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

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.