338. When a ball impinges with force on the center of one of the ribs, and passes into or through the chest, the bone is usually broken into several splinters of different lengths, some of which frequently accompany the ball in the commencement of its course, or are even carried into the substance of the lung, together with a part of the wadding of the gun, or of the clothes of the patient. These should if possible be extracted if they can be seen, and the sharp ends of the rib rounded off. When the ball fractures a rib on passing out of the chest, the splinters are driven outwardly, and should be removed by incision.
339. When a ball strikes a cartilage of one of the ribs, it does not punch out a piece as it were, but merely divides and passes through it, bending it inward, rarely tearing away a portion. The parts of the cartilage thus bent and turned inward are to be drawn outward, and replaced by the end of the finger, a bent probe, or other curved instrument.
A ball, when striking obliquely but with force on the chest, will frequently penetrate, and then run round, between the lung and the pleura lining the wall of the chest, for a considerable distance, before it makes its exit. In this case the lung may be only slightly bruised, without the pleura pulmonalis or costalis being more than ruffled. In others the lung shows a distinct track or hollow made by the ball. A shade deeper, and the ball penetrates, and forms not a hollow, but a canal. The patient in all these cases spits blood, and the first symptoms are severe; they frequently, however, subside, and are not always followed, under proper treatment, by effusion, although it may always be expected.
340. When a ball fairly passes through the lung, it leaves a track more or less bruised, which continues for a time to bleed according to the size of the vessels which are injured, thus making a wound more dangerous as it approaches the root of the lung where the vessels are largest. More or less blood is spit up, or, if effused, it gravitates in the chest, until it rests on the diaphragm or other most depending part, according to the position of the patient. If it should be in quantity, the filling up of the chest may be ascertained by auscultation, if the wound be closed. As the quantity of effused blood increases, the lung becomes more and more compressed, until at last the hemorrhage ceases under pressure, if the wound be covered; and the patient is saved for the moment, unless he should die of asphyxia, from the lung on the other side being also compressed through the bulging of the mediastinum on it; to prevent which, if possible, the wound should be reopened or enlarged, so as to take off the pressure of the effused and perhaps coagulated blood. If the person wounded shall have suffered formerly from inflammation, and the lung has adhered in consequence to the wall of the thorax, at the parts where the ball enters and goes out, the cavity of the chest will not be opened, and the track only of the ball will communicate with the external parts, unless the ball shall have perforated some of the large vessels, when he will continue to bleed by the mouth. The pressure of the blood effused into the track of the ball, which may become coagulated, will sometimes suffice, under even these circumstances, to effect the suppression of the hemorrhage which the loss of blood, the faintness of the patient, and the weakness of the circulation, under proper treatment, will materially assist in rendering permanent.
General Sir G. Lowry Cole, G.C.B., was struck at the battle of Salamanca, on the 22d of July, 1812, by a musket-ball, which entered immediately below the clavicle, fractured the first rib, and, inclining inward, came out through the scapula behind; as he spat blood for three days, the upper part of the lung was shown to have been injured. The ball appeared to have passed so close to the under part of the subclavian artery that the greatest fears were entertained for his safety; more particularly as a marked difference in the size of the pulse was perceived in the left arm, which did not exist before. He remained three days on the field of battle, in a Portuguese officer’s tent I always carried with me. Under repeated bleedings, and the strictest antiphlogistic treatment, several splinters having come away, and a large piece of the rib and of the scapula having exfoliated, he gradually recovered, so as to be able to resume the command of the Fourth Division in October at Madrid. The subclavian artery never resumed its power, and the radial always beat less forcibly on the left side. He perfectly recovered his health, the respiratory murmur of the lung being natural. He died suddenly in 1844, from rupture, I believe, of an aneurism of the abdominal aorta.
A dragoon of the King’s German Legion, shot in a nearly similar manner on the same occasion, suffered more severely: the clavicle and first rib were splintered to a greater extent, and he lost a large quantity of blood by the mouth. The splinters having been removed, after enlarging both wounds for that purpose, and the inflammatory symptoms subdued, he appeared to be going on favorably for three weeks; when, having eaten some meat obtained irregularly, he suffered what seemed to be a bilious attack of vomiting and purging, attended by fever and oppression in the chest; an ipecacuanha emetic having been given with full effect, relieved him much. During the efforts to vomit, the wounds discharged a quantity of sero-purulent fluid, a piece of the cloth of his coat, and another of bone, which had gone in with the ball, and in all likelihood had been lying with the matter at the bottom of the chest. After this he slowly recovered. This case is peculiarly instructive.
General Sir Andrew Barnard, G.C.B., was wounded when in command of the Rifle Brigade, at the passage of the Nivelle, on the 10th November, 1813, by a musket-ball, which entered between the second and third ribs, in front of the right side of the chest, passed directly through the cavity and through the shoulder-blade, from under the integuments covering which it was removed. He not only felt but heard the sound of the ball as it struck him, and he fell from his horse. Blood gushed from his mouth, and continued to do so until after he was completely exhausted by bleeding from the arm to the amount of two quarts. He was again bled at night, and the subsequent morning, which relieved all the material symptoms. During six weeks he suffered from difficulty of breathing and cough, and from night-sweats. Some pieces of bone and cloth came away from the wounds, with a free discharge in the first instance, which gradually diminished until the wound closed. In eight weeks he was able to resume his command.
More than forty years afterward I found the lung pervious; the vesicular murmur could be freely heard even up to the situation of the wounds, to the internal parts of which it may be concluded the lung adhered, from the sound conveyed to the ear on auscultation. He suffered little or no subsequent inconvenience from the injury, and died in January, 1855, aged 82.
Case of Major-General Broke, by himself.—Toward the close of the battle of Orthez, on the 27th of February, 1814, a musket-shot struck me between the second and third ribs on the right side, near the breast-bone. I was then on horseback, being aid-de-camp to Lieutenant-General Sir Henry Clinton, commanding the Sixth Division. The sensation was precisely as if I had been struck a violent blow with the point of a cane, but it did not unhorse me. I was attended in a very short time by the surgeon of the 61st Regiment, when, on removing my clothes, the air and blood bubbled out from the wound as I drew my breath. The surgeon, turning me on my face, discovered the ball to be lodged under the thin part of the blade-bone. This he cut through and extracted the ball, and with it pieces of my coat, waistcoat, and shirt, which were lodged between the ribs and the blade-bone. This occurred about four P.M. I was then removed to the town of Orthez, a distance of about three miles, and in the course of the afternoon the veins of both arms were opened in at least seven different places, but scarcely any blood came away; breathing became exceedingly painful in a day or two, and I felt nearly suffocated, when, in the evening, my brother, Sir Charles Broke Vere, arrived with my friend, Mr. Guthrie, who examined me carefully. The agony of drawing breath was such that I could scarcely endure it. He opened one of the temporal arteries, and desired that it might be allowed to bleed without interruption. He afterward left me to visit some other wounded men, and returned in about three hours, when I told him that I felt relieved, and had much less of the suffocating pain in breathing. He then opened the other temporal artery, directing as before that its bleeding should not be checked. I shortly after that dropped asleep, and on waking could breathe freely; my recovery was progressive from that time, the wound in front, where the ball entered, being the first closed; but both were healed at the end of about eight weeks, and in about ten I was able to rejoin the army at Bordeaux.