Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

319. In all cases of serous effusion, there can be little doubt that the fluid should be wholly evacuated and the wound closed. When the fluid is purulent, a permanent drain should be early established. It is not, however, common for the operation to be repeated several times without the serous discharge becoming purulent; and, in such cases, it usually becomes necessary at last to allow the wound to remain open until the discharge shall cease of itself. Whenever more than one opening is necessary, and the first is made between the fifth and sixth ribs, the succeeding ones should be made lower down; so that when it is thought right to leave the last puncture to become fistulous, it may be made as near the diaphragm as may be thought consistent with the safety of that part.

When a doubt exists as to the probability of more than one puncture being sufficient, and it seems likely that a third, or even more, will be required, the surgeon may anticipate this necessity by introducing a piece of soft gum-elastic catheter through the canula into the chest to the extent of about three inches, enough being left outside to admit of its being secured by tapes and adhesive plaster; through this a certain quantity of the fluid may be drawn off daily until it ceases to be discharged. The elastic tube bends with the heat, and applies itself to the inside of the ribs. If the lung should rub against it, which can be ascertained by a blunt probe, the elastic tube should be removed, and the external wound kept open by a softer plug. In all these operations, care should be taken to prevent the occurrence of inflammation. The accession of pain in the part, of difficulty of breathing, of fever, should be met by the abstraction of a few ounces of blood by cupping, by dry-cupping, by mercury in small doses, by rest, by diet, etc., and, if a tube have been introduced, by its removal.

The propriety of injecting stimulating or even simple fluids into the cavity of the chest has been often advocated, and as frequently repudiated. Warm water or milk and water is certainly admissible, and has been found very useful, particularly when there is an adventitious cause keeping up the irritation, which may possibly be brought to the opening by the sudden abstraction of the injection. Pieces of cloth and bits of exfoliated bone have been floated out by throwing in an injection of tepid milk and water. The opening, in a case of this kind, should be made between the eleventh and twelfth ribs behind.

Dr. Wendelstadt, of Hersfield, in the year 1810, in the twenty-third year of his age, suffered an attack of pleurisy, which became chronic, and ended in effusion. After severe suffering for six months, he was able to attend to his professional duties. The ribs of the right side protruded, but the intercostal spaces did not; the whole side was motionless on respiration taking place. The circumference of the chest continued to increase, and fluctuation within became evident on succussion. In June, 1819, having undergone another attack of pleurisy, he submitted to the operation for empyema, as offering some hope of preserving life. When a pint of fluid had been discharged, the wound was closed, and he experienced great relief. The next day a third of a quart was taken away twice in the day, and on the third day as much more; but he thought this was too much, as he became greatly exhausted, and feared that suffocation was impending. He was recovered by stimulants. On the fourth day the fluid was thicker in consistence, and fetid, and continued more or less so for a fortnight. It was then allowed to flow as it would at each dressing. Astringent injections were used for six weeks, but were then abandoned, and he gradually recovered his strength. Thirteen years afterward, in 1830, the wound was still open, discharging twice a day, sometimes only half a drachm, sometimes three or four ounces daily. The right side had altogether shrunk, and did not move on inspiration; he had no cough, and was otherwise in good health; a piece of a rib became loose, and was removed at the end of thirteen years, when the report of the case terminated, the patient being in health.

It may be remarked on this case, that the admission of air did no harm; that the lung remained compressed; that the whole side thickened and flattened, as a consequence, so as to obliterate the cavity; but the cure would not have been effected even then, if the piece of carious rib had not been discovered and removed.

