Chapter XX: Part 20

A French gentleman, fencing with his pupil in July, 1834, received a blow under the right axilla in a very violent lunge, whereby the button of the foil was broken off, and the foil itself passed into and through the back part of the thorax, the point coming out between the sixth and seventh ribs on the left side near the angles. There was but little bleeding. The chief symptoms were those of great inflammation of the contents of the cavity, which gave way to full and repeated bleeding from the arm, with perfect rest and almost starvation. He recovered very favorably, and was quite well in about eight weeks. He remains well, and is following his profession as a teacher of fencing.

330. When an incised wound into the chest is large and direct, injuring the lung, two very important points usually demand immediate attention. The first is to relieve the oppressed state of the breathing; the second, to suppress the bleeding.

In large penetrating wounds of the chest, with injury of the lung, it has been observed that the patient has breathed most easily when the external wound has been covered; and has been hardly able to breathe when it was opened, which is attributed to the air getting into that side of the thorax in inspiration, instead of entering the lung by the trachea. If the wound admit of being well closed, the difficulty of breathing diminishes; adhesion may take place, and the inflammatory action within the chest may terminate; but if the inflammatory symptoms continue, adhesion does not take place, and the secretion and effusion of a quantity of serous fluid are the consequence. This secretion of fluid is the natural consequence of inflammation which has passed the stage of adhesion, whether the injury of the chest have occurred from a stab or from a gunshot. It is the leading fact in the treatment of these injuries, hitherto disregarded by writers on this subject, but on the proper management of which, in both instances, a successful result principally depends. If the closure of the wound lead, in the course of a few days, to the re-establishment of the breathing, and the antiphlogistic means employed to the cessation of all urgent inflammatory symptoms, adhesion has most likely taken place, or is about to take place, in the neighborhood of the wound, and the patient will in all probability recover without much further suffering. If this should not occur, and effusion take place, the wound should be reopened, or the fluid otherwise evacuated.

A soldier of the 9th Regiment was wounded at Roliça, in 1808, by the point of a sword in the left side; it penetrated the chest, making a wound somewhat more than an inch long, through which air passed readily, accompanied by a very little frothy blood, which was also spit up on any effort being made to cough, leaving no doubt of the lung having been injured, that viscus appearing to be retained against the wall of the chest. As the edges of the wound could not be accurately kept in apposition by adhesive plaster, two sutures were applied through the skin, and the man was desired to lie on the injured side, with the hope that adhesion might take place, as there appeared to be no effusion of blood into the cavity. He was freely bled on each of the two days following the receipt of the wound, and gradually recovered.

A French soldier was brought into the village after the battle of Vimiera, wounded by a sword in the right side of the chest. He said he had lost a good deal of blood; was very pale; pulse small; extremities cold; breathing hurried and oppressed; had spit up some blood. On removing the handkerchief, a gaping wound presented itself, an inch and a half long, through which the cavity of the chest could be seen, the lung having receded. The wound did not bleed. As adhesive plasters would not keep the edges of the skin in perfect contact if he attempted to move, they were sewn together, and after the application of a compress he was much relieved. The next day all the symptoms were alleviated, and after the supervention of some serious inflammatory symptoms, he was forwarded to Lisbon, for embarkation for France, in a fair state of recovery.

It was the successful results of these cases which led to the closure of all such wounds in the first instance, with the hope of preventing thereby the extension of the inflammation to the whole sac of the pleura, which in many instances it succeeds in doing; and thus that which was done in the first instance from apparent necessity, rather than scientifically adopted, became a rule of practice, which may be laid down as a principle to be followed in similar cases. When persons thus wounded are neglected, the wound remains open, and the cavity of the pleura passes into a state of suppuration, after all the symptoms of acute pleuritis or of pleuro-pneumonia have taken place.

331. If the union of a large incised or other wound by the adhesive process does not take place, a bloody, serous fluid oozes out from under the dressings, if the oppression of breathing should not have led to their removal; the patient is relieved by the discharge, which, after a time, as the case proceeds toward recovery, will become less in quantity and more purulent in quality.

If the union of the divided parts should take place externally, and the general as well as local symptoms become more urgent, there can be little doubt of a collection of some kind having taken place, and then auscultation and percussion, if the latter can be borne, become of the greatest importance. From the moment the wound is closed the ear becomes the most important guide; the only one in fact to be depended upon as to what is going on within the chest. The case is one of pleuritis, perhaps of pleuro-pneumonia, and hence the reason that the symptoms and treatment of these complaints have been more fully noticed than might be considered to appertain to the province of surgery. The effusion of a bloody, serous fluid comes on, after a penetrating injury, from the third until the seventh or ninth day, by which time the cavity of the pleura may be filled; puncturing the chest between the sixth and seventh ribs at the point of election, or reopening the wound, should be early resorted to for its evacuation.

