .. ... ......... ... .. ...... . ... . ..... . Chest ............. . .. . .... .. ... . .. . .. . . . . . . . . .... . Abdomen ....... . .. . ... . .... .... ...... .. ......... . Upper limb .... . .. . ..... . .................... . ... . Lower limb ..... . ...... . . .. . .. . ..... . .. . . . . . ..... .
1
1
4 4 4
7
6 12
5
19
3 18 16 35 28
Total . . . ......... .. . .. . ... . .......... . .. . . .. ... .
18
35
100
These wound distribution data represent the primary regions of the body injured by enemy missiles regardless of what other region was traversed by the same missile tract. None of the casualties in which the fatal wound was confined to the thorax sustained injuries to the genito-urinary tract. Four of the eleven of 36 per cent of the casualties in which only the abdominal wound was fatal had involvment of the genito-urinary system. Nine of twenty-three or 40 per cent of the casualties whose fatal wound involved both abdomen and thorax had involvement of the genito-urinary organs. Thirteen of 34 casualties (38 per cent) of the total one hundred forty-seven due to abdominal or abdomino-thoracic wounds had involvement of the genitourinary tract. In five of the fourteen (35.7 per cent) casualties in which the genito-urinary system was involved there was fractµre of the bony pelvis. Two of these wounds involved the kidneys, two the bladder and one involved the external genitalia. WOUNDS OF THE GENITO-URINARY TRACT
Mobile warfare has been the predominant type in this campaign whereas in the 1914-18 conflict, trench warfare was more common. This mobile warfare has resulted in a greater percentage of injuries to the lower extremities and external genitalia. The percentage of wounds due to high explosive has increased in proportion to the decrease in bullet wounds. Nine wounds of the external genitalia were due to land mines. This report considers 235 consecutive wounds of the genito-urinary system treated in General Hospitals. The incidence and percentage were as follows: CASE S
33
PER CENT
Kidney .... . .. . . . . ...... ... .. .. .. ........ . . ... . Ureter . . . . . .. .. . . . .... ...... ... . .... . .. . ..... . . Bladder ...... . . . . .. ..... .. . .. . .. . ...... . . ... . . E xternal genitalia ...... . . .. . . .. ... ... . .. ..... .
8
3.4
34 160
14.5 68 .1
Total. .. . ..... . . ..... . ... . . .. . . . ... .. .. .. . . . .
235
14
100
The incidence of ureteral injury is much greater than was observed in previous wars, which apparent increase may be due, at least in part, to the better urolgical
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WAR WOUNDS OF THE UROGENITAL TRACT
training of surgeons in recent years, making them urologically minded and enabling them to note a greater number 9f ureteral wounds that would have been overlooked in previous years. The kidney, 1.~.reter, bladder and prostate are organs deeply placed in the body and well protected l;>y skeletal and muscular tissue, so that injuries of these organs are usually associated with extensive wounds of adjacent structures with early mortality due to wounds other than urological. WOUNDS OF THE KIDNEY
In the stress of warfare, it is often impossible to maintain the perfectionists' attitude concerning diagnosis of renal injury. Also, in many cases, the multiplicity of severe wounds makes complete urological examination impracticable. The presence and extent of renal injury are ascertained by considering the symptoms, physical signs, extent of the wounds and whatever special urological procedures may be practicable or available. Hematuria is the most common symptom. The urine of all patients with abdominal wounds should be examined. The presence of blood in the urine means injury to the genito-urinary tract. In treating shock in patients with renal injury, it is necessary to determine the extent to which such injury is contributing to the shock. Before or during operative procedures involving the kidneys, it is imperative to ascertain the condition of the opposite kidney. Excretory urography may be used in field and evacuation hospitals and is always available to carry out more complete studies in the general hospitals. The value of this procedure is easily overrated. The function of damaged kidneys is usually suspended several hours after injury and renal x-ray outline will not be present even in mild injury. It is valuable in determining the condition of the uninjured kidney. Cystoscopy and retrograde urography during combat are procedures of questionable value in field and evacuation hospitals because of the time required and the trauma incident to instrumentation. Such procedures have their greatest value in the general hospitals. In any case, they should be attempted only by the experienced urologist. Urography, excretion and retrograde, is an important and necessary procedure in determining the results of conservative treatment of renal injuries. There were 33 wounds of the kidney, 14 per cent of the total number of cases reported: right kidney, 15; left kidney, 18. Causes
cases
Bullet wounds............................................................... 7 High explosives .............................................................. 22 Blast........................................................................ 3 Other injuries............................................................... 1 33 Type of injury Penetrating ................................................................. 17 Lacerating.................................................................. 8 Contusion ...... ;............................................................ 6
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JAMES C. KIMBROUGH
Hematuria was present in 29 patients. Associated wounds cases
11 Abdominal ... .. Bowel .. ...... .. . . . .... . . .. . . ........ . . . . . . . ..... .. . .. . . . .. .. . ... 7 Spleen . . . .. ................... . .. . ..... .. . .. . . ....... . . ... . .. . .. . . . . .... 1 Liver ... ........ . .... . ........... . . . .... .. . . ........ . . .. ... . . . .. . ....... . 3 Thorax . . . ..... ... . . .. . ............. . ... . ... ...... ..... . . . . . . . . . . ......... 5 Extremities .. . . . . . .. . .. .. . ... . ............ . .... . ........ . .... .. . . . . . .. .... 13 No other serious wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Treatment Conservative ... . .... .. .. .. ........ ... . . .. . . .. ...... . .. . ........ . . ...... . . 23 N ephrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Repair and drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The importance of conservative treatment is emphasizeq. In more than 70 per cent the only operative treatment necessary was that required by the associated wounds. N ephrectomy was necessary in eight, 24 per cent, on account of the severe renal damage. In 2 cases it was possible to repair the kidney wound. This conservative treatment does not support the trend in recent years to institute early exploratory operation in renal injury. Results cases
Duty in European theater. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Returned to United States .. . . . . . . .. . .... ... . . . . . .. . .. . ... . . . .. . . . ........... 13 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The cause of death and the return to the United States in the 14 cases were due to the associated injury in almost all patients. The disability was usually due to the injuries other than renal. WOUNDS OF THE URETER
There were 8 cases of ureteral wounds. The diagnosis of ureteral injury is often made by observation at time of operation. The presence of urine in the wound is positive evidence. Urography, excretory and retrograde, with ureteral catheterization, may be employed when patients are received at general hospitals, but is rarely practicable at time of the initial operations. The low incidence of ureteral wounds reported is probably due to the fact that they are associated with such severe injuries that death occurs early before the patients reach hospital facilities. Cause cases
Bullet . . ... . . .... . .. ... .... .. ... . . . ..... . .... .. .. . . . . . .. ...................... 2 High explosive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Type Severed . . .... . ... . . ... . . .. . .. ... . .............. . ......... .. .. . . . . . . . . .. . . . ... 3 Lacerated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Associated injuries Abdomen and bowel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extremities .. . . ... . ... . . .. .. . ...... . .. . . . . .. . ........... . . . . .. .. ..... . . ..... . . Head .. .... . ..... . ... . . .... . . . ....................... . ... . ...... . . . . ...... . . .. Othe• . .. ... . ... . . . .. . ... . .. . . ... . . .. . . . ....... .. . ... .. . . .. ... .. . .. .... .... . . ..
