Chapter XXI: Part 21

Captain Cane, 23d Fusiliers, was wounded at the affair of Saca Parte, in front of Alfaiates, in 1812, by a musket-ball, which struck him below and a little to the outside of the left nipple, fractured the rib, and entered the chest, giving rise to the sensation as if the ball had passed diagonally downward and backward to the loins of the same side. He spat blood, and was very faint. The next day he could scarcely breathe, was in great pain, continued flushed and anxious; pulse 100. He was bled into a washhand-basin until he fainted, and every day afterward, some days twice, to a less extent, for ten days, and once again until syncope was induced, on an accession of symptoms after an imprudence in taking a little wine, which nearly smothered him, he said. Some pieces of flannel shirt, of braces, coat, etc. were removed from the wound, and several portions of bone gradually followed, together with a quantity of matter, which continued to flow from May until the end of the following September, when the wound healed.

On the 23d Jan., 1821, I had an opportunity of examining this gentleman. My report says, he is never free from a little pain in the loins, where the ball is supposed to be, and cannot take a full inspiration without pain in the chest; expectorates more or less constantly, and occasionally a little blood about once in three or four months in half congealed lumps. Cannot ride or take any exercise because it brings on the pain. The cicatrix shows a large, deep hole, and the deficiency of the rib is well marked. The side of the chest is altogether contracted and flatter; the heart has been moved behind the sternum; the beat of the apex being on the other side of the xiphoid cartilage, and that of the heart, as a whole, is more indistinct than usual. In other ways in good health. It is possible that the ball may be lodged in or be retained by layers of coagulable lymph in the angle formed between the diaphragm, the ribs, and the spine.

William Downes, of the 11th Regiment of infantry, aged thirty-three, was wounded by a musket-ball, on the 31st of August, 1813, in the Pyrenees; it fractured the fourth rib of the left side, passed through the chest, and came out behind through the scapula. He spat a good deal of blood, although little flowed from the wound. The next day he was bled largely twice, to relieve the bleeding from the lung, and was sent to Passages, where he was bled daily; and thence, a ship being ready, to Santander, where he arrived on the 14th of September. A free, bloody, purulent discharge took place from the anterior wound, but little from the posterior, and he expectorated a bloody, purulent matter, and occasionally a little blood. Toward the end of September the sanguineous expectoration ceased; but the soft parts of the chest had sloughed and separated under an attack of hospital gangrene, from which he had a narrow escape during the month of October. The wound in the chest gradually closed during the month of November; and on the 14th of December he was discharged convalescent, his health tolerably good, but his breathing by no means free; no expectoration. The left arm was impaired in power, in consequence of the mischief done to the muscles of the fore part of the chest and shoulder by the hospital gangrene. The chest was altogether somewhat flattened and shrunk, but there did not seem to be any diseased action going on within.

_Case of Lieutenant-Colonel Dumaresq, aid-de-camp to Lord Strafford, by himself._--While turning round, after a successful charge of infantry, at Hougomont, on the 18th of June, 1815, I was wounded by a musket-ball, which passed through the right scapula, penetrated the chest, and lodged in the middle of the rib in the axilla, which was supposed to be broken. When desired to cough by the medical officer who first saw me, almost immediately after receiving the wound, some blood was intermixed with the saliva. I became extremely faint, and remained so about an hour and a half, after which I rode four or five miles to the village of Waterloo, where I was bled, which relieved me from the great difficulty I had in breathing; this difficulty was accompanied by a severe pain down my neck, chest, and right side. I was much easier until the evening of the 19th; but in the course of the night, the difficulty of breathing becoming much greater, and the spasmodic affection having very much increased, I was bled seven times, until the middle of the next day.--20th. I continued better, but was then seized with the most violent spasms imaginable in my neck, chest, and stomach. I could scarcely breathe at all, and was in the greatest possible pain; I was again bled twice very largely, and my stomach and chest fomented for a length of time with warm water and flannels. I passed a very tolerable night, and continued pretty well until two o’clock the following day, when I was again very largely bled, by which I was very much relieved. I continued pretty well, and free from much pain; but my pulse having very much increased, and having a good deal of fever, on the 23d I was bled again; after this I continued free from much pain or difficulty of respiration, and on the 26th was removed into Bruxelles, when I came under your care. I forgot to mention that when I was so violently attacked I had two lavements most vigorously applied; salts, etc. proving of no avail, took digitalis, commencing with ten drops every four hours, increasing to fifteen from the second day.

N.B.--Up to this period, the 2d of July, the devil a bit have I eaten.

While with fat mutton-chops, and nice loins of veal,
You stuff your d--d guts, your hearts are all steel.
Oh! ye doctors and potecaries, you’ll all go to hell,
For cheating our poor tripes of their daily meal.
H. Dumaresq.

The ball in this case was lodged in the rib, which ultimately became thickened around it. He recovered with good health, but with occasional spasms in the chest; and died of apoplexy, in Australia, twenty-five years afterward. His doggerel lines show the buoyant and unconquerable spirit of a soldier, who knew that his chance of recovery was small. It was a most gallant, a most friendly spirit. Peace to his manes.