A picket of Portuguese infantry being surprised by a sudden rush of French cavalry from the town, during the first unsuccessful siege of Badajos, were nearly all sabred. The survivors were brought to me. Two had been run through one side of the chest, and one through both sides; the last died a few minutes after I saw him. The other two seemed to be nearly in a similar situation from loss of blood by the mouth and from the wounds. These were immediately closed by stitches, compresses, and adhesive plasters. A little hot brandy and water was given to each, and they were laid aside without hope of recovery. They did not die, however; the breathing became more easy, the distress less, and the pulse more distinct; reaction after a time took place. The next morning, the siege being abandoned, they were removed to Elvas, where I afterward heard they were doing well.

A soldier of the Third Division of Infantry, under the command of Sir James Kempt, was wounded at Waterloo, by a straight sword or sabre, which penetrated the left side of the chest. He fell, and lost a considerable quantity of blood from the mouth as well as from the wound, and was supposed to be dying. On showing some signs of life, the wound was covered by a part of his shirt; and on his arrival at the Elizabeth Hospital in Brussels, four days afterward, it was closed. On the ninth day, when my attention was drawn to him, he was sitting up in great distress, from difficulty of breathing, his hand pressed upon the wounded part, the cicatrix of which was red, swollen, and projecting. I recommended the assistant-surgeon in charge to open this with an abscess lancet, which he did, giving vent to a very large quantity of bloody and purulent matter, to the great relief of the patient for several days, although he did not ultimately recover.

The advantage derived from the closure of the wounds in these cases was manifest. It relieved the breathing, and caused the hemorrhage to cease, aided, in all probability, by the exhausted state of the patients. The relief to the breathing was at the moment the most essential point, the wounds of entrance being nearly two inches long, and the free admission of air quite unopposed; the lung had receded from the opening.

332. _The important question of hemorrhage_, in cases of incised wounds admitting of being accurately closed, remains for consideration. In many instances, the quantity of blood effused is trifling, and in others, although greater, it is absorbed without being productive of evil. In a third class, the quantity extravasated is larger than can be absorbed, although it does not flow in an inconvenient or dangerous manner through the wound, and may ultimately become coagulated and adherent to the diaphragm and spine in the angle between them, when the patient lies long on his back. In the worst or most alarming cases, the loss of blood is and has been so great that its suppression offers the only chance for the continuance of life. It is between these two last cases only that a difference of opinion exists as to the treatment to be pursued: one party desiring that the effused blood, if moderate in quantity, should be allowed to discharge itself, the wound being kept open; the other, that under all circumstances, whether the quantity of blood poured out be small or great, the wound should be closed, and the result awaited. The right course is, I apprehend, to remove all the blood which can be evacuated by position, provided it can be done without danger to the patient, rather than to allow it to fill the chest; but as the bleeding vessel in the lung cannot readily be got at, if seen, nor be secured by ligature with advantage, it is advisable, if the bleeding continue, to close the wound, and allow the cavity of the pleura to be filled, until the lung shall be sufficiently compressed to cause the hemorrhage to cease, if the person survive so long. The first object is to save life; after that, if time be given, the next will be to relieve the loaded cavity. After the wound has been closed, and the patient has so far recovered that reaction has begun to take place, it may be concluded that the bleeding has ceased. The chest should then be most carefully auscultated from day to day, so that its respiratory state may be known, particularly with regard to the increase of effusion, which will then be serous. This will not take place until after the third, and not perhaps before the fifth or sixth day, in any considerable quantity; when, if it should have occurred, the wound should be reopened, or another opening made at the most convenient place for the evacuation of the effused blood and serum. It is probable that the wound of the vessel in the lung which furnished the blood will be closed in five or six days: while it is of great importance that the lung should be early relieved from pressure, that it should be allowed to expand, and not be bound down by false membranes; which will be the case if the compressing fluid be not removed, and the inflammatory symptoms subdued. There is no object to be gained but the suppression of the hemorrhage by retaining the blood and serum within the chest; while the probability of a return of the bleeding is not great after an opening has been made, and the blood and serum have been evacuated, although much mischief will inevitably follow the effused fluids remaining too long.

Repeated observation has shown that in sabre-wounds penetrating the chest and lung, which have not united, and from which no excessive hemorrhage has occurred, a great discharge of serous fluid usually takes place from the cavity, which, gradually diminishing, becomes purulent, and at last ceases, without the function of the lung being destroyed; while, if the wound had been early closed, and the fluid collected too long retained, the functions of the lung would be impaired, and a counter-opening, for the relief of the resulting empyema, may be unavailing. Whenever, therefore, the adhesive process between the pleuræ has failed, and great effusion has taken place, the sooner it is discharged the better.

In addition to the closure of the wound, it is desirable to arrest the hemorrhage by other means, if possible, such as the abstraction of blood from the arm to such an extent as it may be considered the patient can bear, the administration of the acetate of lead with opium, turpentine, matico, or the mineral acids; and the external and internal use of cold or iced water, if it can be borne. If there be reason to believe that a rib or ribs have been injured--that any extraneous body is inclosed in the wound--or, from its appearance, that it will certainly reopen, an incision should be made in the part injured, for the purpose of giving the necessary assistance. The cure, however, will not only be assisted, but mainly effected, by procuring a depending opening by means of the small trocar and canula introduced as low down as auscultation will authorize; the introduction of this instrument will give the desired information on the one hand, and do little or no harm on the other.