3 1 1 3
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WAR WOUNDS OF THE UROGENITAL TRAC'l'
Treatment cases
N ephrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Repair ....................................................................... 4 None ......................................................................... 3 Results Duty in European Theater .................................................... 5 Returned to U. S. with fistula ................................................ 2 Died ......................................................................... 1
The two returning to the U. S. will require nephrectomy at a later date. Ureteral injuries should be repaired at the time of the first operative procedure. Severed ureters should be sutured and ureteral catheter left in place. Diversion of the urinary stream above the injury is a basic principle in treating these wounds. Because of massive scar tissue it is rarely possible to repair ureteral injuries at late operations. The three severed ureters were treated as follows: recognized at initial operation was sutured and catheter left in place, l case; returned to U.S. with fistula, 1 case; nephrectomy will be required; the injury was not recognized at time of abdmninal operation; not recognized at early operation, patient died and ureteral injury noted at autopsy, l case. Four of the five lacerated injuries were repaired and catheter splint left in place. One was not recognized at operation, fistula resulted. N ephrectomy will be necessary. When the massive injuries of these patients is considered, it is not remarkable that the ureteral wound was not noted at primary operation in 2 patients (25 per cent of cases). WOUNDS OF THE BLADDER
The injuries reported in this series were due to penetration or laceration by bullets or by high explosives. One was due to blast injury by high explosives. The diagnosis presented no great difficulty and was often ascertained by general physical examination and by evaluation of the associated wounds. Diagnostic urethral catheterization has been useful. The early evaluation of bladder injury is imperative. Rarely is it necessary to employ x-ray examination with air or fluid injection or cystoscopy in field or evacuation hospitals. These procedures are valuable aids in the general hospitals to which the patients ultimately are transferred, but the diagnosis must be made at the first place of treatment if a high mortality is to be avoided. The refinements of diagnostic technique so splendidly described in standard texts and current literature have little application in war surgery of the bladder. The diagnosis must be made at the time of the first examination and primary operat10n. Urinary extravasation is not tolerated. Digital rectal examination with the urethral catheter in place is a valuable diagnostic procedure. If these measures do not establish sufficient information, exploratory operation is preferred to delay in doubtful cases. It is important to avoid waste of time for determining if the wound is extra- or intraperitoneal. This can be ascertained at operation.
184
JAMES C. KIMBR.O UGH cases
Cases reported. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Causes Bullet wound ......... .. . .. .. .................... ..... ... ..... .. ...... .. ... 19 High explosive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Type of wound Penetrating. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Lacerating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Blast..... ..... . .. .. .................. .. ... ...... ... . ........ .... .... ..... . 1 Associated injuries Fracture of pelvis .. . ........... . . . ....... .... ... .... .... . . ... .. . ... ...... . Abdominal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bowel .............. .. ... ..... . .. .. .. .. .... ... ..... ..... ..... .... .......... Buttock and pelvis .. ... .... .... .. . .. . . . .. . . .. ..... .. . . .. . .. . . .. ........... Extremities ... . . .... . .. .... .. . . ......... ..... .... .... .... .. . .. .. . ....... . ..
6 9 4 10 5
Treatment Cystostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Repair and catheter drainage.... . ... . .. . .. . ... ... ... .... .. . . . ..... .... .... 6 Result Duty in European theater of operations ... ... ....... .. . .. ... . ... . .. ... .... . 23 Returned to U. S .... ..... ................................., .... : .....•,. .,. _ 10 Died . .. . . . .. ... ...... . .......... . .... ...... .. . . . ....... ....... ........•,. .,. 1
Early drainage, usually by cystostomy, is necessary in penetrating wounds of the bladder. Rarely is catheter drainage satisfactory. The urethral catheter left in place is almost always a source of grave danger. It is desirable to do repair of the injury at time of primary operation, but urinary drainage by cystostomy is imperative. The general principles of the treatment of bladder injury are as follows: (1) The control of hemorrhage and management of shock; (2) drainage by cystostomy; (3) repair of the bladder wound. The recognition and treatment of associated wounds of the bowel and ureter are essential. Rarely is the bladder the only organ involved in the injury. WOUNDS OF EXTERNAL GENITALIA
Classification of wounds of the external genitalia according to the organ involved presents great difficulty because of the fact that injuries to these organs are usually multiple and involve several parts. They are reported here according to the tissue involved in the major injury and the associated wounds are recorded as secondary injuries. One hundred sixty patients were observed with wounds of the external genitalia. These are recorded as urethra, 34; penis, 44; scrotum and testicles, 82; according to the tissue primarily involved in the injury. The high incidence of external genitalia involvement is in part due to the mobile warfare in which the entire body was exposed in contradistinction to trench warfare in which the upper part of the body is vulnerable to the enemy fire. Land mines account for only nine of these wounds. One case of laceration of the prostate was reported with injury to pelvis and post urethra.
