Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

CONCLUSIONS.

421.—1. Severe blows on the abdomen give rise to the absorption of the muscular structures, and the formation of ventral hernia, in many instances; this may, in some measure, be prevented during the treatment, by quietude, by the local abstraction of blood, and by the early use of retaining bandages.

2. Abscesses in the muscular wall of the abdomen, from whatever cause they arise, should be opened early; for although the peritoneum is essentially strong by its outer surface, it is but a thin membrane, and should be aided surgically as much as possible.

3. Severe blows, attended by general concussion, frequently give rise to rupture of the solid viscera, such as the liver and the spleen, causing death by hemorrhage. When the hollow viscera are ruptured, such as the intestines or the bladder, death ensues from inflammation.

4. Incised wounds of the wall of the abdomen to any extent rarely unite so perfectly (except, perhaps, in the linea alba) as not to give rise to ventral protrusions of a greater or less extent.

5. As the muscular parts rarely unite in the first instance after being divided, sutures should never be introduced into these structures.

6. Muscular parts are to be brought into apposition, and so retained principally by position, aided by a continuous suture through the integuments only, together with long strips of adhesive plaster, moderate compression, and sometimes a retaining bandage.

7. Sutures should never be inserted through the whole wall of the abdomen, and their use in muscular parts under any circumstances is forbidden; unless the wound, from its very great extent, cannot be otherwise sufficiently approximated to restrain the protrusion of the contents of the cavity. The occurrence of such a case is very rare.

8. Purgatives should be eschewed in the early part of the treatment of penetrating wounds of the abdomen. Enemata are to be preferred.

9. The omentum, when protruded, is to be returned by enlarging the wound through its aponeurotic parts if necessary, but not through the peritoneum, in preference to allowing it to remain protruded, or to be cut off.

10. A punctured intestine requires no immediate treatment. An intestine, when incised to an extent exceeding the third part of an inch, should be sewn up by the continuous suture in the manner recommended, Aph. 391.

11. The position of the patient should be inclined toward the wounded side, to allow the omentum or intestine being closely applied to the cut edges of the peritoneum. Absolute rest, without the slightest motion, should be observed. Food and drink should be restricted, when not entirely forbidden.

12. If the belly swell, and the propriety of allowing extravasated or effused matters to be evacuated seem to be manifest, the continuous suture or stitches should be cut across to a certain extent, for the purpose of giving this relief.

13. If the punctured or incised wound be small, and the extravasation or effusion within the cavity seem to be great, the wound should be carefully enlarged, and the offending matter evacuated.

14. A wound should not be closed until it has ceased to bleed, or until the bleeding vessel has been secured, if it be possible to do so. When it is not possible so to do, the wound should be closed, and the result awaited.

15. A gunshot wound penetrating the cavity can never unite, and must suppurate. If a wounded intestine can be seen or felt, its torn edges may be cut off, and the clean surfaces united by suture. If the wound can neither be seen nor felt, it will be sufficient for the moment to provide for the free discharge of any extravasated or effused matters which may require removal.

16. A dilatation or enlargement of a wound in the abdomen should never take place, unless in connection with something within the cavity rendering it necessary.

17. If the epigastric, circumflexa ilii, or other artery in the wall of the abdomen, be injured and bleed, the wound should be enlarged, and the bleeding vessel secured by ligature. If the main trunk or the external iliac artery be sought for and tied, the patient will in all probability die.

18. When balls lodge in the bones of the pelvis, they should be carefully sought for and removed, if it can be done with propriety and safety.

19. In a wound of the bladder, an elastic gum catheter should be kept in the urethra, frequently without a stopper, until the wound is presumed to be healed—unless its presence should prove injurious, from excess of irritation, not removed by allowing the urine to pass through it by drops as it is brought into the bladder.

20. In all cases in which a catheter cannot be introduced, in consequence of the back part of the urethra or the neck of the bladder being injured, an opening for the discharge of the urine should be made from the perineum into the bladder. It is essential to the preservation of life.

21. The treatment of all these injuries must be eminently antiphlogistic, principally depending on general and local blood-letting, absolute rest, abstinence from food, and in some cases almost even from drink, the frequent administration of enemata, and the early exhibition of mercury, and especially of opium, in the different ways usually recommended, with reference to the part injured.

422. As the operation for opening into the colon may be necessary, after an injury of that part, as well as from disease below it, the following method, recommended by Mr. Hilton, is briefly transcribed from the Reports of Guy’s Hospital. A line drawn parallel to the spinous processes directly downward from the angle of the seventh, eighth, or ninth rib across the costo-iliac space to the crest of the ilium, will correspond with the outer edge of the erector spinæ muscle and the apices of the transverse processes. A measured inch outwardly corresponds with the outer edge of the quadratus lumborum muscle. A vertical incision, two inches long, made at the extremity of the measured inch, should divide the skin, cellular tissue, and the tendon of the internal oblique muscle, and expose the outer edge of the quadratus lumborum muscle. Any bleeding vessels to be secured. The last dorsal nerve, if seen lying across the upper part of the incision, should be divided, to prevent the occurrence of pain from its being engaged in the cicatrix. The transversalis abdominis muscle is then to be divided vertically to nearly the same extent of two inches, parallel to the edge of the quadratus, when a quantity of loose lobulated fat will be seen, which should be partly removed and partly displaced by the blunt end of a director, in the vertical direction of the original incision, when the intestine will be brought into view. Any bleeding vessels should be secured, and pressure made on the abdomen, which will cause the intestine to become more prominent at the bottom of the incision. A silk ligature is now to be passed into the bowel and through the integuments at the upper part, so as to fix the intestine above, when a second ligature is to be applied in a similar manner below. The intestine is then to be opened between them, care being taken to apply another ligature above and below it, if the intestine should not appear to be firmly held in its place. If a vessel in its wall should bleed, it must be tied. Inflammation, pain, and restlessness should be obviated as far as possible by fomentations, opiates, and diaphoretics, and strict attention paid to cleanliness and the comfort of the patient, until the first symptoms have passed away, and he is able to assume the erect position.

423. These commentaries are restricted to those points which constitute, in a great degree, what the French call la haute chirurgie. They are published that every soldier should have the opportunity of knowing how he ought to be treated, when suffering for a country not too grateful for the services rendered by her bravest sons; and I have labored with the hope that some few of them, when they find that their limbs, perhaps their lives, have been saved under the precepts I have laid down, may acknowledge, when I am beyond that bourn whence no traveler returns, that they owe them, under the will of God, to those efforts I, more than any one else, have made, and continue to make, for the adoption of that practice which led to their preservation.