A soldier of the 3d Regiment of Infantry was wounded by a lance at the battle of Albuhera, in the left side, between the fifth and sixth ribs; and was thrown down, bleeding from the mouth and from the wound, which was afterward closed by his comrades, by confining upon it a piece of his shirt folded up for the purpose. Brought to the hospital, at the village of Valverde, he appeared ten days afterward to be dying from difficulty of breathing. On enlarging the opening in the integuments, a quantity of blood, partly fluid, partly coagulated, issued from the cavity of the chest. The wound was kept open to allow the discharge of this, and of a reddish, watery fluid, which, after a few days, became purulent. At the end of three weeks I sent him to Elvas, doing well, and with but little discharge from the wound.

A heavy dragoon, of the German Legion, was wounded at the battle of Salamanca by a sword, which penetrated the cavity of the right side of the chest, between the sixth and seventh ribs. He fell from his horse, and lost a considerable quantity of blood from the mouth and from the wound. On examining the wound next day, a black coagulum was seen filling up the orifice, the cellular membrane around being considerably ecchymosed, and little doubt existed that the oppression in breathing under which he labored was caused by blood effused into the cavity. On separating the edges of the wound with a director, several ounces of blood, half fluid, half coagulated, were evacuated by making the external opening, which was enlarged, quite dependent. The lung was then seen in contact with the external opening of the wound, having expanded as the pressure of the blood was removed from it. The wound was closed simply by lint, compress, and adhesive plaster, without bandage; the man was largely bled, and placed upon his wounded side on the ground, being the most comfortable position, in some degree relieved from the oppression in breathing. Two days after, the wound discharged freely a reddish-colored watery fluid, evidently from the cavity of the chest, the exit of which was aided by keeping the wound generally dependent. This continued for several days, the fluid gradually becoming less in quantity, and purulent; under careful management he was able to go to the rear, nearly well, by the end of October.

333. On the subject of the ecchymosis, which Valentin considers to be a pathognomonic sign of effusion of blood within the chest, he says: “It is very dissimilar to that which occurs after a blow or wound, and which takes place shortly after the accident, beginning around the wound, if there be one, and extending from it. The patient also complains of pain when the bruised part is pressed by the fingers. These characters are not observed in the ecchymosis, the sign of effusion, which always takes place near the angles of the lower or false ribs descending toward the loins. Its color is identical with that which appears on the abdomen of persons some time after death, a bright violet, (_violet très éclairci_.) It appears about ten days after the receipt of the injury, sometimes later.” The same sort of thing, he thinks, takes place when the cavity of the chest is filled with pus, but that edematous swelling is without discoloration.

334. In order to be explicit on points so important as those of which I have treated, I have thought it right to lay down certain general conclusions, subject to occasional deviations:--

_a._ All _incised_ or _punctured wounds_ of the chest should be closed as quickly as possible by a continuous suture through the skin only and a compress supported by adhesive plasters, the patient being afterward placed on the wounded side--a precept which is absolute only with respect to _incised_ wounds capable of being united by suture in the manner directed.

_b._ As soon as the presence of even a serous fluid in the chest is ascertained to be in sufficient quantity to compress the lung, a counter-opening should be made in the place of election for its evacuation by the trocar and canula, which may be afterward enlarged; unless the reopening of the wound should be thought preferable, which will not be the case unless it should be low in the chest.

_c._ If blood flow freely from a small opening, the wound should be enlarged so as to show whether it does or does not flow from within the cavity. If it evidently proceed from a vessel external to the cavity, that vessel must be secured by torsion or by a ligature applied on it, all the other methods recommended being simply surgical absurdities.

_d._ If blood flow from within the chest in a manner likely to endanger life, the wound should be instantly closed; but as the loss of a reasonable quantity of blood in such cases, say from two to three pounds, will be beneficial rather than otherwise, this closure may be delayed until syncope takes place or until a further loss of blood appears unadvisable.

_e._ If the wound in the chest have ceased to bleed, although a quantity of blood is manifestly effused into the cavity of the pleura, the wound may be left open, although lightly covered, for a few hours, if the effused or extravasated blood should seem likely to be evacuated from it when aided by position; but as soon as this evacuation appears to have been effected, or cannot be accomplished, the wound should be closed. It must be borne in mind that the extravasation which does take place is usually less than is generally supposed--a point which auscultation will in all probability disclose.

_f._ If the cavity of the pleura be full of blood, and the oppression of breathing and the distress so great as to place the life of the patient in immediate danger from suffocation, the wound should be reopened, if it have been closed, or freely enlarged, if small, to such an extent as will allow a clear evacuation of the effused blood. It has been supposed that in such a case the lung does not sufficiently collapse, and the bleeding is therefore continued because the vessel cannot contract; but the lung will usually collapse under pressure of the air, unless prevented by previously-formed adhesions, when the hemorrhage may possibly cease--instances of which are said to have taken place, and the practice should therefore be borne in mind.

