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 other cases, portions of wadding, of leather belts, of splinters of different lengths, pieces of buttons, and even balls, have been found loose in the chest, showing the necessity for an especial and decided treatment.

A French soldier was wounded by a musket-ball at the battle of Waterloo; it penetrated the chest, fracturing the second rib, then passed through the lung, and went out behind in nearly a straight line, close to the spine. Left on the field of battle for five days before he was brought to Brussels, he was nearly dead with difficulty of breathing and other symptoms of inflammation, from which he recovered in the course of the next ten days, under repeated bleedings and the strictest antiphlogistic regimen. At the end of this time, when apparently doing well, an accession of inflammation and of all his bad symptoms took place, destroying him at the end of four weeks from the receipt of the injury. On dissection, the lung was found adherent to the chest by false membranes of some thickness, with a quantity of purulent fluid in the cavity. The track of the ball was in a suppurating state, and two pieces of rib were found in the center of its course. The whole of the lung appeared to be filled with a sero-purulent fluid, which could be readily squeezed out.

John Roth, of the 5th battalion of the 60th Regiment, aged twenty-nine, had been wounded by two balls, one on the 10th of April, 1814, at the battle of Toulouse, which grazed the left temporal bone; the other had gone through the upper part of the right chest, in the Pyrenees, the autumn before. Both wounds had healed. He was seized on the 8th of May, after a little intemperance, with pains in his body and joints, pain in the chest, and cough, with bloody expectoration; skin hot, tongue foul, and bowels confined. On the 9th he was bled, and purged by calomel, antimony, and salts. On the 10th symptoms augmented, pulse 120, small, and wandering, but no pain in the head. Repeat the medicines. Head shaved and cold applied; bleeding to ten ounces. 11th. Every symptom increased; great pain on touching the chest; pulse 126; skin hot. On the 12th passed his urine and feces involuntarily; and on the 13th he died, his body being covered by petechiæ.

The head, on examination, showed pus under the dura mater, at and behind the situation of the wound he had received. The right lung adhered to the walls of the chest where the ball had entered and passed out, the track made by it being very visible, indurated, and inflamed, from the last attack: the parts otherwise sound; no fluid in the cavity.

Mr. Drummond was wounded by a pistol-ball in the back, low down, about two inches from the spine, and three inches from the inferior angle of the scapula; it was afterward found to have entered between the eleventh and twelfth ribs, and to have passed between the base of the lung and the diaphragm, abrading the former, and passing through the latter into the abdomen, ultimately lodging in the fat under the skin, over the cartilage of the eighth rib of the left side, nearly at an opposite point in front. From the absence of all symptoms of shock and alarm, it was hoped by some that the ball might have run round, but on the removal of the little ball its course could not be traced. This occurred on Friday. On Saturday morning at five o’clock he suffered great uneasiness and difficulty of breathing, accompanied by a particular catch or jerk in respiration, indicating a wound of the diaphragm. The stethoscope and the ear attested the clearness of the respiratory murmur in every part of the chest, which sounded well, and I was satisfied the lung was not materially injured; twelve ounces of blood were drawn with difficulty from both arms. At ten o’clock, the jerk and difficulty of breathing being greater, the left temporal artery was opened, as no blood could be drawn from the veins; five ounces only could be obtained; a dose of calomel and a senna draught had been followed by the discharge of a teaspoonful or two of blood, leaving no doubt on my mind that the ball had penetrated the cavity of the abdomen, as well as of the chest, and that a bowel had been injured. With a constitution apparently unequal to bear an inflammation of the most dangerous character, or the remedies necessary to subdue it, the prospect was but melancholy. Thirty-six leeches were applied around the wound in front, but they drew little blood. Pulse from 108 to 112. Dr. Hume, Mr. B. Cooper, and Mr. Jackson were added in consultation on Monday at twelve, when the jerk became worse, the oppression in breathing greater. Muriate of morphia, half a grain; at two, bled to twelve ounces; blood very buffy; calomel, two grains, opium, half a grain, every two hours. In the evening, bleeding, repeated to fourteen ounces; no more would flow. Tuesday morning, at five, bled again to twelve ounces. The ear now indicated effusion for the first time. It was not, however, in sufficient quantity to render the evacuation of the fluid necessary. After this he gradually sank, and died on Wednesday morning. He lost on the whole fifty-six ounces of blood. On examination after death, it was found that the ball, after entering the cavity of the chest, had slightly abraded the left lung at its lower and inferior edge, which was covered by recent lymph, the lung being internally sound. The left side of the chest contained nearly a pint of red-colored serum. The ball had perforated the diaphragm, grazed the fat of the left kidney, passed through the great omentum below the stomach, to the part where it was extracted, injuring apparently no important organ in the abdomen in its transit, but giving rise to an effusion of blood from some small vessel which had sloughed, the blood being partly coagulated and partly diffused to the amount of many ounces; its loss appeared to have been the immediate cause of death.

