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

23d.—Has passed a good night; wounds dressed; is allowed a small proportion of bread with his tea.

28th.—So far recovered as to be able to be removed to Elvas.[5]

That a blunt instrument, like the small end of a ramrod, should be forced between the loose viscera of the abdomen without wounding any of them, may be easily conceived, but that balls or sharp-pointed swords should do so, is not to be understood so easily. Ambrose Paré, our own Wiseman, Ravaton, Lamotte, Muys, and others, however, have related instances of this kind, in which the patients recovered in an inconceivably short space of time; but these and other recoveries of a similar nature must be considered as exceptions to general rule.

[5] He marched with his regiment, in the summer, to Valladolid, and was drowned in the Douro.—G. J. G.

385. Wounds penetrating the wall of the belly, when made by cutting or lacerating instruments, or by musket-balls, are usually followed, if to any extent, by a protrusion of some portion of the contents of the cavity, generally of the omentum or intestine, if not of both. This may take place at the rounded orifice of entrance of a ball, as well as at the more slit-like opening of exit, which, if the patient should recover, becomes closed by a thin tendinous-like expansion, under the cicatrix formed by the common integuments. These soon yield to the general pressure on the abdominal cavity, and admit of the formation at the part of a ventral rupture, requiring the application of a restraining bandage.

386. When a piece of omentum only protrudes, the direction given by the latest writers on surgery is, that it shall be returned into the cavity of the abdomen whence it came, the finger following to ascertain that it is quite free; after which the wound is to be carefully closed by sutures applied close to the peritoneum, so that the omentum may not again protrude through it. Having objected already to the manner of employing the suture, I now object to the treatment of the omentum, and do not approve of its being so dextrously returned by the finger within the peritoneum to its natural loose situation. I desire, on the contrary, that it may be retained between the cut edges of the peritoneum, but without the slightest pressure or possible strangulation, in order that by its retention it may more readily adhere to these edges, and thus form a more certain barrier against the extension of inflammation than is likely to take place when moving at liberty in the cavity of the abdomen, however closely it may be supposed to be applied to the inner surface of its paries.

It sometimes happens that a portion of omentum is altogether without the cavity of the abdomen, and the opening through which it has protruded seems too small to allow its restoration to the cavity. The latest authors on this subject recommend a blunt director to be introduced between the upper edge of the wound and the protruded part, be it omentum or intestine, or both, upon which a blunt-ended bistoury is to be passed into the cavity as far as the enlargement of the wound seems to require, after which the director and the bistoury are to be withdrawn together. I altogether dissent from this. It is scarcely ever necessary to enlarge the opening in the peritoneum, the obstacle to reduction being situated in the tendinous expansion or aponeurosis of the wall of the belly, a slight division of which will give sufficient space for the restoration of the protruded part in almost every instance. I have unavoidably opened into the cavity of the peritoneum, and have seen it done in other instances, but no inconvenience follows small openings not exceeding a quarter of an inch in length, when they are properly covered over by the healthy parts. It is therefore important in all cases to have as small an opening as possible in the peritoneum, and certainly no addition should be made to the size of a small opening if it can by any possibility be avoided, however indifferent half an inch, more or less, may be in the length of a large one. All protruded parts, whether omentum or intestine, should be gently cleansed with warm water, and the fingers of the surgeon should be wetted in a similar manner, the mesentery being returned first if protruded, then the intestine, and lastly the omentum; the two former under all circumstances; the latter not so, if it be adherent or inflamed, torn or jagged, or in a state of suppuration or gangrene. It should in these cases be left to itself, and treated in the most simple manner; a ligature should never be applied to it, neither should it be spread out and cut off, as was formerly recommended, as it will gradually retract and be withdrawn into the cavity of the abdomen. If suppuration should take place in its substance, and the swelling of the part lead to its constriction, or the formation of matter under the integuments or between the layers of muscular or tendinous fibers, these may be carefully divided.

Evan Thomas, aged seventeen, was admitted into the Westminster Hospital, Sept. 1st, 1828, having been stabbed with a dinner-knife immediately above the umbilicus; the wound was three-quarters of an inch long; the omentum protruded and could not be returned until the skin, cellular membrane, and fascia had been divided; the opening in the peritoneum was then distinctly seen, against the inside of which the omentum was left, the wound in the skin being sewed up by the continuous suture. In the evening he was bled to sixteen ounces, and, as he had thrown up his dinner, an enema only was administered. On the 2d, the belly being tense and slightly painful, although he was not in constant pain, the blood drawn before being buffy, twenty-two ounces more were taken away, a purgative enema administered, and, as the bowel was not believed to be injured, four grains of calomel and six of the compound extract of colocynth were given, with a draught of senna and salts every four hours. 3d. The bowels open; no pain and scarcely any uneasiness on pressure; abdomen soft. No food; barley-water and gruel; pulse 84. On the 6th the sutures were removed, the wound having reunited. He was then made an out-patient, having a comfortable home.

A soldier of the Second Division of Infantry received several stabs from a lance in different parts of the body, at the battle of Albuhera, as the lancers rode past him, while lying on the ground, one only being of any importance: it was on the right side and lower part of the belly, and through it a portion of omentum protruded. On this being reduced, the epigastric artery, which had been divided, bled freely; a ligature was readily applied, and the wound closed by the continuous suture. The patient, after undergoing a very rigorous treatment, recovered.

A Spanish soldier was wounded in a scuffle in Madrid, in 1812, at the gate of the British Hospital, near the Prado, into which he was brought, with a wound on the right side of the abdomen, near and below the umbilicus, through which a portion of omentum protruded about the size of a small orange. As this could not readily be returned, I carefully enlarged the wound at its under part, some three or four hours afterward, by dividing the skin, and then found that it was the aponeurotic or tendinous expansion of the muscles going to form the sheath of the rectus, which prevented the return of the omentum into the belly; on the division of this part it slipped back without difficulty, but as it did not recede further than the peritoneum I left it there, and closed the wound, which was about an inch long, by sewing it up in the manner described. He was bled and starved, and was delivered up to the proper authorities out of danger, with his wound nearly healed, when the army evacuated the place.