LECTURE XXIII.

WOUNDS OF THE CHEST, ETC.

335. Gunshot wounds of the chest, penetrating the cavity, are always exceedingly dangerous. After the battle of Toulouse, on the 10th of April, 1814, one hundred and six cases of wounds in the chest in officers and soldiers, in all of whom the cavities were not penetrated, were received into hospital. Between the 12th of April and the 28th of June thirty-five died, fourteen were discharged to duty, and fifty-seven were transferred to Bordeaux to proceed to England, some to die, some to be pensioned, but few in all probability to return to the service--being an ultimate loss of nearly one-half, if the fifty-seven cases sent to England could be traced. M. Menière, in giving an account of the wounded carried to the Hôtel-Dieu of Paris, in the three remarkable days of July, 1830, where every case was immediately taken care of, says forty cases were received into the hospital; of these twenty died; he states the case of ten more, seriously wounded, who recovered; and he gives the names of seven more, in six of whom the cavity of the chest was not perforated, and alludes to three wounded by small-swords, who recovered--the loss being thus one-half, even if the rest happily and perfectly recovered, which may be doubted, thus showing that with the ablest assistance the Hôtel-Dieu of Paris could afford the loss was one-half. After the battle of Waterloo the loss was much greater; with the army on the Sutlej the loss was deplorable, in consequence of the want of a sufficient number of medical officers and of means--a state of destitution to which I have drawn the attention of the directors of the East India Company in the strongest possible terms, but which they will not rectify, but which will some day, I hope, become the subject of Parliamentary discussion, and, I doubt not, of public reprobation. That the wounds of the chest with the army in the Crimea will afford a more satisfactory result, cannot, I fear, be expected, and for similar reasons.

336. When a musket-ball fairly passes through the cavity of the chest, the orifice of entrance is round, depressed, dark colored, and more or less bloody in the first instance; the orifice of exit is generally more of a rugged slit or tear than a hole. The alarm is great, and the powers of life are much depressed. The wounds may or may not bleed; the sufferer may spit up more or less blood; respiration may be difficult, countenance pale, extremities cold, pulse variable--symptoms dependent on particular constitutions and circumstances connected with the extent of the injury.

It has been said that balls are apt to run round the body, coming out at a point opposite to that at which they entered, without penetrating the cavity of the chest; this, whenever it does take place, is a rare exception to a general rule, dependent on the ball being reflected from something solid which it cannot penetrate, such as a button, a piece of money, a rib, etc. If the ball run under the integuments exterior to the fascia covering the intercostal muscles, it is usually marked by a tenderness in its course on touching the part and a discoloration of the skin. A ball may, however, run between two ribs for some distance, injuring the muscular structures between them without penetrating the cavity, in which case, after the first moments of alarm have passed away, the symptoms indicative of a penetrating wound either cease or do not occur, although those of inflammation of the pleura or lung may and often do follow to a considerable extent.

When the ball cannot be traced, the absence of symptoms, after the first period of alarm has subsided, will enable the surgeon to form the surest prognosis; their absence, however, cannot too certainly be relied on.

A ball will occasionally rebound from the sternum, leaving merely a black mark; from the spongy nature of that bone in which they frequently lodge, they require the application of the trephine. If a ball should be felt through a wound in the sternum, the broken portions of bone should be removed by the small saw or by the trephine, and the ball extracted.

337. An enlargement of the wound, the “_debridement_” of the French, does no harm beyond the pain it occasions, unless there be something to be removed, when an incision becomes necessary, in many instances, for the removal of extraneous bodies or for the evacuation of blood, etc. When a wound from a musket-ball appears likely to have penetrated the cavity of the chest, and is too small to admit the end of the finger, the opening ought to be enlarged so as to allow its introduction as far as the ribs, in order to ascertain whether those bones have sustained any injury, or whether anything is lodged exterior to or within them. It is not necessary that a man should be cut simply because he has been shot; and an enlargement of the wound should be of no greater extent than is absolutely necessary for the purpose intended. When pieces of shell, or of a sword or lance, are broken off and partly lodged in the cavity of the thorax, which is more likely to happen when they enter through the large muscles of the back, they will require larger incisions to give room for their removal. Great praise was given of old to Gerard, surgeon-in-chief of La Charité in Paris, who, having perceived that a small sword, after going through a rib, was broken off close to it, thought it advisable to make an incision through the intercostal muscles into the chest, and then to introduce his forefinger, armed at the end with a thimble, with which he pressed back the point of the broken blade. In a case of this kind, the surface and outer edge of the bone should be removed, until the piece of steel can be firmly seized and withdrawn by a fine pair of pincers or pliers.

When a ball sticks firmly between two ribs, it requires some care to remove it, as the rib both above and below may be more or less interested, although not actually fractured. The attempt should be made during inspiration, when the lower rib should be depressed, and some thin but not sharp-pointed instrument like an elevator should be gently pressed around and under the looser edge of the ball, in order to extricate it.