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WAR WOUNDS OF THE UROGENITAL TRACT
cases
Wounds of the urethra ........................................................... 34 Cause Bullet wounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 High explosives ............................................................ 16 Land mines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Other injuries............................................................. 3 Location of wound Anterior urethra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Posterior urethra.......................................................... 4 Associated wounds External genitalia ......................................................... 24 Bowel..................................................................... 2 Perineum .................................................................. 3 Extremities................................................................ 4 Prostate................................................................... 1
In!J'the treatment of urethral injuries, repair should be carried out as soon as practicable. During the pressure activity in combat, early treatment often consists in the control of hemorrhage and the conservation of tissue. Later repair is complicated by scar tissue formation and the resulting deformity. cases
Plastic repair in European theater of operations .............................. 24 Returned to U.S. for repair ................................................. 10 Cystostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Results Returned to duty in European theater of operations .......................... 24 Transferred to U. S. for later repair ......................................... 10
Those returned to the U. S. for later treatment were severe cases with much loss of tissue and will require diversion of the urinary stream by cystostomy prior to plastic operations for repair. cases
Wounds of the penis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Type of wound Laceration ............................................................... 41 Amputation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Cause Bullet wounds ............................................................ 22 High explosive ........................................................... 21 Land mine............................................................... 1 Associated injuries Head..................................................................... 1 Kidney................................................................... 1 Abdominal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Extremities...................................................... . . . . . . . . . 8 External genitalia ........................................................ 22 No associated injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
186
JAMES C, KIMBROUGH cases
Treatment Repair .................... . ...... .. ...... . ........ ..... . .. . . . .... ... . . ... Amputation, partial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amputation, complete. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cystostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34 7 3 6
Results Returned to duty in European theater of operations .. .... . . . .. .. ... .. ..... 28 Returned to U. S. for further treatment . . .. .. . . .. ....... . . . . . . . .. . . . ...... 16 Wounds of scrotum and testes ...... ........ .. ... .... ... .......... . . . .. ... .. .. .. . 82 Cause Bullet ....... . . .. . ... .. ... . . .... .. . . .. .. .... . .. . .. . .... .. .. . .... . . . ..... . . 34 High explosive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Land mines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Type of Wound Penetrating . . . .....••.. .. . ........ ......... . . ....... .... ... .... . . .. ... . . . 63 Lacerating . .... . ..... .. . . .... . . . . .... . .. . .. . ..... . . . ........... .. . .... ... 19 Associated Inj uries Penis and urethra . .. .... .. ...... . . . . ... . . .. .. ... ... ... ... . .' . . . . . . .. ... . .. 32 Extremities and other wounds .... .... . .. .. . ...... ..... .. . . . ... . ... ... . . .. 50 Treatment Repair . . . . ... ... . . . ........ . . . . . ... . ... . .... .. ........... .. . .. . . . . . . .. ... 59 Orchidectomy Unilateral. . .. .. ....... . . ... .. . . ..... . ... . .. ... . .... ... . . . . . ... . . . 21 Bilateral.... .. . . . . ... ... . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 R esults Duty in European theater of operations .. . .. . .. ... . .. . . .. .. .. .. .. . ... .. . . . 63 Returned to U. S. . ............... .. ...... . .. . . . . . . . . . . . . .. . . . . .. . . . . . . . . . 14 Died .. . . . .. ......... . .. . . ... .... . ....... .. .. . 5
The deaths occurred in patients with severe associated injuries and were not due to the wounds of scrotum and testes. In the treatment of wounds of the scrotum and testicles the control of hemorrhage and conservation of tissue is imperative. All testicular tissue must be saved. The only cause for removal of these organs should be complete destruction of the blood supply. The scrotal tissue has remarkable power of regeneration and will often renew adequate covering for the testicle after great destruction. Extensive loss of scrotal tissue can be treated satisfactorily by plastic repair with the transplanting of skin from other parts of the body. NEUROGENIC BLADDER
In the management of war wounds during the 1914-18 conflict there are few conditions in which greater confusion is found than in the treatment of neurogenic bladder. The autonomic nervous system was not understood. Adequate knowledge of neurogenic control of the bladder had not been gained. Mistreatment was the rule. The catheter in t he presence of bladder distension was justly considered an instrument of great danger. The advantages of cystostomy drainage were not appreciated. The mortality from urinary tract infection and concomitant renal calculous diseases was alarming.
WAR WOUNDS OF THE UROGENITAL TRACT
187
Knowledge of the autonomic nervous system was gained during the decade 1920-30 and the basic principles of the mechanism of bladder function were published by Learmonth and others in the early 1930's. Since these original publications, many articles have been contributed on this matter, a great many of which only confused the issue. There are two sets of nerve supply to the bladder, motor and sensory. The motor innervation is derived from the autonomic sympathetic, autonomic parasympathetic and the somatic (pudic nerve). The autonomic sympathetic nerve supply (filling mechanism) has origin in the twelfth thoracic and the first, second, and third lumbar segments of the cord. Stimulation of these nerves causes relaxation of the detrusor muscle and contraction of the bladder neck, the so-called internal sphincter. The autonomic parasympathetic nerves have origin in the second and third sacral segments of the cord. Stimulation of these nerves causes contraction of the detrusor muscle, and relaxation of the vesical outlet. These nerves control the mechanism by which the bladder is emptied of its contents. The parasympathetic is the most important nerve supply to the bladder. The somatic nerve supply (pudic) is derived from the third and fourth sacral . segments and has voluntary control of the external sphincter. Innervation of the blood vessels, trigone and seminal vesicles is supplied by the autonomic sympathetics from the thoraco-lumbar segments of the cord. The sensory nerves of pain and temperature are derived from the thoraco-lumbar segments_ and accompany the sympathetic trunks in the presacral nerve fibers. Neurogenic bladder results from injury to the brain, spinal cord, or the peripheral nerves supplying the bladder. The majority of cases are due to spinal cord lesions. Those resulting from injury to the brain are usually transient and recover in 48 to 72 hours. Rarely is the condition due to peripheral nerve lesions; none in the series herein reported. The symptoms may be due to damage directly to the cord by missiles or bone fragments, or by edema and hemorrhage without actual penetration of the cord. The injury due to edema, hemorrhage and other types of compression are usually mild and the urinary retention is transient. Injury due to division of elements in the cord is more serious and persistent retention is present. The type and gravity of the bladder dysfunction depend upon the location of the brain or cord lesion and the severity of the damage. Injuries to the brain are attended often by no more than transitory retention of 2 or 3 days' duration. Lesions of the cervical and upper dorsal cord offer a fair prognosis for establishing the so-called automatic bladder. Bladder dysfunction due to lesions of the lower dorsal and lumbar cord is more serious. Those due to involvement of the sacral cord are the most serious and the patients rarely recover. The treatment of cord bladder is definite from the time of injury until recovery or death, and is based on fundamental principles. Any variation from these fundamentals will result in disaster for the patient and humiliation for the physician.