If the ball had caused a greater degree of irritation, I was prepared to cut down upon the rib, and remove a part of it, if necessary; for I have seen balls so situated slip from their lodgment, roll on the diaphragm, and cause general inflammation, suppuration of the cavity, and death, which must almost always ensue in such cases, unless the ball can be removed, and the matter evacuated by an operation to be hereafter described.

General Macdonald, of the Royal Artillery, was present at Buenos Ayres, when a bombarder of that corps received a wound from a two-pound shot, which went completely through the right side, so that when led up to the general, who was lying on the ground, he saw the light quite through him, and supposed he was of course lost. This, however, did not follow, and some months afterward the man walked into General (then Captain) Macdonald’s room, so far recovered from the injury as to be able to undertake several parts of his duty before he was invalided; thus proving the advantage of a shot, however large, going through rather than remaining in the chest.

LECTURE XXIV.

Appearances After Death, Etc.

343. The appearances after death differ materially even in apparently similar wounds.

A French soldier, shot through the right side of the chest at the siege of Badajos, died in December, 1812, in Lisbon, apparently of consecutive phthisis. The ball had gone through the chest from before directly backward; the posterior wound was closed; the anterior one was fistulous, and discharged a small quantity of matter, of which he spat up daily a large quantity until he died. The lung was diseased throughout, and contained several vomicæ or small abscesses, from which the matter expectorated was secreted. The track of the ball was nearly filled up, although the part immediately around was harder than usual. The lung adhered in many places to the wall of the chest, which was much flattened.

In other cases, portions of wadding, of leather belts, of splinters of different lengths, pieces of buttons, and even balls, have been found loose in the chest, showing the necessity for an especial and decided treatment.

A French soldier was wounded by a musket-ball at the battle of Waterloo; it penetrated the chest, fracturing the second rib, then passed through the lung, and went out behind in nearly a straight line, close to the spine. Left on the field of battle for five days before he was brought to Brussels, he was nearly dead with difficulty of breathing and other symptoms of inflammation, from which he recovered in the course of the next ten days, under repeated bleedings and the strictest antiphlogistic regimen. At the end of this time, when apparently doing well, an accession of inflammation and of all his bad symptoms took place, destroying him at the end of four weeks from the receipt of the injury. On dissection, the lung was found adherent to the chest by false membranes of some thickness, with a quantity of purulent fluid in the cavity. The track of the ball was in a suppurating state, and two pieces of rib were found in the center of its course. The whole of the lung appeared to be filled with a sero-purulent fluid, which could be readily squeezed out.

John Roth, of the 5th battalion of the 60th Regiment, aged twenty-nine, had been wounded by two balls, one on the 10th of April, 1814, at the battle of Toulouse, which grazed the left temporal bone; the other had gone through the upper part of the right chest, in the Pyrenees, the autumn before. Both wounds had healed. He was seized on the 8th of May, after a little intemperance, with pains in his body and joints, pain in the chest, and cough, with bloody expectoration; skin hot, tongue foul, and bowels confined. On the 9th he was bled, and purged by calomel, antimony, and salts. On the 10th symptoms augmented, pulse 120, small, and wandering, but no pain in the head. Repeat the medicines. Head shaved and cold applied; bleeding to ten ounces. 11th. Every symptom increased; great pain on touching the chest; pulse 126; skin hot. On the 12th passed his urine and feces involuntarily; and on the 13th he died, his body being covered by petechiæ.

The head, on examination, showed pus under the dura mater, at and behind the situation of the wound he had received. The right lung adhered to the walls of the chest where the ball had entered and passed out, the track made by it being very visible, indurated, and inflamed, from the last attack: the parts otherwise sound; no fluid in the cavity.

Mr. Drummond was wounded by a pistol-ball in the back, low down, about two inches from the spine, and three inches from the inferior angle of the scapula; it was afterward found to have entered between the eleventh and twelfth ribs, and to have _passed between the base of the lung and the diaphragm_, abrading the former, and passing through the latter into the abdomen, ultimately lodging in the fat under the skin, over the cartilage of the eighth rib of the left side, nearly at an opposite point in front. From the absence of all symptoms of shock and alarm, it was hoped by some that the ball might have run round, but on the removal of the little ball its course could not be traced. This occurred on Friday. On Saturday morning at five o’clock he suffered great uneasiness and difficulty of breathing, accompanied by a particular catch or jerk in respiration, indicating a wound of the diaphragm. The stethoscope and the ear attested the clearness of the respiratory murmur in every part of the chest, which sounded well, and I was satisfied the lung was not materially injured; twelve ounces of blood were drawn with difficulty from both arms. At ten o’clock, the jerk and difficulty of breathing being greater, the left temporal artery was opened, as no blood could be drawn from the veins; five ounces only could be obtained; a dose of calomel and a senna draught had been followed by the discharge of a teaspoonful or two of blood, leaving no doubt on my mind that the ball had penetrated the cavity of the abdomen, as well as of the chest, and that a bowel had been injured. With a constitution apparently unequal to bear an inflammation of the most dangerous character, or the remedies necessary to subdue it, the prospect was but melancholy. Thirty-six leeches were applied around the wound in front, but they drew little blood. Pulse from 108 to 112. Dr. Hume, Mr. B. Cooper, and Mr. Jackson were added in consultation on Monday at twelve, when the jerk became worse, the oppression in breathing greater. Muriate of morphia, half a grain; at two, bled to twelve ounces; blood very buffy; calomel, two grains, opium, half a grain, every two hours. In the evening, bleeding, repeated to fourteen ounces; no more would flow. Tuesday morning, at five, bled again to twelve ounces. The ear now indicated effusion for the first time. It was not, however, in sufficient quantity to render the evacuation of the fluid necessary. After this he gradually sank, and died on Wednesday morning. He lost on the whole fifty-six ounces of blood. On examination after death, it was found that the ball, after entering the cavity of the chest, had slightly abraded the left lung at its lower and inferior edge, which was covered by recent lymph, the lung being internally sound. The left side of the chest contained nearly a pint of red-colored serum. The ball had perforated the diaphragm, grazed the fat of the left kidney, passed through the great omentum below the stomach, to the part where it was extracted, injuring apparently no important organ in the abdomen in its transit, but giving rise to an effusion of blood from some small vessel which had sloughed, the blood being partly coagulated and partly diffused to the amount of many ounces; its loss appeared to have been the immediate cause of death.