When a musket-ball fractures a rib, there ought to be no hesitation about the propriety of enlarging the wound, to allow the splintered portions of bone to be removed. It is possible that in doing this some pieces of cloth or other matters may be extracted, which might else glide into the cavity of the thorax, or stick in the lung itself.

A soldier of one of the regiments on the left of the position of Talavera was brought to me, wounded by a ball in the left side of the breast; it had struck the sixth rib, and passed out about four inches nearer the back. As the point of the finger indicated the presence of broken bone, I enlarged the anterior wound, and then found that the ball had driven some spiculæ of bone into the surface of the lung, which appeared to have been previously attached to the pleura costalis at that part. These having been removed, together with a piece of coat which had been carried in with the ball, a small, clean wound was left, which gradually healed up, the man accompanying me on the retreat over the bridge of Arzobispo.

338. When a ball impinges with force on the center of one of the ribs, and passes into or through the chest, the bone is usually broken into several splinters of different lengths, some of which frequently accompany the ball in the commencement of its course, or are even carried into the substance of the lung, together with a part of the wadding of the gun, or of the clothes of the patient. These should if possible be extracted if they can be seen, and the sharp ends of the rib rounded off. When the ball fractures a rib on passing out of the chest, the splinters are driven outwardly, and should be removed by incision.

339. When a ball strikes a cartilage of one of the ribs, it does not punch out a piece as it were, but merely divides and passes through it, bending it inward, rarely tearing away a portion. The parts of the cartilage thus bent and turned inward are to be drawn outward, and replaced by the end of the finger, a bent probe, or other curved instrument.

A ball, when striking obliquely but with force on the chest, will frequently penetrate, and then run round, between the lung and the pleura lining the wall of the chest, for a considerable distance, before it makes its exit. In this case the lung may be only slightly bruised, without the pleura pulmonalis or costalis being more than ruffled. In others the lung shows a distinct track or hollow made by the ball. A shade deeper, and the ball penetrates, and forms not a hollow, but a canal. The patient in all these cases spits blood, and the first symptoms are severe; they frequently, however, subside, and are not always followed, under proper treatment, by effusion, although it may always be expected.

340. When a ball fairly passes through the lung, it leaves a track more or less bruised, which continues for a time to bleed according to the size of the vessels which are injured, thus making a wound more dangerous as it approaches the root of the lung where the vessels are largest. More or less blood is spit up, or, if effused, it gravitates in the chest, until it rests on the diaphragm or other most depending part, according to the position of the patient. If it should be in quantity, the filling up of the chest may be ascertained by auscultation, if the wound be closed. As the quantity of effused blood increases, the lung becomes more and more compressed, until at last the hemorrhage ceases under pressure, if the wound be covered; and the patient is saved for the moment, unless he should die of asphyxia, from the lung on the other side being also compressed through the bulging of the mediastinum on it; to prevent which, if possible, the wound should be reopened or enlarged, so as to take off the pressure of the effused and perhaps coagulated blood. If the person wounded shall have suffered formerly from inflammation, and the lung has adhered in consequence to the wall of the thorax, at the parts where the ball enters and goes out, the cavity of the chest will not be opened, and the track only of the ball will communicate with the external parts, unless the ball shall have perforated some of the large vessels, when he will continue to bleed by the mouth. The pressure of the blood effused into the track of the ball, which may become coagulated, will sometimes suffice, under even these circumstances, to effect the suppression of the hemorrhage which the loss of blood, the faintness of the patient, and the weakness of the circulation, under proper treatment, will materially assist in rendering permanent.

General Sir G. Lowry Cole, G.C.B., was struck at the battle of Salamanca, on the 22d of July, 1812, by a musket-ball, which entered immediately below the clavicle, fractured the first rib, and, inclining inward, came out through the scapula behind; as he spat blood for three days, the upper part of the lung was shown to have been injured. The ball appeared to have passed so close to the under part of the subclavian artery that the greatest fears were entertained for his safety; more particularly as a marked difference in the size of the pulse was perceived in the left arm, which did not exist before. He remained three days on the field of battle, in a Portuguese officer’s tent I always carried with me. Under repeated bleedings, and the strictest antiphlogistic treatment, several splinters having come away, and a large piece of the rib and of the scapula having exfoliated, he gradually recovered, so as to be able to resume the command of the Fourth Division in October at Madrid. The subclavian artery never resumed its power, and the radial always beat less forcibly on the left side. He perfectly recovered his health, the respiratory murmur of the lung being natural. He died suddenly in 1844, from rupture, I believe, of an aneurism of the abdominal aorta.