188
JAMES C. KIMBROUGH
Fundamentals: a. As soon as the presence of neurogenic bladder is determined, insert an urethral catheter and leave it in place until the patient recovers, dies, or undergoes cystostomy. b . Maintain continuous catheter drainage, tidal or otherwise, until bladder function recovers, or it is determined that the bladder will not recover. c. Do suprapubic cystostomy at end of 4 weeks, or earlier if bladder function does not show definite evidence of recovery, provided the general condition of the patient offers reasonable life expectancy. Precaution: a. Do not permit the bladder to become overdistended. b . Do not depend on spontaneous overflow or manual expression of urine. c. Do not depend on intermittent catheterization. d. Do not continue the catheter in place in the presence of severe infection. These are the fundamental principles of the treatment and axioms of the management of cord bladder. They cannot be violated with impunity. All other measures such as nursing care to prevent decubitous ulcers, urinary antiseptics, and regulation of fluid intake, are secondary considerations. A urethral cathet er cannot be left in place indefinitely without serious consequences. Complications can usually be avoided for a period of 4 to 6 weeks after which cystostomy should be done. The chief and almost the only problem of treatment is the prevention of infection and its complications. Cystometric studies: Cystometric studies are valuable procedures in determining the condition of the bladder musculature. E arly evidences of return of function are ascertained by this method before any clinical signs of recovery are manifest . Simple apparatus is preferred. The wat er monomet er is adequate. The more complicated mercury monometers may be employed by those who desire to carry out this examination in great detail. The Lewis cystometer is one of the latest and most complete type of apparatus available. Report of cases: The clinical records of 193 patients with neurogenic bladder have been examined. The associat ed lesions of the nervous system listed as the etiologic factor are as follows : cases
Skull .. . Cervical vertebrae. Lumbar vert ebrae . . ... .. . . . .. . . . . Dorsal vertebrae ..... ... . .. . .. . . . . .. . . . . . .. . . . . . . .. . . .. . . .. .. . Sacral region. T otal. . .. .
6
15 54
107 11
193
Cathet er drainage was carried out from the time of diagnosis until recovery of bladder function, or until it was evident that the return of such function was uncertain. T ype of treatment cases
Cystostomy. . . . . . . . . . . . . . . . .. . Cathet er drainage. T idal or otherwise . . . . . . .... .. .
130
63
Bladder function did not return in 134 patients. Cystostomy was performed in one hundred and thirty of these and four were transferred t o t he Zone of t he
189
WAR WOUNDS OF THE UROGENITAL TRACT
Interior with catheter drainage. Five patients died of associated injuries. The patients were not observed over sufficient time to determine mortality due to urinary tract complications. Bladder function returned in 54 patients treated by urethral drainage. The time required for recovery with catheter drainage -was as follows: cases
Less than 27 days. 32 days. 36 days. 56 days.
. ...................................................... 51
Total.
.................... 54
. ................................................... . ...................
1 1 1
It is apparent that recovery rarely occurs in patients who manifest no evidence of return of bladder function at the end of 1 month. It is the standard procedure to perform suprapubic cystostomy in all patients showing no evidence of return to bladder function at the end of 4 weeks. It is not desired to discuss in detail the relative merits of the different type of cystostomies. Each procedure has its enthusiastic advocates. Mr. Riches' ingenious instrument has great merit. The perineal cystostomy of Lt. Col. Lloyd G. Lewis is not without distinct advantages. Because of the fact that patients will be treated in several hospitals in the process of evacuation, individualistic methods of operations are not desirable. It is believed that the suprapubic cystostomy properly performed is the best standard procedure for general use by army surgeons. SUMMARY
A report is presented of 235 patients with wounds of the genito-urinary tract, the incidence of urinary tract injury is one hundred forty-seven killed in action casualties, and the early results of treatment of 193 cases of neurogenic bladder due to wounds of the brain and spinal cord. CONCLUSION
Conservative treatment has proved efficient in renal damage. Early operation gives the best results in wounds of the ureter and bladder. Conservation of tissue is important in the treatment of wounds of the external genitalia. Suprapubic cystostomy is the approved method of treating neurogenic bladders in which the function does not show definite evidence of recovery within 4 weeks. The author desires to express his appreciation to Lt. Col. John N. Robinson (MC) AUS, Senior Consultant in Urology, European Theater of Operations, for assistance in assembling the records of the cases reported; to Major Allan Palmer (MC) AUS, Operational Research Section, Chief Surgeon's Office, for the information concerning the Killed in Action report; to Major John H. Dougherty (MC) AUS, Chief Urologist, 48th U.S. General Hospital, for report of special cases; and to Lt. Col. Lloyd G. Lewis (MC) AUS, Chief Urologist, Walter Reed General Hospital, for the lantern slide showing bladder innervation.
The scope of this paper is three-fold: to present a preliminary report of the management of wounds of the genito-urinary tract observed in the operations on the continent from June 6, 1944 to October 6, 1944; to report a study of the wounds of the urogenital tract found in one hundred forty-seven killed in action in air crew casualties during a period of 5 months; and to discuss the treatment of neurogenic bladder of 193 patients due to injury of the central nervous system during the first three months of combat on the continent. N eurogenic bladder is not essentially a war wound of the genito-urinary tract, but because of the fact that the care of the genito-urinary tract in such injuries so often determines the ultimate results of the treatment, it is believed permissible to include these cases in the report. The information regarding the wounds of the genito-urinary tract was obtained from reports rendered by the urologists on duty in the general hospitals receiving patients from the mobile hospitals of the Army. In some cases these hospitals were located so close to the front line that patients were evacuated direct to them from the division dressing stations. In these hospitals it was necessary to evacuate the patients rapidly so that definitive treatment in many cases was not completely carried out. The reports were made by individual urologists working under the stress of caring for large numbers of casualties and do not assume the thoroughness of information which may later be obtained from a review of the completed clinical records. REPORT OF KILLED IN ACTION CASUALTIES
The genito-urinary tract injuries of 147 soldiers of air crews killed in action were compiled from the records of the operational research section of the Chief Surgeon's office during the 5 months period, June to October 1944. These bodies were examined immediately on removal from the aircraft and data were assembled regarding the character of the wounds, the type of missiles causing the wounds and the conditions under which the injuries were received. In the 147 bodies, 14 or 9.5 per cent had injuries of the genito-urinary system in addition to the other fatal wounds. The tabulation of these wounds is as follows: cases
Kidney: Laceration of both kidneys.............................. Laceration of right kidney .......................................... Laceration of left kidney. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bladder: Perforation or rupture of the bladder ................................ Scrotum and testicles: Perforation wounds ................................... Traumatic amputation ................................