A gamekeeper’s gun burst at the Red House, Battersea, and a small part of the lock entered the middle of the left arm, and passed upward into the axilla, where it could not be traced by Mr. Keate, who saw him within an hour after the accident. The symptoms which followed were those of inflammation of the chest, and were subdued by active treatment; the wound healed, and he returned to his occupation in Wiltshire. Having exposed himself to the night air some weeks afterward, the inflammation of the chest returned, and he died. On opening the thorax, one edge of the bit of iron was found impacted in the surface of the lung, the other edge was rubbing against the inside of the sixth rib, which was nearly worn through by the constant friction it underwent during respiration; there was also a mark on the pericardium as of a cicatrix, and of a graze on the surface of the heart.

Among the French prisoners in Lisbon, in the spring of 1813, I saw a man in whose chest a ball had entered midway between the fifth and sixth ribs, and lodged; from this a constant and considerable discharge of purulent matter took place. The ball was found after death lying between the diaphragm and the spine, surrounded by coagulable lymph, and adhering by its envelope to the spine and diaphragm at the angle formed between them; there was a very thickened pleura costalis; the lung was shrunk and attached by membrane almost equally thickened across the chest, the lower part of which was filled in the upright position by the discharge, which was only evacuated in quantity when the opening of the wound was made dependent.

A case was met with after the battle of Waterloo, among the French wounded, which was somewhat similar. A portion of rib had been driven in, and the assistant-surgeon was aware that the ball could occasionally be felt. The man died at the end of a fortnight, the cavity containing a quantity of sero-purulent bloody matter. The lung had been injured by the ball, which had fallen loose into the cavity of the chest.

344. The removal of splinters of bone, or of other foreign bodies from the lung, has occupied the attention of surgeons from the earliest periods, and some of them proposed to draw a piece of cambric or other things through the chest, for the purpose of removing them. These extreme measures have been abandoned; but there can be no doubt of the propriety of removing as many of these causes of irritation as can be either seen or felt. If the ball have broken a rib, the orifice of entrance especially should be enlarged as early and as carefully as possible, so as to give an opportunity for the removal of the splinters and of all angular points of bone which may be turned inward. A little addition to the original opening can do no harm, and if the lung should not collapse, or should it be adherent, it will enable the surgeon to see whether any splinters are impacted in it, and to remove them. It is possible that the end of the finger even may be introduced, and the lung felt, if it should not have receded too far; as it is insensible to such an operation, no evil will ensue; but all probings with small, sharp-pointed instruments should be avoided. That wadding, buttons, pieces of cloth, and of bone have been frequently coughed up, I have had experience; but although it is said that even balls have been thus brought up, I have not had an opportunity of seeing them.

An officer was wounded by a musket-ball on the 9th of July, 1745; it passed through the chest, entering in front, fracturing the seventh rib near its junction with the cartilage attaching it to the sternum, and passing out behind near the angle of the same rib, which it again broke, together with the one immediately below it. M. Guerin enlarged the openings of entrance and of exit to the extent of nearly two inches, by dividing the pleura, the intercostal muscles, and the integuments from within outward. Several splinters of the rib injuring the lung were removed, the smallest of which might be half an inch or six lines long, by two wide. A tent was then passed through the wound. The patient suffered much, and spat a great deal of blood; pulse feeble, extremities cold. He was bled three times the first night, and twenty-six times during the first fifteen days, the seton being retained in the chest the whole time. On the twenty-second day, a piece of cloth was felt by the finger, after removing the seton, and was extracted; a splinter was also felt, but so deeply that it could not be removed without enlarging the incision. As the inflammatory symptoms were re-excited, he was bled for the twenty-ninth time. On the thirtieth day these symptoms had so much increased that the seton was withdrawn, under the impression that it was doing more harm than good, and the thirty-first bleeding was effected. The next morning the patient complained of something pricking him within, and the parts left between the two original wounds, after the incisions which had already been made, were divided. The chest was now open from the articulation of the head of the rib with the sixth and seventh vertebræ behind, nearly to the cartilage in front; and the whole course of the ball was seen; it had made a groove in the surface of the lung, in the substance of which a splinter was sticking. This was extracted, and the wound dressed simply, after which the patient gradually improved, and was quite cured in four months.