A dragoon of the King’s German Legion, shot in a nearly similar manner on the same occasion, suffered more severely: the clavicle and first rib were splintered to a greater extent, and he lost a large quantity of blood by the mouth. The splinters having been removed, after enlarging both wounds for that purpose, and the inflammatory symptoms subdued, he appeared to be going on favorably for three weeks; when, having eaten some meat obtained irregularly, he suffered what seemed to be a bilious attack of vomiting and purging, attended by fever and oppression in the chest; an ipecacuanha emetic having been given with full effect, relieved him much. During the efforts to vomit, the wounds discharged a quantity of sero-purulent fluid, a piece of the cloth of his coat, and another of bone, which had gone in with the ball, and in all likelihood had been lying with the matter at the bottom of the chest. After this he slowly recovered. This case is peculiarly instructive.

General Sir Andrew Barnard, G.C.B., was wounded when in command of the Rifle Brigade, at the passage of the Nivelle, on the 10th November, 1813, by a musket-ball, which entered between the second and third ribs, in front of the right side of the chest, passed directly through the cavity and through the shoulder-blade, from under the integuments covering which it was removed. He not only felt but heard the sound of the ball as it struck him, and he fell from his horse. Blood gushed from his mouth, and continued to do so until after he was completely exhausted by bleeding from the arm to the amount of two quarts. He was again bled at night, and the subsequent morning, which relieved all the material symptoms. During six weeks he suffered from difficulty of breathing and cough, and from night-sweats. Some pieces of bone and cloth came away from the wounds, with a free discharge in the first instance, which gradually diminished until the wound closed. In eight weeks he was able to resume his command.

More than forty years afterward I found the lung pervious; the vesicular murmur could be freely heard even up to the situation of the wounds, to the internal parts of which it may be concluded the lung adhered, from the sound conveyed to the ear on auscultation. He suffered little or no subsequent inconvenience from the injury, and died in January, 1855, aged 82.

_Case of Major-General Broke, by himself._--Toward the close of the battle of Orthez, on the 27th of February, 1814, a musket-shot struck me between the second and third ribs on the right side, near the breast-bone. I was then on horseback, being aid-de-camp to Lieutenant-General Sir Henry Clinton, commanding the Sixth Division. The sensation was precisely as if I had been struck a violent blow with the point of a cane, but it did not unhorse me. I was attended in a very short time by the surgeon of the 61st Regiment, when, on removing my clothes, the air and blood bubbled out from the wound as I drew my breath. The surgeon, turning me on my face, discovered the ball to be lodged under the thin part of the blade-bone. This he cut through and extracted the ball, and with it pieces of my coat, waistcoat, and shirt, which were lodged between the ribs and the blade-bone. This occurred about four P.M. I was then removed to the town of Orthez, a distance of about three miles, and in the course of the afternoon the veins of both arms were opened in at least seven different places, but scarcely any blood came away; breathing became exceedingly painful in a day or two, and I felt nearly suffocated, when, in the evening, my brother, Sir Charles Broke Vere, arrived with my friend, Mr. Guthrie, who examined me carefully. The agony of drawing breath was such that I could scarcely endure it. He opened one of the temporal arteries, and desired that it might be allowed to bleed without interruption. He afterward left me to visit some other wounded men, and returned in about three hours, when I told him that I felt relieved, and had much less of the suffocating pain in breathing. He then opened the other temporal artery, directing as before that its bleeding should not be checked. I shortly after that dropped asleep, and on waking could breathe freely; my recovery was progressive from that time, the wound in front, where the ball entered, being the first closed; but both were healed at the end of about eight weeks, and in about ten I was able to rejoin the army at Bordeaux.

H. G. Broke, _Major-General_.

He is now, in 1855, in perfect health, the respiratory murmur being free all over the chest.

The Duke of Richmond, then Earl of March, was wounded by a musket-ball at the battle of Orthez, while at the head of his company in the 52d Light Infantry. He was standing at the moment with his right face toward the enemy. The ball entered that side of the chest, between the fourth and fifth ribs, nearly in a line with the lower edge of the scapula. He fell to the ground with great violence, and was speechless for some time. He stated to me at a subsequent period that the sensation he felt at the moment was as if he had been “_cut in two_.”

On immediate examination there was no other opening to be found but the _one_ where the ball had entered; nor were the medical officers able to feel the ball anywhere under the skin or under the muscles.

The wound having been dressed he was laid on a door and removed to Orthez, about three miles from the scene of action, during which he complained of excruciating pain, extending from the wound to the top of the os ilii on the same side, the pain being much aggravated by frequent and severe cough, with copious expectoration of frothy mucus, and much florid blood; respiration hurried; countenance pale.

The moving him to Orthez occupied nearly three hours; a great part of the ground being very rough and broken, the men could not well step together, and the consequent unavoidable shaking and jolting caused him much pain. On his arrival at Orthez, he was extremely languid, with a tendency to syncope. Pulse feeble; extremities rather cold.

Seven in the evening: After having been faint for an hour, he became hot and restless; pulse 108, and full; skin more hot, and the respiration short and more hurried. After he was placed in bed hemorrhage from the wound took place to a very considerable extent. Eight ounces of blood were taken from the arm. (Could bear no more.)

