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

William Fletcher, of the 18th Hussars, a healthy man, thirty-seven years of age, received a kick from a horse, immediately above the os pubis, on the 15th of April, 1810, (about a league from Cartaxo, on the Tagus;) great tension of the belly soon followed, with excessive pain and vomiting. The pulse rose rapidly. He was bled to syncope twice during the day, to the extent of sixteen ounces each time. In the evening he was removed to Cartaxo, and taken into hospital; the pain continued, accompanied by retching, without much vomiting; the abdomen was constantly fomented with hot water, and injection was thrown up, and two ounces of infusion of senna with salts were given every two hours. In spite, however, of the most active treatment, he died on the 17th. On dissection, the peritoneum was found to contain a large collection of fluid, partaking of a fecal character; the bowels appeared to have suffered to the greatest extent, and a laceration was discovered in the ileum.

A child, just able to walk, was placed under my care in the Westminster Hospital, in consequence of its having received some injury on the side of the belly, from having been tossed up into the air by its father with his right hand, and caught in its descent in the crutch formed by the thumb and fingers of the left, on the thumb of which it unfortunately at last fell; this caused the child great pain, which was soon followed by considerable swelling and inflammation of the belly, of which it died. On examination after death, the small intestine was discovered to have been ruptured by the end of the thumb, from which extravasation of its contents into the abdomen had ensued.

The first effect of a rupture of the intestine must be the extravasation of such gas as may be contained in or secreted from it, giving rise to the sudden swelling, as well as to the sudden effusion, of part of its contents, but which, from the support of continuity, and of the general pressure of the abdominal parietes, is perhaps more gradually poured out. The rapid swelling and tension of the belly is perhaps then a distinguishing symptom of a rupture of the intestines.

A Spanish soldier was brought to me, near the conclusion of the battle of Toulouse, in consequence of having been struck obliquely by a cannon-shot on the right side of the abdomen and back, which appeared to be badly braised, although no abrasion of the skin had taken place. The shock was great, however; he was unable to move his limbs, and appeared likely to die, which he did in fact, in the course of the night, having passed bloody urine, but without any reaction having taken place. On making an incision through the skin, which was then quite a blue black, although not torn, all the soft parts were found reduced to a state approaching to the appearance of jelly; the spine was injured, the right kidney ruptured, and the cavity of the abdomen full of blood.

A soldier of the 40th Regiment was struck by a ricochet cannon-shot, on the last day of the siege of Ciudad Rodrigo. He saw the ball, which destroyed his left forearm so as to render amputation necessary, strike the ground a little distance from him, before he was himself injured. He thought, from the sort of shock he received, that it had also struck his belly; but this I should not have credited, if it had not been for a bruise across the umbilical region without actual abrasion of the integuments, on which account my attention was drawn to him on the fourth day after the injury, at the hospital of Aldea Gallega. He had been bled in consequence of complaining of pain, and because of the quickness of pulse and the fever which had ensued, and which were attributed to irritation after amputation. The belly was swollen and tender under pressure. Calomel, antimony, and opium were given: he was bled again, and blisters were applied. The stump took on unhealthy action, and he died a fortnight after the receipt of the injury. The abdomen, when opened, was found to contain a quantity of opaque serous fluid, mixed with shreds of coagulable lymph. The omentum and intestines were of a dark color, and loaded with blood, distinctly indicating the chronic state of inflammation which had taken place.

If the injury should not destroy the patient, but prove sufficient to give rise, after several weeks, to effusion into the cavity, the fluid should be evacuated by the trocar.

When the fixed viscera are ruptured by severe blows, such as those received by falls or from cannon-shot, the sufferers usually die from hemorrhage and not from inflammation. The arm has been carried away, and the liver ruptured without almost a sign of injury to the skin of the abdomen, death ensuing from hemorrhage.

380. When an incised wound is made through the wall of the abdomen to any extent, except perhaps in the linea alba, the muscular parts are rarely found to unite in a more perfect manner than when they are ruptured and bruised. In those cases in which I have tied the common iliac artery by an incision on the face of the lateral part of the abdomen, the patients recovering afterward, the incision through the muscular wall did not remain united, although union appeared to have taken place in the first instance, and a herniary protrusion formed in the course of the greater part of the line of the wound.

The constant occurrence of this non-union, except by skin and cellular membrane, led me to repudiate the introduction of ligatures through other parts for the purpose of keeping them in apposition, as it does not lead to the permanent cohesion of the parts, while it exposes the sufferers to all the dangers which the irritation of sutures commonly occasions, thus offering another instance of the improvement surgery owes to the war in the Peninsula.

Chelius recommends “several flat ligatures to be introduced through the skin and muscles, the needle being placed close to the muscular surface of the peritoneum.” Graëfe (section 514) is declared to be of the same opinion, he recommending, however, that a soft tape should be substituted for a ligature. Reference is made to Weber in support of this practice, to which Mr. South, the translator, does not raise any objection.