A gamekeeper’s gun burst at the Red House, Battersea, and a small part of the lock entered the middle of the left arm, and passed upward into the axilla, where it could not be traced by Mr. Keate, who saw him within an hour after the accident. The symptoms which followed were those of inflammation of the chest, and were subdued by active treatment; the wound healed, and he returned to his occupation in Wiltshire. Having exposed himself to the night air some weeks afterward, the inflammation of the chest returned, and he died. On opening the thorax, one edge of the bit of iron was found impacted in the surface of the lung, the other edge was rubbing against the inside of the sixth rib, which was nearly worn through by the constant friction it underwent during respiration; there was also a mark on the pericardium as of a cicatrix, and of a graze on the surface of the heart.

Among the French prisoners in Lisbon, in the spring of 1813, I saw a man in whose chest a ball had entered midway between the fifth and sixth ribs, and lodged; from this a constant and considerable discharge of purulent matter took place. The ball was found after death lying between the diaphragm and the spine, surrounded by coagulable lymph, and adhering by its envelope to the spine and diaphragm at the angle formed between them; there was a very thickened pleura costalis; the lung was shrunk and attached by membrane almost equally thickened across the chest, the lower part of which was filled in the upright position by the discharge, which was only evacuated in quantity when the opening of the wound was made dependent.

A case was met with after the battle of Waterloo, among the French wounded, which was somewhat similar. A portion of rib had been driven in, and the assistant-surgeon was aware that the ball could occasionally be felt. The man died at the end of a fortnight, the cavity containing a quantity of sero-purulent bloody matter. The lung had been injured by the ball, which had fallen loose into the cavity of the chest.

344. The removal of splinters of bone, or of other foreign bodies from the lung, has occupied the attention of surgeons from the earliest periods, and some of them proposed to draw a piece of cambric or other things through the chest, for the purpose of removing them. These extreme measures have been abandoned; but there can be no doubt of the propriety of removing as many of these causes of irritation as can be either seen or felt. If the ball have broken a rib, the orifice of entrance especially should be enlarged as early and as carefully as possible, so as to give an opportunity for the removal of the splinters and of all angular points of bone which may be turned inward. A little addition to the original opening can do no harm, and if the lung should not collapse, or should it be adherent, it will enable the surgeon to see whether any splinters are impacted in it, and to remove them. It is possible that the end of the finger even may be introduced, and the lung felt, if it should not have receded too far; as it is insensible to such an operation, no evil will ensue; but all probings with small, sharp-pointed instruments should be avoided. That wadding, buttons, pieces of cloth, and of bone have been frequently coughed up, I have had experience; but although it is said that even balls have been thus brought up, I have not had an opportunity of seeing them.

An officer was wounded by a musket-ball on the 9th of July, 1745; it passed through the chest, entering in front, fracturing the seventh rib near its junction with the cartilage attaching it to the sternum, and passing out behind near the angle of the same rib, which it again broke, together with the one immediately below it. M. Guerin enlarged the openings of entrance and of exit to the extent of nearly two inches, by dividing the pleura, the intercostal muscles, and the integuments from within outward. Several splinters of the rib injuring the lung were removed, the smallest of which might be half an inch or six lines long, by two wide. A tent was then passed through the wound. The patient suffered much, and spat a great deal of blood; pulse feeble, extremities cold. He was bled three times the first night, and twenty-six times during the first fifteen days, the seton being retained in the chest the whole time. On the twenty-second day, a piece of cloth was felt by the finger, after removing the seton, and was extracted; a splinter was also felt, but so deeply that it could not be removed without enlarging the incision. As the inflammatory symptoms were re-excited, he was bled for the twenty-ninth time. On the thirtieth day these symptoms had so much increased that the seton was withdrawn, under the impression that it was doing more harm than good, and the thirty-first bleeding was effected. The next morning the patient complained of something pricking him within, and the parts left between the two original wounds, after the incisions which had already been made, were divided. The chest was now open from the articulation of the head of the rib with the sixth and seventh vertebræ behind, nearly to the cartilage in front; and the whole course of the ball was seen; it had made a groove in the surface of the lung, in the substance of which a splinter was sticking. This was extracted, and the wound dressed simply, after which the patient gradually improved, and was quite cured in four months.

