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

A Spanish soldier was wounded at the battle of Toulouse by a musket-ball, which passed in on one side and came out at the other, carrying with it a portion of omentum which gradually became as large as an orange, in which state I saw it four days after the accident. Little had been done; he had not suffered much pain, although the abdomen was tender; he had vomited; passed blood with his motions; was feverish and ill. I visited this man every three or four days; he suffered from privations of every kind, yet each time I found him better. The protruded omentum gradually diminished in size, and was at last drawn into the wound in the abdomen and covered by granulations. He left Toulouse before me, nearly well.

If the omentum be greatly bruised or injured it may be cut off, and the vessels tied if bleeding; but it should not be returned further than the edges of the peritoneum, over which the external wound is to be closed.

Ravaton wrote a hundred years ago: “The views of a surgeon must be very confined who advises the application of a ligature to the omentum when protruding from the cavity of the belly in a healthy state. It is a cruel and deadly maneuver, contrary to reason and experience. To restore it to its place is so simple, just, and reasonable, that I am surprised it does not occur to every one. The reduction is easily effected. It is sometimes difficult to retain the reduced part except by sutures. I admit that when the omentum is strangulated, gorged with blood, black, and about to become gangrenous, the result of its restoration to the cavity may be doubted: yet experience has demonstrated that it is the safest mode of proceeding, taking care not to close the wound entirely, but to leave an opening at the lower part to give vent to any effusion or suppuration that may take place.”

387. When a portion of intestine is protruded without being wounded, it is to be returned, whatever may be its state, unless it be soft and unresisting between the fingers, of a dull blue or black color, and to every surgical eye deprived of life or mortified. At any state previous to this (to Englishmen) almost certainly fatal condition, it should be restored into the cavity of the abdomen. When a portion of intestine is thus returned, three directions are given by most modern surgeons, and especially by Chelius, section 517, on which his English editor makes no comment; and which may therefore be considered to be those which are commonly taught in London, but of which I entirely disapprove. The first is, that the peritoneum is to be divided in cases where an obstacle is interposed to the return of the intestine; this I aver to be less necessary for the intestine than for the omentum. The second is that, “after the reduction, the forefinger must be introduced into the cavity of the belly in order to ascertain that the intestines have not passed into the interspaces of the muscles”—a precaution which is unnecessary, and may do much mischief. The third is, that the patient is then to be placed “in such a posture as that the intestines should least press against the wound,” to which direction I object. The surgeon should certainly take care that the intestine does not pass between the layers of muscle, nor anywhere else than into the cavity of the belly. So far, however, from the intestines being pushed away from the cut peritoneum, the most favorable position for it would be to be applied against the edges of the cut membrane, and even rising up for the least possible distance, without or above it, the great object to be desired being to facilitate adhesion by as perfect an apposition of these parts as possible, while the external wound is accurately closed by the continuous suture, and duly supported by adhesive plaster, compress, and a bandage, provided it be methodically applied. The next best thing which can happen is that, every part being relaxed, and the patient perfectly quiescent, the intestine should press so steadily and yet so gently against the wounded peritoneum that it will be kept in constant apposition with it without protruding through it.

A soldier of the Artillery was stabbed in two places, in 1812, with a long knife, by a townsman, late in the evening, and was carried into the hospital for the sick and wounded French prisoners in Lisbon. The wound in the belly was situated somewhat more than an inch to the right side of the umbilicus, and was about an inch in length from above downward; through it a considerable protrusion of small intestine, without any omentum, had taken place. This was distended by flatus, and of a dark-brown color when I first saw it, some time after the receipt of the injury. The bowel being constricted by the tendinous expansion of the muscular fibers, the latter was carefully divided by a blunt-pointed curved bistoury passed under its upper edge, and resting on the back of the nail of the forefinger, by which the intestine was guarded; the flatus having been pressed out of the intestine, which was gently washed with warm water, it was restored to the cavity of the abdomen. Of the part which had apparently first protruded, the peritoneal coat and a few fibers of the longitudinal layer of muscle were divided to the extent of half an inch, the remaining portion of the gut being unhurt. The skin was then sewed up by a fine continuous suture, and adhesive plaster and a compress duly applied. A good deal of alarm was evinced, the pulse was very small, and the man faint. The other wound was in the back, about half an inch in extent, and near the inferior angle of the right scapula. It appeared to be a penetrating wound, but not giving rise to any peculiar symptoms, he was placed in bed on his back, with his legs raised, and the body slightly bent. Early the next morning, the officer on duty found it necessary to bleed him largely, to forty ounces, according to my directions, on account of pain which had come on in his bowels and in his back, accompanied by difficulty of breathing, the skin being hot and the pulse quick and hard. The cellular membrane around the wound in the back was emphysematous; there was a slight cough, accompanied by an expectoration slightly tinged with blood. The bleeding removed the essential symptoms, but the pain and difficulty of breathing returning next day, it was repeated to eighteen ounces, with an equally good effect. It was necessary to repeat it on the third, fourth, and fifth days, when the pain ceased to return, and the pulse, instead of being small and hard, became softer and fuller. The bowels were open naturally on the third day, and the emphysema had gradually disappeared, no food being allowed, and very little drink for some days, and then only in small quantities of the simplest kind. The threads were removed with scissors on the sixth day, and the man was free from complaint, although very weak, at the end of five weeks.