2 4 3 3 1 1 14
1
Read at meeting of Royal Medical Society, Edinburgh, Scotland, Feb. 16, 1945.
179
180
JAMES C. KIMBROUGH
Wound distribution of killed in action casualties with genito-urinary tract injuries CASES
PER CENT WOUNDS
NO. WOUNDS
Head and neck .. ... ......... ... .. ...... . ... . ..... . Chest ............. . .. . .... .. ... . .. . .. . . . . . . . . .... . Abdomen ....... . .. . ... . .... .... ...... .. ......... . Upper limb .... . .. . ..... . .................... . ... . Lower limb ..... . ...... . . .. . .. . ..... . .. . . . . . ..... .
1
1
4 4 4
7
6 12
5
19
3 18 16 35 28
Total . . . ......... .. . .. . ... . .......... . .. . . .. ... .
18
35
100
These wound distribution data represent the primary regions of the body injured by enemy missiles regardless of what other region was traversed by the same missile tract. None of the casualties in which the fatal wound was confined to the thorax sustained injuries to the genito-urinary tract. Four of the eleven of 36 per cent of the casualties in which only the abdominal wound was fatal had involvment of the genito-urinary system. Nine of twenty-three or 40 per cent of the casualties whose fatal wound involved both abdomen and thorax had involvement of the genito-urinary organs. Thirteen of 34 casualties (38 per cent) of the total one hundred forty-seven due to abdominal or abdomino-thoracic wounds had involvement of the genitourinary tract. In five of the fourteen (35.7 per cent) casualties in which the genito-urinary system was involved there was fractµre of the bony pelvis. Two of these wounds involved the kidneys, two the bladder and one involved the external genitalia. WOUNDS OF THE GENITO-URINARY TRACT
Mobile warfare has been the predominant type in this campaign whereas in the 1914-18 conflict, trench warfare was more common. This mobile warfare has resulted in a greater percentage of injuries to the lower extremities and external genitalia. The percentage of wounds due to high explosive has increased in proportion to the decrease in bullet wounds. Nine wounds of the external genitalia were due to land mines. This report considers 235 consecutive wounds of the genito-urinary system treated in General Hospitals. The incidence and percentage were as follows: CASE S
33
PER CENT
Kidney .... . .. . . . . ...... ... .. .. .. ........ . . ... . Ureter . . . . . .. .. . . . .... ...... ... . .... . .. . ..... . . Bladder ...... . . . . .. ..... .. . .. . .. . ...... . . ... . . E xternal genitalia ...... . . .. . . .. ... ... . .. ..... .
8
3.4
34 160
14.5 68 .1
Total. .. . ..... . . ..... . ... . . .. . . . ... .. .. .. . . . .
235
14
100
The incidence of ureteral injury is much greater than was observed in previous wars, which apparent increase may be due, at least in part, to the better urolgical
181
WAR WOUNDS OF THE UROGENITAL TRACT
training of surgeons in recent years, making them urologically minded and enabling them to note a greater number 9f ureteral wounds that would have been overlooked in previous years. The kidney, 1.~.reter, bladder and prostate are organs deeply placed in the body and well protected l;>y skeletal and muscular tissue, so that injuries of these organs are usually associated with extensive wounds of adjacent structures with early mortality due to wounds other than urological. WOUNDS OF THE KIDNEY
In the stress of warfare, it is often impossible to maintain the perfectionists' attitude concerning diagnosis of renal injury. Also, in many cases, the multiplicity of severe wounds makes complete urological examination impracticable. The presence and extent of renal injury are ascertained by considering the symptoms, physical signs, extent of the wounds and whatever special urological procedures may be practicable or available. Hematuria is the most common symptom. The urine of all patients with abdominal wounds should be examined. The presence of blood in the urine means injury to the genito-urinary tract. In treating shock in patients with renal injury, it is necessary to determine the extent to which such injury is contributing to the shock. Before or during operative procedures involving the kidneys, it is imperative to ascertain the condition of the opposite kidney. Excretory urography may be used in field and evacuation hospitals and is always available to carry out more complete studies in the general hospitals. The value of this procedure is easily overrated. The function of damaged kidneys is usually suspended several hours after injury and renal x-ray outline will not be present even in mild injury. It is valuable in determining the condition of the uninjured kidney. Cystoscopy and retrograde urography during combat are procedures of questionable value in field and evacuation hospitals because of the time required and the trauma incident to instrumentation. Such procedures have their greatest value in the general hospitals. In any case, they should be attempted only by the experienced urologist. Urography, excretion and retrograde, is an important and necessary procedure in determining the results of conservative treatment of renal injuries. There were 33 wounds of the kidney, 14 per cent of the total number of cases reported: right kidney, 15; left kidney, 18. Causes
cases
Bullet wounds............................................................... 7 High explosives .............................................................. 22 Blast........................................................................ 3 Other injuries............................................................... 1 33 Type of injury Penetrating ................................................................. 17 Lacerating.................................................................. 8 Contusion ...... ;............................................................ 6
182
JAMES C. KIMBROUGH
Hematuria was present in 29 patients. Associated wounds cases
11 Abdominal ... .. Bowel .. ...... .. . . . .... . . .. . . ........ . . . . . . . ..... .. . .. . . . .. .. . ... 7 Spleen . . . .. ................... . .. . ..... .. . .. . . ....... . . ... . .. . .. . . . . .... 1 Liver ... ........ . .... . ........... . . . .... .. . . ........ . . .. ... . . . .. . ....... . 3 Thorax . . . ..... ... . . .. . ............. . ... . ... ...... ..... . . . . . . . . . . ......... 5 Extremities .. . . . . . .. . .. .. . ... . ............ . .... . ........ . .... .. . . . . . .. .... 13 No other serious wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Treatment Conservative ... . .... .. .. .. ........ ... . . .. . . .. ...... . .. . ........ . . ...... . . 23 N ephrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Repair and drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The importance of conservative treatment is emphasizeq. In more than 70 per cent the only operative treatment necessary was that required by the associated wounds. N ephrectomy was necessary in eight, 24 per cent, on account of the severe renal damage. In 2 cases it was possible to repair the kidney wound. This conservative treatment does not support the trend in recent years to institute early exploratory operation in renal injury. Results cases
Duty in European theater. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Returned to United States .. . . . . . . .. . .... ... . . . . . .. . .. . ... . . . .. . . . ........... 13 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The cause of death and the return to the United States in the 14 cases were due to the associated injury in almost all patients. The disability was usually due to the injuries other than renal. WOUNDS OF THE URETER