The two first incisions for the removal of the splinters were necessary. The tent or seton drawn through the chest was an error; and although the fortunate result of the case depended probably on the removal of the splinters of bone sticking in the lung, few would survive the formidable operation performed for their removal. The case is suggestive and instructive.

345. When the lung can be seen through the opening made by the ball, or after some moderate enlargement for the purpose of removing any splintered pieces of rib or any spiculæ which can be felt or seen, the object is attained. I have not had experience of the utility of large incisions for the purpose of making the lung more visible, although the importance of extracting foreign substances in the first instance is inculcated, provided their situation can be ascertained.

A Spanish soldier, wounded at the battle of Toulouse, was brought to me the same evening, shot through the right side of the chest, between the fifth and sixth ribs, one of which was fractured, the ball passing out nearly opposite behind. On removing the splinters by the aid of an incision, I found that the lung was adherent to the inside of the chest, and was enabled to withdraw from within the lung some splinters of bone and a part of his coat. He left Toulouse apparently doing well; but natives of warm climates rarely suffer from such severe attacks of inflammation as those of northern habits and constitutions.

A soldier of the German Legion was wounded at the battle of Waterloo, the 13th of June, 1815, by a musket-ball, which entered between the seventh and eighth ribs in front, about two inches from the sternum on the right side, passing out behind. He died in York Hospital, Chelsea, in the month of January following, where he was taken after some drunken fits, which induced an attack of pneumonia. A fistulous opening existed, and had discharged a little matter, which was gradually diminishing; the sinus was from six to seven inches long, extending into and nearly through the base of the lung, and was lined by a mucous membrane, the lung around being thickened to the extent of from a quarter to half an inch. There was but little fluid in the cavity, although the lung on both sides showed signs of recent inflammation, without which he would in all probability have recovered. The orifices of entrance and of exit through the lung adhered to the walls of the chest, thus separating the track of the ball from the general cavity of the pleura, which would in all probability have led to his ultimate recovery, if it had not been for his intemperance.

346. When a ball, or portion of bone, leather, cloth, wadding, or other foreign substance is driven into the cavity of the pleura, it usually gives rise to fatal results, constituting, therefore, cases of the greatest importance, to which attention has not been sufficiently given, but on which too much cannot be bestowed, if life is to be preserved by the art of surgery. The neglect of these cases has probably arisen from the insufficiency of the means of ascertaining their nature--an insufficiency which auscultation has in some measure removed, and which the science of surgery may still further diminish. The presence of a ball, a piece of bone, or of any other substance, lying upon or rolling about on the pleura covering the diaphragm, must give rise to more or less irritation and inflammation, and consequently to suppuration, or the formation of matter upon the surface of that membrane in its thickened state, until, in all probability, the foreign substance has been removed or the person has wasted away and perished.

A dragoon of the King’s German Legion was wounded between the eighth and ninth ribs at the battle of Salamanca. The ball had entered and lodged; the symptoms were severe; the breathing laborious. As the discharge from the wound was not free, I enlarged the opening, removed some scales of bone, a bit of cloth which stuck between the ribs, the lower of which was broken, and evacuated a great quantity of bloody-colored fluid, not purulent. After a few days the discharge became purulent, and, as he felt something, as he thought, roll within him, which he supposed might be the ball, I contemplated again enlarging the wound, so as to be able to see whether anything were loose in the cavity; but a sudden relapse of inflammation, from drinking some brandy, carried him off. On examination, the ball was found lying loose on the diaphragm in the chest, and might, with some enlargement of the wound, have been extracted.

A French prisoner of war, who had been wounded near Almaraz by a musket-ball, which had lodged in the left side of the chest, was sent to Lisbon in 1812, with a considerable discharge through the wound, and died there. The ball was found in the angle formed between the diaphragm and the spine, enveloped in coagulable lymph, by which it was attached to the spine; there were some splinters of bone inclosed with it.

A soldier of the 29th Regiment was wounded at Talavera by a musket-ball, which penetrated the right side of the chest, between the fourth and fifth ribs, and lodged. He died the day after, and on opening the body, I found that the ball had passed through the lung, and was lying loose on the ribs behind, near the union of the diaphragm with the spine.

Major-General Sir Robert Crawford was wounded at the foot of the smaller breach at the storming of Ciudad Rodrigo, by a musket-ball, which passed through the posterior fold of the armpit and entered the side of the chest in the axilla by a small opening or slit, apparently too small to allow a ball to pass through. I saw him a few minutes afterward with Dr. Robb, under whose care he remained, when, from the general anxiety manifested, I was satisfied as to the severity of the injury. The symptoms were not at first urgent, but their continuance and augmentation, in spite of the most rigorous antiphlogistic treatment, led, in a few days, to his death. On examination of the body, the ball was found lying on the diaphragm; the cavity of the chest contained a large quantity of very turbid serum; false membranes had formed on the lung, which was compressed toward the spine, and at the upper part retained the mark of an injury as from a ball which had not had force enough to penetrate and lodge.

