A. Maclean, M.D., late Surgeon, 76th Regiment.
Cases of extravasation or of effusion, terminating by the formation of a sac, pouch, reservoir, or foyer surrounding it, while the rest of the cavity remains free from inflammation, are so rare in natives of our northern climates that I am indisposed to infer that they do take place, except as very accidental circumstances. The fact that such things do take place should be borne in mind, and surgery should not be wanting in giving its aid, under all well-considered and reasonable circumstances. It is easier to do nothing than to think and to act.
The general treatment to be pursued in the acute period of all these cases of inflammation has been sufficiently marked—antiphlogistic to the utmost extent consistent with propriety, by bleeding, leeching, and cupping; the repeated administration of enemata; the early exhibition of mercury and opium, and subsequently of gentle aperients.
397. Continental surgeons, and by pre-eminence Baron Larrey, who is followed on this point by most French surgeons, inculcate the necessity of enlarging the wounds made by a musket-ball in the wall of the belly, although the Baron is particular in confining it to the muscular parts; M. Baudens, one of the latest writers on the subject, points out the additional tendency this gives to the formation of hernia, and furnishes therefore the soundest reason for not doing it without an especial cause. When a slip of the muscular or tendinous structures interferes with the quiescence of the wound; when it is desirable to introduce a finger to make an examination; when it is necessary to divide a portion to allow the restoration of protruded parts, no one will doubt the propriety of the direction. But when neither these nor any other good or sufficient reason can be given for such an operation as that of enlarging the wound (débridant la plaie) simply because it has been usual so to do, at the risk of making a large hernial protrusion instead of a smaller one, it is unnecessary. It gives rise to some bleeding, but that is really nothing; it makes a cut instead of a hole, by which nothing essential is gained; and as this enlargement of the wound can always be accomplished when it may become necessary from a sufficient cause, such interference, especially on the fore part or the sides of the abdomen, may be safely omitted.
398. When a musket-ball, passing across the abdomen, comes out behind through the thick muscles of the back, with perhaps a slit-like opening in the skin, through which some urine, and perhaps fecal fluid or matter may also pass, such wounds should be enlarged both superficially and deeply. There is here an object to be gained, and the operation is necessary. There is no objection to its being done when it is even supposed that these fluids or matters are likely to be soon or ultimately discharged through it, as it is desirable that any secretions or effusions which cannot be evacuated by the natural passages should have every reasonable opportunity offered of making their escape.
399. When it is obvious, from internal hemorrhage, or from the discharge of fecal matter, or from the introduction of the finger, by which it can be felt, that a large hole or rent has been made in an intestine, the wound should then be enlarged so as to allow its being brought into sight, when the edges should, if required, be smoothed, and the continuous suture applied in the manner directed, Aph. 391.
400. When a musket-ball penetrates the cavity of the belly, it may pass across in any direction without injuring the intestines or solid viscera. It usually does injure one or the other, and it has been known to lodge without doing much mischief. The symptoms are generally indicated by the parts injured, although in all the general depression and anxiety are remarkable; their continuance marks the extent if not the nature of the mischief.
The following cases of the survivors of hundreds who died under similar wounds, during the war beginning with the battle of Roliça in Portugal, in August, 1808, and ending with that of Waterloo, in June, 1815, may be read with a melancholy interest, as showing what sometimes will happen in a few rare instances, and even then as more dependent on the wantonness of nature than on the united efforts of science and of art.
A soldier of the brigade of heavy cavalry, under General Le Marchant, advancing in line to charge the French infantry at Salamanca, on which occasion the general was killed, was struck by a musket-ball, which entered in front, between the umbilicus and the ilium of the left side and came out behind on the opposite side above the right haunch-bone, thus traversing the body. The bowel protruded in front, but was uninjured, and was easily restored to its place. He remained at the field hospital with me for the first three days and was rigorously treated, as well as afterward in the San Domingo Hospital, where he gradually recovered, and was ultimately sent to the rear.