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

Mr. Smith, a deputy-purveyor, received a blow on the side of the fore part of the belly from the end of a spanker-boom, which knocked him down, and gave rise for some time to much inconvenience. He showed the part to me in Lisbon, in 1813, in consequence of the formation of a ventral hernia to the extent of the spot originally injured. In neither of these cases was such a result expected; no rupture of the fibers of the muscles was distinguished at the time, and it was supposed that the sufferers would recover without any permanent defect. The absorption of the muscular fibers was therefore a subsequent process; whether this result may or may not be prevented in similar cases by a more active or a longer-continued treatment, with the early application of a retaining bandage, is yet to be ascertained. It may be that some muscular fibers were actually ruptured and others bruised in these cases; but the extent of the absorption was greater than the apparent injury would seem to have warranted.

Abscesses form from neglected injuries of this kind, and give rise to the most serious apprehensions of their bursting into the cavity of the abdomen, which, however, they very rarely do. The safety of the peritoneum and its capability of affording sufficient resistance to the progress of the matter through it seem to depend upon the strength of the fibrous structure on its outer or muscular side; the inner or really serous surface being very delicate, and offering but little resistance to the application of any moderate degree of force.

An officer, whose name I forget, was wounded at the assault of Ciudad Rodrigo, in 1812, by a musket-ball, on the left side and fore part of the abdomen, near the crest of the ilium: it made a wound about four inches in length, cutting away the muscles of the abdominal wall so deeply as to lead to the exposure, and, as I feared, to the ulceration of the peritoneum, when the sloughs should separate. Under these circumstances, although not belonging to my division, I took him with me from the field to the divisional hospital at Aldea Gallega, some ten miles from the battlefield. Granulations sprang up, however, from the bottom and sides of the wound, which gradually closed in and healed without further difficulty.

377. It has been supposed theoretically, to be a matter of importance to discriminate between the orifice of entrance of a ball passing through the abdomen or its wall, and that of its exit. Practically speaking, it is a matter of indifference; the part on which the ball impinges is usually distinguished by a more circular and depressed appearance, while the opening of exit more frequently resembles a tear or slit, the edges of which are rather disposed to protrude.

A ball striking obliquely against the wall of the abdomen has been said to run sometimes nearly round under the skin, or between the muscles and the peritoneum, a proceeding upon the recurrence of which little expectation need be placed. It may, however, do something of the kind for a considerable distance, passing even over or between the spinous processes of the vertebra behind. In such cases, when they actually occur, the course of the ball will usually be marked by a line on the skin, more or less of a reddish-blue color; and the constitutional alarm, if it should occur at all, will subside early. A ball may, however, pass under and between the muscular layers of the wall of the belly, (or run nearer to the peritoneum for several inches,) giving rise to great anxiety, until the sloughs have separated from the openings of entrance and of exit, at which parts they prevail to a greater extent than in the middle of the track of the projectile. In some few instances an opening will require to be made in the middle of this track or course of the ball, for the evacuation of pus or of other extraneous matters which may be detained in it.

When a ball lodges in the wall of the abdomen and is deeply situated, it sometimes escapes notice, and when found is often better left alone unless it prove troublesome. When it approaches the surface, it may be removed if it cause inconvenience. When removed after the lapse of twenty or more years, I have found some dense cellular membrane forming a sac around and adhering to the ball, which is usually more or less flattened and irregular.

378. Injuries of the wall of the abdomen from cuts or stabs affecting the muscular and tendinous parts are said to be frequently troublesome, and even dangerous, from their giving rise to pain, vomiting, and severe general derangement. This only occurs when suppuration takes place, and, from some accidental circumstance, the matter does not find a ready exit, but collects between the muscles, or within or under their aponeurotic sheaths. This is indicated by the pain and swelling of the part, proceeding sometimes to the formation of an abscess, which ought to be prevented, if possible, by an early enlargement of the wound, so as to remove the cause of irritation, and the obstacle to the free discharge of the secreted matter. If the swelling should become prominent in a more convenient situation than the spot of injury, it should be opened at that part.

In these and in all other serious injuries of the abdomen, the recumbent position, with a relaxed state of the muscles, should be observed for several days at least. The antiphlogistic plan of treatment should be fully enforced, especially by leeching, bleeding, and spare diet, and in due time the part should be supported by a proper bandage.

The late General Sir John Elley was wounded in the last charge of heavy cavalry at Waterloo, by the point of a sabre, which entered nearer the extremity of the ensiform cartilage than the umbilicus, causing a wound about two inches in length, penetrating the stomach. From this he recovered in due time without any severe symptoms, but with a small hernia of that organ, which remained until his death, giving rise occasionally to some gastric inconvenience when he did not keep a gentle pressure on it by a retaining bandage.

379. Severe blows, or contusions from falls or from the concussion of foreign bodies, may give rise not only to injury of the internal parts of the abdomen, followed by inflammation, but to rupture of the hollow as well as of the more solid and fixed viscera, and death.