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

James Wilkie, 12th Light Dragoons, aged thirty-four, was suddenly attacked, at four P.M. of the 6th September, 1815, with violent pain in the umbilical and epigastric regions, accompanied with nausea and great irritability of stomach; pulse small, rapid, and regular. Assistant-Surgeon Egan visited him half an hour after the attack, bled him freely, and caused the abdomen to be fomented with hot water; a large blister was applied to the seat of pain, an ounce of castor-oil was given, and emollient and laxative clysters were occasionally administered. At night the symptoms abated, and he slept about three hours. The next morning his countenance exhibited that appearance of haggardness and anxiety which have always been alarming indications; pulse feeble and rapid; the pain severe; at noon he vomited from two to three ounces of black, fetid blood in a fluid state; the pulse became very feeble. At four P.M. the pain increased, he ejected from his stomach from four to six ounces of dark, fluid blood that had less fetor; and at six the same evening he expired in pain.

This man, on the 18th of June, at Waterloo, received a punctured wound from a sword, which entered about an inch below the inferior angle of the scapula on the left side, penetrated the thorax, appeared to have passed through the diaphragm, the point of the weapon coming out on the opposite side of the chest between the first and second false ribs. The wounds were quite healed, and he apparently enjoyed good health, when he arrived from Brussels in August.

Appearances on dissection.—On opening the abdomen, the whole of the intestines, with the exception of the duodenum, were in a high state of inflammation. On tracing the duodenum upward a very small portion of the stomach was found in its natural situation; while, on opening the thorax, a large spherical tumor was seen in its left cavity, containing two quarts or upwards of black, fluid, fetid blood. This sac was soon seen to be the stomach, which had protruded through the aperture in the diaphragm, by which it was so firmly embraced as to render the communication between the portion of the stomach in the thorax and that in the abdomen impervious to each other. The hernial sac and its contents were supported by the diaphragm. The left lung exhibited a shriveled, contracted appearance, as if its function had been impeded by the pressure of the sac and its contained fluid. The cicatrix and the course of the sword were well marked. The cardiac and pyloric orifices of the stomach were in the natural cavity.

S. Fletcher, 31st Regiment, wounded at Sobraon on the 10th of February, 1846; died at Chatham, February, 1847. On opening the thorax, the greater part of the stomach, and a foot and a half of the transverse arch of the colon, with the omentum attached, were found in the left pleural cavity. There was an opening in the diaphragm with a rounded margin two inches and a half in diameter, two inches to the left of the œsophagus. The stomach, colon, and omentum adhered firmly, at one part, to the pleura covering the diaphragm and lining the ribs to the extent of a few inches, although otherwise loose and free in the cavity. The parts in the aperture of the diaphragm were free from adhesions, and the finger passed easily through the opening from below upward. Two cicatrixes were to be seen on the left side of the chest—one between the eleventh and twelfth ribs, close to the transverse processes of the vertebræ; the other between the eighth and ninth ribs, three inches and a half from the cartilages. The preparation is in the museum at Chatham.

352. These cases confirm the fact that wounds of the diaphragm, whether in the muscular or the tendinous part, never unite, but remain with their edges separated, ready for the transmission between them of any of the loose viscera of the abdomen which may receive an impulse in that direction. That parts of these viscera do pass upward and back again, cannot be doubted; and it is probable that incarceration may take place for a length of time before strangulation occurs from some sudden and distending impulse giving rise to it.

When the solid viscera of the abdomen are injured, as well as the diaphragm against which they are applied in their natural situation, the wound may sometimes be considered a fortunate one; for the liver or spleen may adhere to the opening in the diaphragm and fill up the space between its edges.

A wound of the diaphragm may be suspected from the course of the ball, particularly when it passes across the chest below the true ribs. It is necessarily accompanied by an opening into the cavity of the abdomen, and is by so much the more dangerous. The symptoms will partake of an injury to both, although they are principally referable to that of the chest, and are those of intense inflammation, accompanied by a difficulty of breathing, which in the case of Mr. Drummond was a peculiar sort of jerk; in that of Captain Prevost it was more spasmodic. The risus sardonicus, hiccough, pain on the top of the shoulder, and loss of power of the arm, which were all more or less present, in all probability depended on some larger fibrils of the phrenic nerve being wounded. The treatment should be antiphlogistic, with a free external opening for the discharge of matter. The accession of jaundice shows an injury to the liver; vomiting of blood or its passage per anum indicates a wound of the stomach or intestines.

353. When the patient recovers, the probability of a hernia taking place into the chest through the diaphragm should be explained to him. If any reason should exist for the belief that it had occurred, he should be doubly cautious as to eating and drinking in small quantities only, and remaining in the erect position for some time after each meal; he should carefully avoid a stooping posture and all muscular exertion or straining. If symptoms of strangulation should come on, an opening made into the abdomen would appear to offer the only chance for life. The hernia may perhaps be drawn back into its place in the abdomen; but if firm adhesions have formed between the protruded parts and the edges of the opening in the diaphragm, the case must be treated as one of adherent strangulated rupture in any other part, by a simple division of the stricture in the most convenient situation. The opening should be a straight incision through the wall of the abdomen, large enough to admit the hand, immediately over the part where the diaphragm is supposed to be injured. It should be closed by a continuous suture through the skin. This operation, now for the first time recommended, although apparently formidable, cannot be compared as to danger with the incisions of twelve and fourteen inches long through the wall of the abdomen, which have been in some instances successfully made for the removal of diseased ovaria.

354. Wounds of the heart are for the most part immediately fatal. Many persons have, however, been known to live for hours, nay days, and even weeks, with wounds which could scarcely be otherwise than destructive; and several cases are recorded in which the cicatrixes discovered after death, in persons known to have been wounded in the vicinity of the heart, have shown that even severe wounds of that most important organ are not necessarily fatal. As our knowledge of the nature of the injury inflicted can never be distinct, it follows that every wound should be considered as curable until it is unfortunately proved to be the contrary.

355. Auscultation and percussion, and principally auscultation of the whole precordial region, have afforded means of judging of injuries of the heart which were not formerly known. A vertical line, coinciding with the left margin of the sternum, has about one-third of the heart, consisting of the upper portion of the right ventricle, and the whole of the left, on the left. The apex of the heart beats between the cartilages of the fifth and sixth left ribs, at a point about two inches below the nipple and an inch on its external side; or, if one leg of a compass be fixed at a point midway between the junction of the cartilage of the fifth rib on the left side with the rib and sternum, and a circle of two inches in diameter be drawn around, it will define as nearly as possible the space of the precordial region occupied by the heart while uncovered, except by the pericardium and some loose cellular texture. In the rest of the precordial region it is covered, and separated from the walls of the chest by the intervening lung.