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

When the intestine is more largely injured in a longitudinal or transverse direction, or is completely divided as far as or beyond the mesentery, the continuous suture is absolutely necessary.

394. When the abdomen has been penetrated, and considerable bleeding takes place, but not from the intestine, it is necessary to look for the wounded vessel. When it comes from one of the mesenteric arteries or from the epigastric, the wound is to be enlarged until the bleeding artery be exposed, when ligatures are to be placed on its divided ends if they both bleed, the external wound being accurately closed. I have seen the epigastric artery tied several times with success.

A Portuguese caçador on picket was wounded at the second siege of Badajos in a sally made by some French cavalry. He had three or four trifling cuts on the head and shoulders, and one across the lower part of the belly on the right side. He bled profusely, and, when brought to me, had lost a considerable quantity of blood which came through a small wound made by the point of a sabre. This wound I enlarged until the wounded but undivided artery became visible; upon this two ligatures were placed, and the external wound was sewed up. The peritoneum was open to a small extent, but the bowel did not protrude; and the patient (not being an Englishman, and therefore not so liable to inflammation) recovered after being sent to Elvas.

A soldier of the same regiment, cut down at the same time, died as soon as he was brought into camp, having been severely wounded in the chest and abdomen. He was said to have died from hemorrhage, from a wound in the belly, two inches in length, made by one of the long-pointed swords of the French dragoons. I had the curiosity to enlarge the wound, and found one of the small intestines had been cut half across, another part injured, and that the blood came from an artery which had been opened by the point of the sword in going through the mesentery, which wound had caused his death.

395. When this operation cannot be done successfully or with advantage to the patient, whose life is in jeopardy from the continued drain, the wound should be closed by suture, and a compress laid over it and retained by a bandage methodically applied for the purpose of aiding the muscular parietes in keeping up that pressure on the viscera which may be useful in arresting the flow of blood from the wounded part. If the bleeding continue, or, having been arrested, should recur, and the belly become in consequence distended, the sutures being evidently so tense as to be likely to cut their way out, or if the blood should ooze out between the stitches, they may be in part removed in order to give immediate relief. When the belly becomes very painful, tense, and manifestly full after a punctured wound, and not tympanitic from the extrication of air or the distention of the bowel by it, the wound should be enlarged to allow the evacuation of the extravasated blood, which cannot be absorbed when in such quantity. The orifice of a small gunshot wound, which is not sufficiently direct to communicate with the cavity and to allow the issue of blood extravasated in the quantity alluded to, should be enlarged to such an extent as to effect that object.

396. Blood effused in moderate quantity, and circumscribed by the pressure exercised upon the contents of the abdomen by its parietes, may readily be evacuated by the wound, provided it be sufficiently open; and the patient may recover, if the inflammation which must necessarily ensue should not be communicated along the peritoneum throughout the cavity, or if it should be subdued in time. If the blood be in small quantity, it coagulates, and may be absorbed; but if in such a quantity as cannot be absorbed, or from any other cause which may prevent its removal by this means, it becomes after a time a source of irritation, and nature sometimes commences early to cut it off from the general cavity by surrounding it with fibrin—a result which, however desirable, can rarely be expected.

When extravasated blood is thus cut off from the general cavity, and cannot be absorbed or be by accident carried off through an opening in the bowel, a change takes place by which it ceases to be bland and harmless, and causes it to excite inflammation and its ordinary consequence, suppuration, if the patient survive so long. This occurs, for the most part, after the first inflammatory symptoms have subsided, from the tenth to the twelfth, or even to a later, day, when the renewal of irritation is accompanied by an increase of the general symptoms, by a more local pain, and by a circumscribed swelling of some part near the wound, in which fluctuation may perhaps be distinguished even during the existence of the general tenderness of the whole abdomen. Under such circumstances, when it is proposed to make an incision into this part, if it should be thought advisable to do such an operation, it may safely be preceded by an exploring needle or a very fine trocar and canula, which will demonstrate the fact of the purulent and sanious depot, without doing in such a case perhaps any mischief, if the expectations of the surgeon should not be realized. If the exploring needle should show that a bloody, purulent, or other fluid is really distending the abdomen, no doubt ought to be entertained about enlarging the original wound and making a depending opening.