Madame Doucet was applied to a hundred years ago, by a soldier, who having been struck by a halbert, had a wound made across his abdomen from above the ilium, through which a quantity of intestine protruded, which he carried in his hat, enveloped in his shirt. Having had to walk between three and four miles, in the heat of July, to the old lady, his bowels were as dry as parchment by the time he arrived. She therefore bathed them in warm milk and water until they became soft and natural in appearance, returned them into the cavity of the belly, and sewed up the wound with a well-waxed silken thread—thus setting an example which ought to be followed in 1855. The man recovered.

388. When the protruded intestine is wounded, the case is complicated, and much depends on the size of the wound. A mere puncture, or a very small cut, is often of no consequence, and does not require any treatment; the bowel should merely be returned to the cavity of the belly, and the symptoms of inflammation closely watched, and, if possible, steadily subdued.

It is advisable, in investigating this subject further, to consider the abdomen as devoid of cavity during life and health, the contained parts being so gently pressed upon by the containing and retaining muscular parietes around as to enable them all to carry on their ordinary functions, unless suffering from some derangement, exclusive of that which might arise from a deficiency of the pressure usually exercised upon them; but that this pressure can, or generally will, prevent the effusion of the contents of a bowel when ruptured, if the wound be half an inch in length, or that it will prevent the extravasation of blood from an artery or vein of moderate dimensions, if torn, is contrary to facts now considered indisputable, as I have frequently had occasion to verify. That a mere puncture of the intestine does not allow the effusion of air, much less of the contents of the bowel, is not doubted. When the contents of the bowel have been poured out, without an external opening in the paries through which they might escape, inflammation and death have ensued at no long distance of time. When blood is poured out from the great vessels, as in rupture of the liver or spleen—of which instances will be adduced—the general cavity may be filled; but when the injury is less extensive, or the lesion less important, the blood usually gravitates toward the back or sinks into the pelvis. It is possible that blood may be effused in small quantity, and be then confined, under the general pressure of the wall of the abdomen and the resistance offered by its contents, to a particular spot, whence it may be absorbed after coagulation; or, by commencing decomposition, give rise to irritation, and be discharged through the external wound, if one exist, or through the bowel with which it may happily be in contact.

A soldier, belonging to the Second Division of Infantry, was wounded by the Polish Lancers at the battle of Albuhera, in several places slightly, and in the abdomen severely, a penetrating wound having been made an inch long, between the umbilicus and the crest of the ilium on the left side. Brought to me the day after at Valverde, the edges of the wound were stitched together and dressed simply. He said it had bled freely at first, and was then painful. Treated antiphlogistically and sharply, the inflammatory symptoms gradually subsided. The bowels were relieved by gentle aperients, there being no reason to suppose they had been wounded. A small, oval swelling was soon perceived under the wound, which was tender to the touch, indicating mischief of some kind. The edges of the wound, which did not unite fully, although they were retained in contact, at last separated, and allowed about a wineglassful of bloody matter to pass out, which reduced the swelling and removed the uneasiness and pain of which he complained. After this he gradually recovered, and was discharged to Elvas, and thence to Lisbon.

389. Whenever large effusions of blood have occurred, the sufferers have usually been lost, from the occurrence of peritoneal inflammation. That small ones may be absorbed, cannot be doubted. I have seen instances of their having been discharged by the bowel, although I have never been so fortunate as to see a general formation of matter from effusion, and to have opened the abdomen for the evacuation of its contents with success; nevertheless, I do contemplate that such cases may occur, and surgery may come to their relief with good effect.