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

In a simple case of this kind little or nothing is effused into the cavity or secreted from the membranes of the chest, which will interfere with the processes which may have happily begun, and which it is desirable should be aided by the absolute quiescence of the patient, to whom no medicine should be given which may render any movement of the body necessary. It was formerly supposed that the greatest object to be attained was the prevention of inflammation, and a man was no sooner stabbed by his opponent than he was blooded and purged by his surgeon, regardless of the necessity which existed for perfect rest and the presence of a certain amount of inflammation, in order to enable nature to carry on those processes which are essential for the restoration of the injured parts. This inflammation should be allowed to commence without interference and to continue in a moderate degree until the object shall have been effected. It should only be interrupted or subdued when it is supposed to be about to exceed that degree which experience has pointed out as likely to be useful.

328. When the most courageous persons are wounded in parts essential to life, there is more or less alarm or shock created by the injury; although it has been gravely argued that a man does not always know when he is actually shot or run through the body. A continued state of anxiety and depression after an accident of this kind is a disagreeable accompaniment of the injury, during which little should be done beyond the giving a little cordial, and quieting the apprehensions of the patient, leaving him to rest, if possible, after the necessary applications have been made. If a gradual improvement take place, if the pulse rise, if the patient resume more of his natural appearance, and that state of commencing excitement which is denominated reaction follow, hope may then be entertained. The general symptoms, as long as they continue within ordinary bounds, are of little importance; the local ones, significative of action commencing in the injured part, are, however, to be carefully watched. They are those of inflammation of the pleura, and it may be of the lung. This inflammation begins slowly, and a day may elapse before it is well marked; for, when persons have died within the first few hours after such injuries, the pleura has often shown but little sign of inflammatory action. Auscultation should always be resorted to from the moment of injury, and constantly used throughout the treatment. Whenever it is concluded that adhesion between the two pleuræ has failed to take place, the direction to lie on the wounded side ceases to be of importance. Until this period no food whatever should be allowed, and thirst should be allayed by small quantities of water.

329. A punctured, incised, or gunshot wound, going fairly through both cavities of the chest, is usually believed to be quickly if not immediately mortal—an opinion generally correct with respect to wounds made by musket-balls, although it is certainly not the case with regard to punctured wounds, and does not always occur in those made by pistol or musket-balls.

Sergeant-Major Richards, of the 29th Regiment, received thirteen sword or bayonet wounds, and other injuries, on the heights of Roliça, on the 17th August, 1808—one particularly through each side of the chest, between the ribs, as if the small-sword had made a wound of larger size than usual. He had distinguished himself greatly in covering the body of his commanding officer, and was beaten down before the British column, which had been repulsed, could rally and recover its ground. He was an object of particular attention to me, for the few minutes he lived after I saw him; he had coughed up a little blood, and died gasping, as if suffocated, the chest laboring on each side to do its work in vain. His commanding officer, Colonel the Hon. George Lake, lay dead by his side, killed instantaneously by a musket-ball, which passed from the upper part of the left through the right side of the chest.

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.