Ravaton, in his twenty-fifth observation, relates the case of a soldier who was wounded five days before by the point of a sabre, to the right of the umbilicus. When the man was brought to him, the belly was swollen, hard, and very painful, with vomiting, hiccough, etc., announcing the approach of death. Believing that the abdomen contained a fluid, either effused or secreted, he made an opening into the cavity immediately above Poupart’s ligament or the outside of the internal opening of the ring of the right side, when, finding that nothing came from the cavity, he passed his finger upward along the iliac vessels, and, after tearing up some membranous adhesions, evacuated a pint of coagulated blood and fetid, serous fluid. He then introduced a dossil of lint into the wound to keep it open, fomented and oiled the belly, round which he applied a bandage, and placed the patient on his face. The bad symptoms diminished during the night, and the patient declared himself better in the morning. From the fifth to the tenth day of the wound he was in extreme danger. On the eleventh, the bed was inundated with a purulent matter of an almost insupportable smell. The cavity of the abdomen was injected and cleansed, the ordinary dressings applied, and the greatest cleanliness observed. He was subsequently dressed three times a day in a similar manner; portions of omentum were occasionally drawn away with the forceps. His strength was well supported by every kind of nourishment. The night-sweats continued until the thirty-third day, and on the seventy-second he was discharged from the hospital, cured. The discharge at first was serous, and only became purulent on the sixth day after the operation.

Thomas M’Mahon, 76th Regiment, aged twenty-two, was admitted into the Garrison Hospital, Portsmouth, upon the 13th of June, 1845, with all the symptoms of strangulated inguinal hernia of the left side, of two days’ standing, for which the usual operation was performed. Everything went on favorably till the morning of the fourth day after the operation, when he made a sudden effort to go to the close-stool, which was immediately followed by the descent of a considerable portion of intestine and omentum, accompanied with profuse hemorrhage from a small artery on the surface of the intestine, which was taken up and tied, and the parts returned into the abdominal cavity. The greatest excitement followed, with all the symptoms of acute inflammation. These were treated by general bleeding to the extent of fifty ounces, and sixty leeches to the abdomen, with other antiphlogistic remedies. On the morning of the seventeenth day from the performance of the operation, a piece of intestine came away with the fecal contents of the bowels, after which the patient experienced relief in all his symptoms, and appeared to gain health and strength, and after a time the wound seemed disposed to close, three weeks after the sloughing of the intestine. On the sixth day afterward the evacuations ceased, attended with acute tenderness of the abdomen, which began to swell fast. The means adopted had not the slightest effect, and the patient was considered past relief, unless it could be obtained by an external opening. I accordingly made an incision over the site of the former wound, and carefully opened the intestine, to the extent only to allow the tube of the stomach-pump to be inserted, when there was an immediate discharge of flatus and some feculent matter, and the patient expressed himself relieved. By the further use of the stomach-pump apparatus, I was enabled to extract a quantity of feculent matter by the artificial opening, and after some hours the patient was completely relieved from the dangerous symptoms he was suffering from. The artificial opening was left patent for two months, when the bowels again gave evidence of acting naturally. The artificial wound was not, however, closed till the 22d of August, 1845; a week after the bowels appeared to act freely and naturally.

The patient from this time got well and strong, and was discharged to his duty on the 10th of October, 1845, since which period he continued to perform all the duties of a soldier most efficiently, without experiencing any inconvenience to his general health or constitution, until the 6th of October, 1846, when he died of inflammation of the brain, at Fort George, in Scotland. On dissection, the abdominal viscera, including the intestinal canal, appeared perfectly healthy; but on a minute examination of the portion of small intestine (found to be the ileum) situated in the inguinal region of the side operated upon, directly opposite to the cicatrix of the external wound, it was discovered to be firmly attached to the abdominal parietes, by an adventitious membrane, to the extent of two lines, which then diverged, and formed itself into a canal of a funnel shape for about five inches and a quarter in length, of a homogeneous structure, which united itself with the continuous intestinal tube. By this wonderful provision of nature the healthy functions were uninterruptedly carried on, and permanently continued, without any pain or detriment to the patient’s general health. On appearance, Jan. 23d, 1847.