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

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.