Baron Larrey has had the good fortune to meet with some remarkable cases of this kind. In the first he did not see the man for some weeks after the wound had been inflicted, the ball entering at the upper edge of the fourth rib, about an inch from its junction with the cartilage. By means of a bent and flexible sound introduced through the wound, he distinguished a hard, metallic substance at the bottom of the cavity of the chest, which he supposed to be the ball, nearly in the situation of the place where the operation for empyema is usually performed. This operation having been done, about twelve ounces of pus escaped, and the ball was discovered rather flattened. It was easily removed with the aid of a pair of polypus forceps. After this there was every prospect of recovery, until the patient, having unfortunately one day drank too much brandy, was attacked by enteritis, and died.

William Barrett, of the Life Guards, a middle aged, muscular man, of full habit, was wounded by a musket-ball at the battle of Waterloo; it fractured the third and fourth ribs behind on the left side, and broke the left arm. He was brought to Brussels, where the inflammatory symptoms were subdued by repeated general and local bleedings, and the other ordinary but strictly antiphlogistic means, during the first six weeks, by which time the external wound had nearly closed, and no trace of the ball could be perceived. At the end of this time, Staff-Surgeon Collier, now Inspector-General of Hospitals, under whose care he was, and who furnished me with these particulars of the case, which I saw in Brussels, finding that his symptoms became worse, that he had rigors and evening exacerbations, and that the difficulty of breathing had increased almost to suffocation, decided on opening into the cavity of the chest and following the course of the ball. This he did by a deep incision, which enabled him to remove some pieces of the ribs, which were denuded but not detached. A bag-like protrusion was then felt between the ribs near their angles, which was opened, and nearly two pints of thick, fetid pus escaped, the relief which followed being as complete as sudden. The wound was dressed from the bottom, and every means adopted, except introducing a tent, to prevent its closing, but in vain; the opening closed, and matter again collected, requiring a second incision for its removal. Between these two operations small bleedings were resorted to most beneficially. A short gum-elastic catheter was introduced into the cavity of the chest after the second incision; very little matter, however, was secreted. From this time he gradually recovered, and was sent to England, cured, in November.

347. The presence of a ball, rolling about on the diaphragm, can now be ascertained by means of the stethoscope at an early period, so as to admit of an operation being undertaken with confidence for its removal; while the knowledge acquired by auscultation or percussion, of the filling of the chest by fluid, whether serous, bloody, or purulent, is at the same time incontestibly demonstrated. The presence of a ball, or of any other foreign body, decides the question as to the place where the opening into the chest should be made. On this point the information derived from the practice of the French surgeons in Algeria is valuable.

M. Baudens, whose labors I again refer to with great pleasure, says that he has also seen splinters of bone and even a ball, surrounded by a cyst formed by the pseudo-membranes of inflammation, cut off from the general cavity, and confined in the angular space formed behind between the rib, the diaphragm, and the spine. In one case, M. Baudens introduced a _sonde à dard_, such as is used in the high operation for the stone, between the second and third ribs, and made it project behind between the eleventh and twelfth. He then cut down upon it, and extracted a ball and some splinters of the rib. The wound thus made was then closed, the upper one being sucked dry daily by a pump. The patient recovered in forty days.

A., 54th Regiment, was brought to the hospital at Algiers, on the 22d of October, 1833, wounded eleven days before by a ball, which, having broken the right clavicles was lost in the chest, without any sign of effusion having taken place; he appeared to be going on well, until suddenly he complained of pain about the middle of the sixth rib, which could not be removed by the means employed, and was accompanied by a great discharge from the wound. On the 10th of November he died. The clavicle and the first rib had been fractured, and an abscess had formed behind them, the size of a hen’s egg, containing several splinters of bone, which had stuck in and afterward separated from the lung. The ball had passed from above downward and outward, forming a sinus, which terminated at the middle of the sixth rib, to which this part of the lung was attached; the posterior three-fourths of this canal were closed; the anterior fourth contained two splinters of bone, one of which was about to fall into the abscess in front. The sixth rib was broken, although it had not been perceived during life; and a small digital cavity was formed at this part in it by the ball, surrounded by portions of lymph, floating loosely from its edges; from this the ball had been detached, and had given rise to the inflammation which destroyed him. The ball had fallen on the diaphragm, where it was lying loose, surrounded by a quantity of purulent matter.

M. Baudens says himself, and rightly, that the operation of opening into the chest should have been performed in the eleventh intercostal space, and that the wound in front should have been enlarged.

M. Baudens relates another case, in which the posterior wound, situated near the angle of the tenth rib, had healed, the anterior one, half an inch below the clavicle, giving issue to an abundant and weakening suppuration. The lung above this was permeable to air, but the respiratory murmur could not be heard below it. To draw off this offensive fluid, he adapted an empty caoutchouc bag to a gum-elastic canula, which he affixed against the orifice of the wound, and thus sucked out six pints in five days. Some days later the wound behind reopened, and a piece of bone was discharged from it, which saved the man’s life. Two years afterward he was seen in good health.