There were 8 cases of ureteral wounds. The diagnosis of ureteral injury is often made by observation at time of operation. The presence of urine in the wound is positive evidence. Urography, excretory and retrograde, with ureteral catheterization, may be employed when patients are received at general hospitals, but is rarely practicable at time of the initial operations. The low incidence of ureteral wounds reported is probably due to the fact that they are associated with such severe injuries that death occurs early before the patients reach hospital facilities. Cause cases
Bullet . . ... . . .... . .. ... .... .. ... . . . ..... . .... .. .. . . . . . .. ...................... 2 High explosive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Type Severed . . .... . ... . . ... . . .. . .. ... . .............. . ......... .. .. . . . . . . . . .. . . . ... 3 Lacerated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Associated injuries Abdomen and bowel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extremities .. . . ... . ... . . .. .. . ...... . .. . . . . .. . ........... . . . . .. .. ..... . . ..... . . Head .. .... . ..... . ... . . .... . . . ....................... . ... . ...... . . . . ...... . . .. Othe• . .. ... . ... . . . .. . ... . .. . . ... . . .. . . . ....... .. . ... .. . . .. ... .. . .. .... .... . . ..
3 1 1 3
183
WAR WOUNDS OF THE UROGENITAL TRAC'l'
Treatment cases
N ephrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Repair ....................................................................... 4 None ......................................................................... 3 Results Duty in European Theater .................................................... 5 Returned to U. S. with fistula ................................................ 2 Died ......................................................................... 1
The two returning to the U. S. will require nephrectomy at a later date. Ureteral injuries should be repaired at the time of the first operative procedure. Severed ureters should be sutured and ureteral catheter left in place. Diversion of the urinary stream above the injury is a basic principle in treating these wounds. Because of massive scar tissue it is rarely possible to repair ureteral injuries at late operations. The three severed ureters were treated as follows: recognized at initial operation was sutured and catheter left in place, l case; returned to U.S. with fistula, 1 case; nephrectomy will be required; the injury was not recognized at time of abdmninal operation; not recognized at early operation, patient died and ureteral injury noted at autopsy, l case. Four of the five lacerated injuries were repaired and catheter splint left in place. One was not recognized at operation, fistula resulted. N ephrectomy will be necessary. When the massive injuries of these patients is considered, it is not remarkable that the ureteral wound was not noted at primary operation in 2 patients (25 per cent of cases). WOUNDS OF THE BLADDER
The injuries reported in this series were due to penetration or laceration by bullets or by high explosives. One was due to blast injury by high explosives. The diagnosis presented no great difficulty and was often ascertained by general physical examination and by evaluation of the associated wounds. Diagnostic urethral catheterization has been useful. The early evaluation of bladder injury is imperative. Rarely is it necessary to employ x-ray examination with air or fluid injection or cystoscopy in field or evacuation hospitals. These procedures are valuable aids in the general hospitals to which the patients ultimately are transferred, but the diagnosis must be made at the first place of treatment if a high mortality is to be avoided. The refinements of diagnostic technique so splendidly described in standard texts and current literature have little application in war surgery of the bladder. The diagnosis must be made at the time of the first examination and primary operat10n. Urinary extravasation is not tolerated. Digital rectal examination with the urethral catheter in place is a valuable diagnostic procedure. If these measures do not establish sufficient information, exploratory operation is preferred to delay in doubtful cases. It is important to avoid waste of time for determining if the wound is extra- or intraperitoneal. This can be ascertained at operation.
184
JAMES C. KIMBR.O UGH cases
Cases reported. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Causes Bullet wound ......... .. . .. .. .................... ..... ... ..... .. ...... .. ... 19 High explosive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Type of wound Penetrating. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Lacerating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Blast..... ..... . .. .. .................. .. ... ...... ... . ........ .... .... ..... . 1 Associated injuries Fracture of pelvis .. . ........... . . . ....... .... ... .... .... . . ... .. . ... ...... . Abdominal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bowel .............. .. ... ..... . .. .. .. .. .... ... ..... ..... ..... .... .......... Buttock and pelvis .. ... .... .... .. . .. . . . .. . . .. ..... .. . . .. . .. . . .. ........... Extremities ... . . .... . .. .... .. . . ......... ..... .... .... .... .. . .. .. . ....... . ..
6 9 4 10 5
Treatment Cystostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Repair and catheter drainage.... . ... . .. . .. . ... ... ... .... .. . . . ..... .... .... 6 Result Duty in European theater of operations ... ... ....... .. . .. ... . ... . .. ... .... . 23 Returned to U. S .... ..... ................................., .... : .....•,. .,. _ 10 Died . .. . . . .. ... ...... . .......... . .... ...... .. . . . ....... ....... ........•,. .,. 1
Early drainage, usually by cystostomy, is necessary in penetrating wounds of the bladder. Rarely is catheter drainage satisfactory. The urethral catheter left in place is almost always a source of grave danger. It is desirable to do repair of the injury at time of primary operation, but urinary drainage by cystostomy is imperative. The general principles of the treatment of bladder injury are as follows: (1) The control of hemorrhage and management of shock; (2) drainage by cystostomy; (3) repair of the bladder wound. The recognition and treatment of associated wounds of the bowel and ureter are essential. Rarely is the bladder the only organ involved in the injury. WOUNDS OF EXTERNAL GENITALIA
Classification of wounds of the external genitalia according to the organ involved presents great difficulty because of the fact that injuries to these organs are usually multiple and involve several parts. They are reported here according to the tissue involved in the major injury and the associated wounds are recorded as secondary injuries. One hundred sixty patients were observed with wounds of the external genitalia. These are recorded as urethra, 34; penis, 44; scrotum and testicles, 82; according to the tissue primarily involved in the injury. The high incidence of external genitalia involvement is in part due to the mobile warfare in which the entire body was exposed in contradistinction to trench warfare in which the upper part of the body is vulnerable to the enemy fire. Land mines account for only nine of these wounds. One case of laceration of the prostate was reported with injury to pelvis and post urethra.