15th inst., nine A.M.: After the bleeding he became more quiet, and had less pain; but he has since become very restless, and the pain returned, with a full, hard, and frequent pulse. The wound has again discharged a very considerable quantity of blood. Bleeding repeated as before.

Nine P.M.: Deputy-Inspector Thomson and Staff-Surgeon Maling examined the wound. Mr. Maling introduced his finger (the whole length) between the ribs into the wound without any interruption to its progress, and without being able to reach the termination of the passage of the ball; and Dr. Thomson then passed a probe (its whole length) straight into the chest, with a similar result; thus leaving no doubt on the minds of all present that the ball had passed directly into the posterior part of the chest.

Midnight: The blood last taken is very buffy; and there has again been an _immense discharge_ of blood, etc. from the wound; the sheets, mattresses, etc. are saturated with it; and on the floor, under the bed, there is a large pool of blood which had soaked through the bedding. Pulse 114, low and frequent; cough and expectoration as before; pain violent, and great restlessness. Repeat the bleeding.

_Mem._--Perhaps enough has now been stated to show the nature of the wound; and any further detailed statement of his lordship’s sufferings, or the treatment of his case, would be unnecessary. On the latter point, however, it may be mentioned that, exclusive of the _general treatment_, he was bled _seven times_ between the evening of the 27th of February and the morning of the 2d of March, the _cough_, _expectoration_, _breathing_, _pain_, _etc._ being much relieved by each bleeding.

A. Hair, M.D.

Mr. Guthrie saw the Earl of March on the same day as Colonel Broke, and suggested that no further efforts should be made to find the ball, while the treatment adopted should be steadily pursued; and in 1846, he pointed it out lying under the edge of the base of the scapula. His grace is now, 1855, in good health, and the chest, well formed, sounds clearly and healthily in every part, even at the point injured.

341. The ball in passing through the lung, in these cases, destroyed the life of that part only which it touched; and although air would pass out at the time, this would not be of long continuance. The wounds being kept covered, the lung did not and does not usually, in similar instances, collapse or recede from the wall of the chest, but quickly recovers its state of expansion, however impaired it may be at the moment by the injury. The track made by the ball gradually suppurates and heals, leaving merely a depression or cicatrix on the surface attached around or in part to the wall of the chest by adhesion. The track through the lung may be readily seen in such cases after death; although during life it interferes so little with the respiratory murmur as not to be observable, unless by its greater distinctness, from the thinness of the intervening parts.

Mrs. M. was wounded by a small pistol-ball, which entered on the right side from behind, between the seventh and eighth ribs, just under the arm when hanging down, and passed out in front over the cartilage of the sixth rib, more than an inch from the pit of the stomach. She had not spit blood, and the ear declared the lung to be pervious to air at the wounded part, which raised a hope that the ball might not have penetrated the cavity, although it might have injured the pleura. As she suffered great pain twenty-four hours after the injury, the breathing being oppressed, Mr. Adams bled her into a hand-basin, until about to faint. She lost nearly thirty ounces of blood, but her symptoms were quite relieved, so as to render any other bleeding during her treatment unnecessary. At the end of the third day she spat a very little blood after removal in a carriage to another lodging, and then gradually recovered. After four different stethoscopic investigations, I came to the conclusion that the ball had not struck the lung in the first instance, although the lung adhered to the pleura costalis, and suffered from some abrasion or ulceration at that point, which gave rise to the expectorated blood.

These cases are instances of wounds of the upper part of the lung, which are in general more dangerous than those of the lower, from the vessels being larger, and from the greater difficulty with which any extravasated blood or fluids can escape. They also prove that when blood is poured out in small quantity, it may be absorbed, but what that quantity may amount to is doubtful.

342. In cases in which the external opening or wound does not communicate freely with the cavity of the chest, the principal danger arises from the inflammation of the pleura ending in effusion, which, if not evacuated, leads to the loss of the individual. _It is the great fact to be attended to in the treatment of pistol wounds of the chest, or those made by small balls which do not pass out._ All the persons I have seen die from small balls have died with the affected cavity more or less full of fluid. The post-mortem reports of all persons killed in England in duels by wounds through the chest, unwittingly attest this fact, as well as the insufficiency of the surgical treatment they received; and the necessity, for the future, for its amendment. It is in these cases that the stethoscope is most valuable--its frequent use indispensable. When the respiratory murmur ceases to be heard except at what is the upper part of the chest, whatever the position of the patient may be, it is full time to enlarge the original opening, or to draw off the fluid by the trocar and canula.

Laennec thought that when a considerable effusion took place in pleuro-pneumonia, filling the posterior part of the chest when the patient lay on his back, it nevertheless diffused itself over the whole surface of the lung; but dissection has shown, in cases of wounds, that the fore part of the lung may be applied to the anterior part and sides of the ribs, while a serous effusion fills the hollow behind, the respiratory murmur being distinctly heard above it. It is the most important fact to ascertain, particularly in pistol or small penetrating wounds of the chest, in which the opening is not sufficiently large to allow any fluid effused to run out.