The desire to have as dependent an opening in the chest as possible in these injuries has been manifested by all surgeons of experience; and the interspaces between the ninth and tenth, and between the tenth and eleventh ribs, have been often selected for this purpose; but as the operation was formerly done with the trocar, the abdomen was as often opened as the thorax, and death was frequently thus caused, even if it would not have been occasioned by the disease. To prevent, or to avoid this evil, M. Baudens advises its being performed at three fingers’ distance from the spine, by incision, and he says he has frequently done it with success, although he does not give any circumstantial directions as to the operative method to be pursued. I therefore caused several experiments and dissections to be made in the workroom of the College of Surgeons by Mr. Quekett, with the following results:--

348.--1. That a trocar and canula pushed in between the eleventh and twelfth ribs, in a diagonal direction upward, on a line with the angle of the ribs generally, will in the _dead body_ invariably enter the cavity of the chest without injuring the diaphragm.

2. That the same operation performed on the _living body_ would, in all probability, if done at the moment of expiration, first enter the thorax, then pierce the diaphragm, and thus open into the cavity of the abdomen,--a difference in result to be explained by reference to the anatomy and physiology of the parts concerned; showing that this operation, when required on man, should always be done cautiously by incision, and not by puncture with the trocar and canula.

On examining the lower part of the chest from within, after removing the pleura, the diaphragm is seen forming the boundary between the thorax and the abdomen, commencing from the transverse process of the first lumbar vertebra, and forming an arch under which the upper part of the psoas muscle passes, (the ligamentum arcuatum proprium.) From this part extends another aponeurotic arch along the lower border, to the end of the last rib, called the _false ligamentum arcuatum_, (ligament cintré du diaphragme of Cruveilhier,) which is nothing more than the upper edge of the anterior layer of the aponeurosis of the transversalis muscle, folded upon itself in all its extent. The diaphragm is afterward attached to the lower border of the twelfth, and in succession to the eleventh, tenth, ninth, eighth, seventh, and sometimes to the sixth, ribs, counting from below upward. The external intercostal muscles are distinctly seen between the ribs, extending from the spine until they meet and are concealed by the fibers of the internal intercostal muscles, near the angles of the ribs. The vessels and nerves, after passing on the external intercostal muscles, subsequently run between them and the internal ones.

The lower intercostal arteries arise from the aorta on each side, and before they enter the space between the ribs give off a branch passing backward to the vertebral canal and the posterior muscles of the spine. The eleventh and twelfth intercostal arteries, covered at first by the pillar of the diaphragm, ascend on leaving the vertebræ to reach the under edges of the ribs, and are accompanied by a vein and nerve. The tenth intercostal artery, and those immediately above it, run almost horizontally, and nearly in the mid-spaces of the ribs, as far as their angles, at which part a small artery is commonly given off, which descends from the main trunk at an acute angle to the rib below, and may be injured in opening into the chest, and be perhaps mistaken, in operating, for the intercostal artery itself. From the angles each artery runs in a groove in the under edge of the rib as far as the anterior third, when they all become very much diminished in size, and, leaving the grooves, run in the middle of the intercostal spaces, until lost in their different anastomoses with the branches of the epigastric, phrenic, lumbar, and circumflexa ilii arteries.

In making an opening into the chest between the tenth and eleventh, or between the eleventh and twelfth ribs, the artery will not be injured, provided the opening be made below the middle of the intercostal space, which is wider between the eleventh and twelve ribs than between those above it. The vein is situated above the artery, and proceeds to the vena azygos major on the right, and to the smaller azygos vein on the left side.

The intercostal nerves are the anterior branches of the dorsal nerves, and lie below the arteries under the pleura upon the external intercostal muscles, until they approach the angles of the ribs, where they enter between the layers of the intercostal muscles.

It is worthy of observation that the pleura is necessarily continued over the inside of the twelfth rib to line the different attachments of the diaphragm, and that an incision may always be made into the chest above this point, if done carefully.

On removing the integuments of the back, covering the muscles and the lower ribs, the broad expanse of the _latissimus dorsi_ muscle is brought into view, extending from the ilium and spine upward and outward, and covering all the parts of importance beneath in the operation to be described. On the removal of the lower part of this muscle the _serratus posticus inferior_ is seen, of a somewhat quadrilateral form, arising by a thin aponeurosis common to it and to the latissimus dorsi, from the spinous processes of the three superior lumbar vertebræ and the two inferior dorsal, and proceeding upward and outward to be inserted by four flat, tendinous digitations into the four lower ribs.

If this muscle be separated from its origins and turned outward, or divided in the middle, and its two portions reflected, the posterior spinal or long muscles running in and filling up the groove or hollow of the side of the spine will now be distinctly seen, composed chiefly of the sacro-lumbalis and the longissimus dorsi muscles, sometimes called as a whole the _erector spinæ_ or the _sacro-spinal_ muscle. This, which forms a thick mass over the beginning of the tenth, eleventh, and twelfth ribs, is not to be divided or interfered with beyond a very few at most of its external fibers; the opening into the chest about to be made should begin at its external edge and go through the external intercostal muscle, which is now exposed on a plane below it.