185
WAR WOUNDS OF THE UROGENITAL TRACT
cases
Wounds of the urethra ........................................................... 34 Cause Bullet wounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 High explosives ............................................................ 16 Land mines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Other injuries............................................................. 3 Location of wound Anterior urethra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Posterior urethra.......................................................... 4 Associated wounds External genitalia ......................................................... 24 Bowel..................................................................... 2 Perineum .................................................................. 3 Extremities................................................................ 4 Prostate................................................................... 1
In!J'the treatment of urethral injuries, repair should be carried out as soon as practicable. During the pressure activity in combat, early treatment often consists in the control of hemorrhage and the conservation of tissue. Later repair is complicated by scar tissue formation and the resulting deformity. cases
Plastic repair in European theater of operations .............................. 24 Returned to U.S. for repair ................................................. 10 Cystostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Results Returned to duty in European theater of operations .......................... 24 Transferred to U. S. for later repair ......................................... 10
Those returned to the U. S. for later treatment were severe cases with much loss of tissue and will require diversion of the urinary stream by cystostomy prior to plastic operations for repair. cases
Wounds of the penis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Type of wound Laceration ............................................................... 41 Amputation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Cause Bullet wounds ............................................................ 22 High explosive ........................................................... 21 Land mine............................................................... 1 Associated injuries Head..................................................................... 1 Kidney................................................................... 1 Abdominal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Extremities...................................................... . . . . . . . . . 8 External genitalia ........................................................ 22 No associated injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
186
JAMES C, KIMBROUGH cases
Treatment Repair .................... . ...... .. ...... . ........ ..... . .. . . . .... ... . . ... Amputation, partial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amputation, complete. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cystostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34 7 3 6
Results Returned to duty in European theater of operations .. .... . . . .. .. ... .. ..... 28 Returned to U. S. for further treatment . . .. .. . . .. ....... . . . . . . . .. . . . ...... 16 Wounds of scrotum and testes ...... ........ .. ... .... ... .......... . . . .. ... .. .. .. . 82 Cause Bullet ....... . . .. . ... .. ... . . .... .. . . .. .. .... . .. . .. . .... .. .. . .... . . . ..... . . 34 High explosive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Land mines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Type of Wound Penetrating . . . .....••.. .. . ........ ......... . . ....... .... ... .... . . .. ... . . . 63 Lacerating . .... . ..... .. . . .... . . . . .... . .. . .. . ..... . . . ........... .. . .... ... 19 Associated Inj uries Penis and urethra . .. .... .. ...... . . . . ... . . .. .. ... ... ... ... . .' . . . . . . .. ... . .. 32 Extremities and other wounds .... .... . .. .. . ...... ..... .. . . . ... . ... ... . . .. 50 Treatment Repair . . . . ... ... . . . ........ . . . . . ... . ... . .... .. ........... .. . .. . . . . . . .. ... 59 Orchidectomy Unilateral. . .. .. ....... . . ... .. . . ..... . ... . .. ... . .... ... . . . . . ... . . . 21 Bilateral.... .. . . . . ... ... . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 R esults Duty in European theater of operations .. . .. . .. ... . .. . . .. .. .. .. .. . ... .. . . . 63 Returned to U. S. . ............... .. ...... . .. . . . . . . . . . . . . .. . . . . .. . . . . . . . . . 14 Died .. . . . .. ......... . .. . . ... .... . ....... .. .. . 5
The deaths occurred in patients with severe associated injuries and were not due to the wounds of scrotum and testes. In the treatment of wounds of the scrotum and testicles the control of hemorrhage and conservation of tissue is imperative. All testicular tissue must be saved. The only cause for removal of these organs should be complete destruction of the blood supply. The scrotal tissue has remarkable power of regeneration and will often renew adequate covering for the testicle after great destruction. Extensive loss of scrotal tissue can be treated satisfactorily by plastic repair with the transplanting of skin from other parts of the body. NEUROGENIC BLADDER
In the management of war wounds during the 1914-18 conflict there are few conditions in which greater confusion is found than in the treatment of neurogenic bladder. The autonomic nervous system was not understood. Adequate knowledge of neurogenic control of the bladder had not been gained. Mistreatment was the rule. The catheter in t he presence of bladder distension was justly considered an instrument of great danger. The advantages of cystostomy drainage were not appreciated. The mortality from urinary tract infection and concomitant renal calculous diseases was alarming.