Mr. Winter, secretary to Admiral Sir C. Napier, was wounded by two musket-balls, one in the arm, while the other entered between the inferior edge of the left scapula and the thorax, which it penetrated, fracturing a rib in its progress, and lodged. He fell, and spat up some blood, and as symptoms of inflammation supervened in twenty-four hours, he was bled largely; this was repeated frequently until these symptoms were subdued. He was after a time sent to the Marine Hospital, Lisbon, in a miserable plight, suffering from hectic fever, with a flushed face, hot skin, glassy eye, great prostration of strength, cough, restlessness, dyspnœa, and copious night-sweats. The wound discharged a watery, sanious, fetid matter in quantity, and he was unable to do anything but eat, and for food he had a great craving. From this state, under good treatment, he gradually recovered his strength, and on the 18th of June, 1834, a piece of the rib was removed. The wound remained open with a great purulent discharge, which kept him in a reduced state; a little more than one year after the injury, he reached London, and was taken into the Westminster Hospital. The left side of the chest was flattened and contracted, and the lung was doing very little in the respiratory way; the wound discharging a quantity of matter, which he could readily evacuate by making the opening the dependent point, but not otherwise. On enlarging the external wound, so as to make the opening into the chest direct, I found a round-pointed gum-elastic bougie could pass into it for four inches, and, on bending it down, for six inches more, it having to pass over a thickened pleura, and false membrane of an almost cartilaginous nature, for the extent of an inch, before it could be felt to be in a large cavity. As it did not appear that he had any chance of recovery, unless another opening were made lower than the sixth rib, in a more dependent position, I proposed the operation, but he would not submit; and after a time he left the hospital and went into the country, where he died.

A non-commissioned officer, of the 2d Division of cavalry, was wounded at the battle of Albuhera, on the 10th of July, 1811, in several places, by the lances of the Polish cavalry; one of these penetrated the left side of the chest behind, immediately below and in front of the inferior angle of the scapula. He spat and coughed up blood, and lost so much from the wound that he became insensible, the bleeding having been stopped by a part of his shirt being bound upon it tightly by means of his woolen sash. Brought to the village of Valverde, my attention was drawn to him some days afterward, in consequence of the difficulty of breathing having increased so that he was obliged to be raised nearly to an upright position, as well as from his inability to rest on the part wounded, round which a dark-blue inflammatory swelling had taken place, the wound having closed. An incision being made into it, a quantity of bloody purulent matter and clots of blood flowed from it. The incision was then enlarged, so as to allow of a direct opening into the cavity of the chest, which was kept open. The relief was immediate. He was removed to Elvas, apparently doing well, some three weeks afterward.

This case offered the nearest approach I have seen to the ecchymosed edema described by Valentin as accompanying effusions of blood into the cavity of the chest; and, as well as the following, is an instance of operations, not by election, but by necessity.

A French soldier had been wounded at Almaraz by a musket-ball, which went through the right side of the chest, in a line nearly horizontal from a little below and to the outside of the nipple, backward. The first symptoms having subsided, he gradually descended the Tagus to Lisbon, where, after some months of continual discharge, the wounds closed, first the back, and then the front. He did not recover his strength, always looking sickly, and suffering from pain, difficulty of breathing, and other inconveniences, which did not prevent his walking about in the confined space to which he was doomed as a prisoner of war. My attention was drawn to him in consequence of an obvious fullness of the intercostal spaces, of the great difficulty of breathing, and of a puffy inflammatory swelling which was forming around and at the seat of the wound in front. Through this I made an incision into the cavity of the chest, the walls of which, on introducing the finger through the opening, appeared to be very much thicker than usual. A large quantity of pus was discharged, and the man was relieved, but this amelioration was not of long continuance, and he gradually sank and died. On opening the body, the inside of the wall of the chest was found to be half an inch in thickness, in consequence of a firm deposition on the pleura, of a yellowish-ash color, honey-combed or ulcerated, as it were, in plates, particularly where the opening had been made. The lung was shrunk up from the anterior and lower part of the chest, but adhered to the wounded part behind, and was covered by a layer of false membrane of considerable thickness. The wound through the lung could not be distinctly traced, from its being diseased throughout.

At Santander, in October of the same year, 1813, I received some eight hundred wounded in the affairs of Le Saca, Vera, etc. One of the Light Division had been shot through the left side of the chest: the posterior wound had closed, but a sufficiently large quantity of matter was discharged through a small anterior one to show that there must be some depot from which it proceeded. The wound was laid open into the cavity of the chest, and free vent given to a quantity of matter. Some small pieces of rib were discharged, and a bit of something like the cloth of his coat also came away. He could lie on either side, and hopes were entertained of his recovery, until after I left Santander in December, to join the army in France, when he suffered a relapse of inflammation, and died.