The eleventh and twelfth ribs, unlike all those which precede them, except the first, have only one surface of articulation with the corresponding vertebræ, to which they are attached, instead of two facettes articulating--one with the body of the vertebra above, the other with that below. They form, particularly the twelfth, a more acute angle with the spine than the other, which gives to them their greater degree of obliquity, while the freedom of their cartilaginous extremities enables the twelfth, particularly, to be depressed or separated by a moderate force from the rib above to a greater extent than at any other part, by which means a foreign body of larger size may be removed from between them more readily than elsewhere.

349. _Operation._--The eleventh and twelfth ribs having been distinctly traced, and the obliquity of their descent from the spine having been clearly made out, the patient ought, if possible, to be placed on a stool, with the upper part of the chest supported by a pillow on a table before him. An incision should then be made over the intercostal space between these ribs, three inches long and slightly curved, through the integuments down to the latissimus dorsi muscle, and as the mass of long spinal muscles is usually three inches in width, and can in general be seen, the incision should commence two inches from but between the spinous processes of the eleventh and twelfth vertebræ, and be continued obliquely or diagonally downward in the course of the interspace between these ribs. The latissimus dorsi and the serratus posticus inferior muscles having been divided at the upper part where they cover the longissimus dorsi or the long spinal muscular mass alluded to, its edge becomes apparent; from this point the latissimus and the serratus are to be further divided downward. The external intercostal muscle being thus exposed, its fibers should be scratched through or separated in the middle of the interspace between the ribs, which can now be seen as well as felt. A director should be introduced below the muscle, on which it may be carefully cut through, as well as any fibers of the internal intercostal muscle which may extend as far as the wound thus made. The pleura will then be exposed, and if the cavity of the chest contain fluid in any quantity, it can scarcely fail to project in such a manner as to convey to the finger the assurance of its being beneath. An opening may then be carefully made into it at the upper part of the incision close to the external vertical fibers of the spinal mass of muscles, _at the moment of inspiration_, and on the existence of fluid being ascertained by its discharge, the opening should be enlarged by a director previously introduced under the pleura, the patient being desired to draw a full breath at the time, in order that the diaphragm may descend as low as possible. If there should not be any fluid in the chest, the diaphragm, in ascending during expiration, may be applied to the inside of the pleura lining the chest as high even as the fifth rib, counting from above, and might easily be divided with the pleura, if great care were not taken to make the opening during the process of inspiration.

In all cases of wounds of the chest, in which auscultation points out the presence of a ball rolling loose on the diaphragm, this operation should be performed for its removal, and may save the life of the sufferer. It would, perhaps, have done so in the case of Sir Robert Crawford. At a later period the presence of a foreign body, perhaps, can only be known by the sounds or defect of sounds which may be observed at the back part of the chest, in which the ball or other foreign bodies lodge or become enveloped by matters confining them in that situation.

LECTURE XXV.

HERNIA OF THE LUNG, ETC.

350. _Hernia of the lung_, as a consequence of a wound in the chest which has healed, is a complaint of rare occurrence. It appears to take place when the intercostal muscles have been much injured and are deficient, the opening through them being merely covered by the common integuments which have yielded to the pressure exerted from within. It has been supposed that it might be mistaken for the thinning of parts from the formation of matter within, or empyema. The early occurrence of the abscess after the receipt of the injury forbids the supposition, while the ear, applied to the protruded part which is most prominent during EXPIRATION or coughing, perceives not only a crepitation, felt equally by the touch, but the natural respiratory murmur stronger, softer, but less vailed and more like the sound given out by a pulmonary lobule inflated close to the ear, but without enlargement of the part.

A portion of lung will sometimes protrude during the efforts made by the sufferer to breathe, particularly in expiration, when the wound is left open and the lung is sufficiently free to admit of it. When protruded, it sometimes happens that the efforts of nature are not sufficient for its retraction, and it remains filling up the opening into the thorax. A large portion of lung is rarely protruded, except through an opening which readily admits of its return; but when the wound is small, the return of a portion of protruded lung, when it is not positively strangulated, should not be interfered with. The surface of the lung is but little sensible; touching it causes no apparent pain, and its adhesion to the edges of the cut pleura is more advantageous than its separation from it. It should, therefore, be allowed to remain or be only so far returned, if it can be so managed, as to rest within the edges of the divided pleura and fill up the gap made by the incision, over which the integuments should be accurately drawn and retained. The adhesion of the lung to the pleura costalis arrests the inflammation, and may prevent its progress to other parts of the cavity. That the inflammation may extend farther into the substance of the lung, is possible, but when the sufferers are otherwise healthy, the chance of evil from pneumonia is less than from inflammation of the general cavity. Whenever the protruded lung has been completely returned, more inflammation has followed than where it has been allowed to remain under the precautions recommended. Three cases were brought under my notice at Brussels, after the battle of Waterloo, which were not interfered with, greatly to the advantage of the patients. It is rare, however, to see a protrusion of the lung after a gunshot wound.

The protruded lung, when left uncovered and unprotected, soon loses its natural brilliancy, dies quickly, shrinks, and becomes livid, without being gangrenous. In such cases the protruded part may be removed, but it should never be separated at its base from its attachment to the pleura costalis by which it is surrounded.