WAR WOUNDS OF THE UROGENITAL TRACT
187
Knowledge of the autonomic nervous system was gained during the decade 1920-30 and the basic principles of the mechanism of bladder function were published by Learmonth and others in the early 1930's. Since these original publications, many articles have been contributed on this matter, a great many of which only confused the issue. There are two sets of nerve supply to the bladder, motor and sensory. The motor innervation is derived from the autonomic sympathetic, autonomic parasympathetic and the somatic (pudic nerve). The autonomic sympathetic nerve supply (filling mechanism) has origin in the twelfth thoracic and the first, second, and third lumbar segments of the cord. Stimulation of these nerves causes relaxation of the detrusor muscle and contraction of the bladder neck, the so-called internal sphincter. The autonomic parasympathetic nerves have origin in the second and third sacral segments of the cord. Stimulation of these nerves causes contraction of the detrusor muscle, and relaxation of the vesical outlet. These nerves control the mechanism by which the bladder is emptied of its contents. The parasympathetic is the most important nerve supply to the bladder. The somatic nerve supply (pudic) is derived from the third and fourth sacral . segments and has voluntary control of the external sphincter. Innervation of the blood vessels, trigone and seminal vesicles is supplied by the autonomic sympathetics from the thoraco-lumbar segments of the cord. The sensory nerves of pain and temperature are derived from the thoraco-lumbar segments_ and accompany the sympathetic trunks in the presacral nerve fibers. Neurogenic bladder results from injury to the brain, spinal cord, or the peripheral nerves supplying the bladder. The majority of cases are due to spinal cord lesions. Those resulting from injury to the brain are usually transient and recover in 48 to 72 hours. Rarely is the condition due to peripheral nerve lesions; none in the series herein reported. The symptoms may be due to damage directly to the cord by missiles or bone fragments, or by edema and hemorrhage without actual penetration of the cord. The injury due to edema, hemorrhage and other types of compression are usually mild and the urinary retention is transient. Injury due to division of elements in the cord is more serious and persistent retention is present. The type and gravity of the bladder dysfunction depend upon the location of the brain or cord lesion and the severity of the damage. Injuries to the brain are attended often by no more than transitory retention of 2 or 3 days' duration. Lesions of the cervical and upper dorsal cord offer a fair prognosis for establishing the so-called automatic bladder. Bladder dysfunction due to lesions of the lower dorsal and lumbar cord is more serious. Those due to involvement of the sacral cord are the most serious and the patients rarely recover. The treatment of cord bladder is definite from the time of injury until recovery or death, and is based on fundamental principles. Any variation from these fundamentals will result in disaster for the patient and humiliation for the physician.
188
JAMES C. KIMBROUGH
Fundamentals: a. As soon as the presence of neurogenic bladder is determined, insert an urethral catheter and leave it in place until the patient recovers, dies, or undergoes cystostomy. b . Maintain continuous catheter drainage, tidal or otherwise, until bladder function recovers, or it is determined that the bladder will not recover. c. Do suprapubic cystostomy at end of 4 weeks, or earlier if bladder function does not show definite evidence of recovery, provided the general condition of the patient offers reasonable life expectancy. Precaution: a. Do not permit the bladder to become overdistended. b . Do not depend on spontaneous overflow or manual expression of urine. c. Do not depend on intermittent catheterization. d. Do not continue the catheter in place in the presence of severe infection. These are the fundamental principles of the treatment and axioms of the management of cord bladder. They cannot be violated with impunity. All other measures such as nursing care to prevent decubitous ulcers, urinary antiseptics, and regulation of fluid intake, are secondary considerations. A urethral cathet er cannot be left in place indefinitely without serious consequences. Complications can usually be avoided for a period of 4 to 6 weeks after which cystostomy should be done. The chief and almost the only problem of treatment is the prevention of infection and its complications. Cystometric studies: Cystometric studies are valuable procedures in determining the condition of the bladder musculature. E arly evidences of return of function are ascertained by this method before any clinical signs of recovery are manifest . Simple apparatus is preferred. The wat er monomet er is adequate. The more complicated mercury monometers may be employed by those who desire to carry out this examination in great detail. The Lewis cystometer is one of the latest and most complete type of apparatus available. Report of cases: The clinical records of 193 patients with neurogenic bladder have been examined. The associat ed lesions of the nervous system listed as the etiologic factor are as follows : cases
Skull .. . Cervical vertebrae. Lumbar vert ebrae . . ... .. . . . .. . . . . Dorsal vertebrae ..... ... . .. . .. . . . . .. . . . . . .. . . . . . . .. . . .. . . .. .. . Sacral region. T otal. . .. .
6
15 54
107 11
193
Cathet er drainage was carried out from the time of diagnosis until recovery of bladder function, or until it was evident that the return of such function was uncertain. T ype of treatment cases
Cystostomy. . . . . . . . . . . . . . . . .. . Cathet er drainage. T idal or otherwise . . . . . . .... .. .
130
63
Bladder function did not return in 134 patients. Cystostomy was performed in one hundred and thirty of these and four were transferred t o t he Zone of t he
189
WAR WOUNDS OF THE UROGENITAL TRACT
Interior with catheter drainage. Five patients died of associated injuries. The patients were not observed over sufficient time to determine mortality due to urinary tract complications. Bladder function returned in 54 patients treated by urethral drainage. The time required for recovery with catheter drainage -was as follows: cases
Less than 27 days. 32 days. 36 days. 56 days.
. ...................................................... 51
Total.
.................... 54
. ................................................... . ...................
1 1 1
It is apparent that recovery rarely occurs in patients who manifest no evidence of return of bladder function at the end of 1 month. It is the standard procedure to perform suprapubic cystostomy in all patients showing no evidence of return to bladder function at the end of 4 weeks. It is not desired to discuss in detail the relative merits of the different type of cystostomies. Each procedure has its enthusiastic advocates. Mr. Riches' ingenious instrument has great merit. The perineal cystostomy of Lt. Col. Lloyd G. Lewis is not without distinct advantages. Because of the fact that patients will be treated in several hospitals in the process of evacuation, individualistic methods of operations are not desirable. It is believed that the suprapubic cystostomy properly performed is the best standard procedure for general use by army surgeons. SUMMARY
A report is presented of 235 patients with wounds of the genito-urinary tract, the incidence of urinary tract injury is one hundred forty-seven killed in action casualties, and the early results of treatment of 193 cases of neurogenic bladder due to wounds of the brain and spinal cord. CONCLUSION
Conservative treatment has proved efficient in renal damage. Early operation gives the best results in wounds of the ureter and bladder. Conservation of tissue is important in the treatment of wounds of the external genitalia. Suprapubic cystostomy is the approved method of treating neurogenic bladders in which the function does not show definite evidence of recovery within 4 weeks. The author desires to express his appreciation to Lt. Col. John N. Robinson (MC) AUS, Senior Consultant in Urology, European Theater of Operations, for assistance in assembling the records of the cases reported; to Major Allan Palmer (MC) AUS, Operational Research Section, Chief Surgeon's Office, for the information concerning the Killed in Action report; to Major John H. Dougherty (MC) AUS, Chief Urologist, 48th U.S. General Hospital, for report of special cases; and to Lt. Col. Lloyd G. Lewis (MC) AUS, Chief Urologist, Walter Reed General Hospital, for the lantern slide showing bladder innervation.