Sir C. B. was wounded by a pistol-ball in the back, which passed into the chest through the lower part of the lung of the right side, and lodged on the inside of the wall of the chest in front of the same side, sticking in and against a rib, but giving rise to no external marks or signs of mischief at that part, so as to admit of an operation for its removal. The inflammatory symptoms having been restrained, it was nevertheless obvious that the cavity of the chest was full of fluid, and that the oppression in breathing arose from it, and not from the injury done to the lung. The stethoscope was then unknown, the ear was not in use; my older colleagues were obstinate; they would not hear of an operation for enlarging the wound into the chest; and as our patient was, unfortunately for him, shot in London, instead of at the pass of Roncesvalles, or on the bridge over the Bidassoa at Irun, we let him die on the eighth or ninth day, without all the aid which surgery might have given him. It is possible he would not have recovered under any circumstances, from the ball having lodged, and from his advanced age.

A soldier of the Fifth Division of Infantry was wounded at Toulouse by a musket-ball, which entered between the fourth and fifth ribs of the right side, near the sternum, and came out behind nearly opposite, fracturing the ribs, the splinters of which were removed. The first symptoms of inflammation, having been in some degree subdued by the sixth day, were followed by those more immediately indicating effusion; such, particularly, as great oppression, difficulty of breathing, and inability to lie in the recumbent position, which induced me to introduce, after a little pressure, a gum-elastic catheter into the posterior wound, through which a quantity of red, serous fluid was withdrawn, exceeding, perhaps, three pints by measure. On the removal of the catheter the discharge of fluid ceased, and, under a strict antiphlogistic treatment, the man gradually recovered, so as to be sent to England in the following June. If the symptoms of oppression had returned, I should have repeated the operation perhaps lower down. Auscultation, if it had been then known, would have smoothed away many doubts and difficulties.

A soldier of the 40th Regiment was wounded at Toulouse on the 10th of April by a musket-ball, which entered about two inches below the nipple of the right breast, passed through the cavity and the lung, and came out behind at a nearly opposite point, injuring the ribs above and below, without entirely destroying their continuity. He was bled largely on the morning of the 11th, and again at night. On the 12th the bleeding was repeated; some small pieces of ribs were extracted from both orifices, and some part of his dress from the anterior one. He spat blood when he coughed, and respiration was difficult. Calomel, opium, and antimony were given in pills every six hours, and the bleedings were repeated daily, and sometimes oftener, for the first eight days, during which time a free discharge, at first serous, afterward purulent, took place from the wound, after which the inflammatory symptoms subsided; the cough became easier, the expectoration less, and free from blood; breathing easy. The calomel was omitted; a mild farinaceous diet was allowed instead of a little gruel, and a very little bread and milk. In a fortnight the wounds began to heal. On the 1st of May, some small pieces of rib were removed from the anterior wound, after which both gradually closed, and he was forwarded to Bordeaux on his way to England in the beginning of June, cured.

Corporal Dunleary, of the 69th Regiment, was wounded on the 16th of June, 1815, at Quatre Bras, by a musket-ball, which entered the thorax, fracturing the seventh rib on the fore part of the right side, and lodged. He said he had lost a large quantity of blood from the mouth, and some from the wound, between that and the 19th, when he was brought to the hospital in Brussels. The pulse was then quick and hard, respiration difficult and anxious, and a bloody discharge issued from the wound on every respiration; bowels confined since the accident; was bled to forty-four ounces; saline purgatives, with calomel, antimony, and opium, were given until the 29th of June, when the wound discharged good pus. From this time, at different periods for six weeks, he lost ninety-two ounces more blood, being strictly placed on milk diet. Several pieces of rib exfoliated. He was sent home on the 31st of August, declaring himself quite as well as ever he had been in his life; the ball remaining undiscovered.

A soldier of the Fusilier Brigade was struck by a musket-ball on the right side of the front of the chest, at the battle of Albuhera; it entered between the fifth and sixth ribs, passed through the lungs, and lodged. Three days afterward, when the first symptoms were in part subdued, he complained of pain in a particular spot, nearly opposite to where the ball had entered, at which part something could be felt deeply seated. An incision being made, the ball was found lodged in the intercostal muscles between the ribs, whence it was easily removed. A considerable discharge of reddish-colored serum followed, with great mitigation of the symptoms, after which, under strict treatment, the man recovered, and was sent to Elvas with every prospect of a cure.

Lieutenant-Colonel Harcourt and Major Gillies, of the 40th Regiment, were both shot through the chest, at the head of the regiment, at the successful assault of Badajos; the wounds were as nearly similar as possible, from before directly backward. They were taken to the same tent, and treated alike with the same care by the late Mr. Boutflower, the surgeon of the regiment, with whom I saw them daily. The inflammatory symptoms ran high in both. In Major Gillies, a tough old Scotchman, they could not be subdued, and he died, at the end of a few days, of pleuro-pneumonia. Colonel Harcourt slowly recovered, and died Marquis d’Harcourt, near Windsor, more than twenty-five years afterward, suffering little or no inconvenience from his chest, when I last saw him.