351. _Wounds of the diaphragm_ were known to the older surgeons from the time of Paré; they were aware that these wounds were not immediately, although generally, mortal. They knew that the viscera of the abdomen did sometimes pass through such wounds into the cavity of the chest, but they did not know that a wound of the diaphragm never closes, except under rare and particular circumstances; that it remains an opening during the rest of the life of the sufferer, ready at all times to give rise to a hernia which may become strangulated and destroy the patient, unless relieved by an operation as yet unperformed, but to which attention is especially directed--a fact first pointed out by me early in the war in the Peninsula.

A soldier of the 29th Regiment was wounded at the battle of Talavera, and died in four days after the receipt of the ball, which went through the chest into the liver. I found, on examining the body, an opening in the central part of the diaphragm of an oval shape, the edges smoothing off as if they were inclined to become round; this opening was nearly two inches long, evidently ready to allow either the stomach or the intestines to pass through it on any exertion.

Captain Prevost, aid-de-camp to Sir E. Packenham, was wounded by a musket-ball, on the 27th September, 1811, on the heights of Saca Parte. It penetrated the chest from behind, splintering the ninth and tenth ribs of the left side, and made its exit a little below and to the right of the xiphoid cartilage. A good deal of blood was lost from the posterior wound, but he did not spit up any. He was carried to Alfaiates, and there he threw up a small quantity of bloody matter by vomiting. The posterior wound was enlarged and continued to discharge some blood, the intercostal artery being in all probability wounded. Sixteen ounces of blood were taken from the arm, giving great relief, and the bowels were opened by the sulphate of magnesia.

Sept. 29th.--Bleeding to eighteen ounces; on the 30th he was bled again to thirty-two ounces, from which great relief was obtained; he fainted, however, on making a trifling exertion to relieve his bowels.

Oct. 1st.--Accession of symptoms as yesterday, relieved by bleeding in a similar manner; bowels open.

3d.--The inflammatory symptoms recurred this morning, and were again removed by the abstraction of sixteen ounces of blood. Beef-tea.

5th.--Passed a sleepless night, and was evidently suffering from considerable internal mischief; wandered occasionally; pulse quick, 120, and small; felt very weak and desponding. A little light, red wine given, with beef-tea and bread; opium night and morning.

6th and 7th.--Much the same; pulse always quick, with much general irritability.

15th.--The wounds discharged considerably, particularly the posterior one; has a little cough; pulse continues very quick; spasms of the diaphragm troubled him for the first time, and caused great pain and uneasiness; they were relieved by opium in large and repeated doses.

On the 18th the spasmodic affection of the diaphragm and the pain returned with great violence, so as to threaten his dissolution, which took place on the 20th.

On examination, I found that the ball had passed through the under part of the inferior lobe of the left lung, and through the pericardium under the heart, through the tendinous part of the diaphragm, and into the liver, before it made its exit. The wound in the lung was suppurating; the matter and fluid from the cavity of the chest had a free discharge by the shot-hole; the edges of the wound in the diaphragm were smooth as if cicatrized, leaving between them an elliptical opening an inch long. The injury to the liver was through the substance of the anterior part of its right lobe; the matter having a free discharge, and generally slightly yellow, as if tinged with bile in small quantity. The skin did not show a yellowish tinge, neither were the conjunctivæ discolored.

A soldier of the 23d Regiment was wounded at the same affair, by a musket-ball, on the right side; it fractured the sixth rib, from three to four inches from the sternum, and passed out behind, between the ninth and tenth ribs, near the spine. The rib being fractured, the splinters were removed after an enlargement of the wound by incision, when the opening into the cavity of the chest was manifest, air being discharged freely from it. The shock in the first instance was great; but after a time reaction took place, and he lost a considerable quantity of blood in six bleedings during the first sixty hours. The discharge, at first serous and bloody, gradually became purulent, and the occurrence of jaundice showed that the diaphragm and liver had in all probability been injured. Under the administration of calomel, antimony, and opium, this symptom was gradually disappearing, when I left him to rejoin the army. He was sent to the rear at the end of ten weeks nearly well.

On the day preceding the battle of Fuentes d’Onor, in 1811, Sergeant Barry was wounded in the chest. The ball entered close to the nipple of the left breast, and passed out at the back, between the eighth and ninth ribs. The anterior opening of the wound soon healed, but the posterior one did not do so for a considerable period, when he became affected by such severe cough, with expectoration, that his medical attendant deemed it proper to reopen it. The symptoms were relieved, and portions of his shirt and jacket were discharged. After this his health improved so rapidly as to enable him soon to rejoin his corps. The wound in the back repeatedly opened and healed--generally at intervals of twelve or fourteen months; but for five or six years it ceased to do so. His appetite was small and delicate; flatulence was much complained of; and if the stomach at any time happened to be overloaded, vomiting occurred. He died of mortification of the left leg, January 4th, 1833.

On examination, the whole of the stomach and the greater part of the transverse arch of the colon were found in the left cavity of the chest, having passed through an opening in the diaphragm extending about three inches in a transverse direction, near the center of the dorsal attachments of that muscle. The peritoneum lining the diaphragm was firmly attached to the parts passing through it.