The two first incisions for the removal of the splinters were necessary. The tent or seton drawn through the chest was an error; and although the fortunate result of the case depended probably on the removal of the splinters of bone sticking in the lung, few would survive the formidable operation performed for their removal. The case is suggestive and instructive.
345. When the lung can be seen through the opening made by the ball, or after some moderate enlargement for the purpose of removing any splintered pieces of rib or any spiculæ which can be felt or seen, the object is attained. I have not had experience of the utility of large incisions for the purpose of making the lung more visible, although the importance of extracting foreign substances in the first instance is inculcated, provided their situation can be ascertained.
A Spanish soldier, wounded at the battle of Toulouse, was brought to me the same evening, shot through the right side of the chest, between the fifth and sixth ribs, one of which was fractured, the ball passing out nearly opposite behind. On removing the splinters by the aid of an incision, I found that the lung was adherent to the inside of the chest, and was enabled to withdraw from within the lung some splinters of bone and a part of his coat. He left Toulouse apparently doing well; but natives of warm climates rarely suffer from such severe attacks of inflammation as those of northern habits and constitutions.
A soldier of the German Legion was wounded at the battle of Waterloo, the 13th of June, 1815, by a musket-ball, which entered between the seventh and eighth ribs in front, about two inches from the sternum on the right side, passing out behind. He died in York Hospital, Chelsea, in the month of January following, where he was taken after some drunken fits, which induced an attack of pneumonia. A fistulous opening existed, and had discharged a little matter, which was gradually diminishing; the sinus was from six to seven inches long, extending into and nearly through the base of the lung, and was lined by a mucous membrane, the lung around being thickened to the extent of from a quarter to half an inch. There was but little fluid in the cavity, although the lung on both sides showed signs of recent inflammation, without which he would in all probability have recovered. The orifices of entrance and of exit through the lung adhered to the walls of the chest, thus separating the track of the ball from the general cavity of the pleura, which would in all probability have led to his ultimate recovery, if it had not been for his intemperance.
346. When a ball, or portion of bone, leather, cloth, wadding, or other foreign substance is driven into the cavity of the pleura, it usually gives rise to fatal results, constituting, therefore, cases of the greatest importance, to which attention has not been sufficiently given, but on which too much cannot be bestowed, if life is to be preserved by the art of surgery. The neglect of these cases has probably arisen from the insufficiency of the means of ascertaining their nature—an insufficiency which auscultation has in some measure removed, and which the science of surgery may still further diminish. The presence of a ball, a piece of bone, or of any other substance, lying upon or rolling about on the pleura covering the diaphragm, must give rise to more or less irritation and inflammation, and consequently to suppuration, or the formation of matter upon the surface of that membrane in its thickened state, until, in all probability, the foreign substance has been removed or the person has wasted away and perished.
A dragoon of the King’s German Legion was wounded between the eighth and ninth ribs at the battle of Salamanca. The ball had entered and lodged; the symptoms were severe; the breathing laborious. As the discharge from the wound was not free, I enlarged the opening, removed some scales of bone, a bit of cloth which stuck between the ribs, the lower of which was broken, and evacuated a great quantity of bloody-colored fluid, not purulent. After a few days the discharge became purulent, and, as he felt something, as he thought, roll within him, which he supposed might be the ball, I contemplated again enlarging the wound, so as to be able to see whether anything were loose in the cavity; but a sudden relapse of inflammation, from drinking some brandy, carried him off. On examination, the ball was found lying loose on the diaphragm in the chest, and might, with some enlargement of the wound, have been extracted.
A French prisoner of war, who had been wounded near Almaraz by a musket-ball, which had lodged in the left side of the chest, was sent to Lisbon in 1812, with a considerable discharge through the wound, and died there. The ball was found in the angle formed between the diaphragm and the spine, enveloped in coagulable lymph, by which it was attached to the spine; there were some splinters of bone inclosed with it.
A soldier of the 29th Regiment was wounded at Talavera by a musket-ball, which penetrated the right side of the chest, between the fourth and fifth ribs, and lodged. He died the day after, and on opening the body, I found that the ball had passed through the lung, and was lying loose on the ribs behind, near the union of the diaphragm with the spine.
Major-General Sir Robert Crawford was wounded at the foot of the smaller breach at the storming of Ciudad Rodrigo, by a musket-ball, which passed through the posterior fold of the armpit and entered the side of the chest in the axilla by a small opening or slit, apparently too small to allow a ball to pass through. I saw him a few minutes afterward with Dr. Robb, under whose care he remained, when, from the general anxiety manifested, I was satisfied as to the severity of the injury. The symptoms were not at first urgent, but their continuance and augmentation, in spite of the most rigorous antiphlogistic treatment, led, in a few days, to his death. On examination of the body, the ball was found lying on the diaphragm; the cavity of the chest contained a large quantity of very turbid serum; false membranes had formed on the lung, which was compressed toward the spine, and at the upper part retained the mark of an injury as from a ball which had not had force enough to penetrate and lodge.
Baron Larrey has had the good fortune to meet with some remarkable cases of this kind. In the first he did not see the man for some weeks after the wound had been inflicted, the ball entering at the upper edge of the fourth rib, about an inch from its junction with the cartilage. By means of a bent and flexible sound introduced through the wound, he distinguished a hard, metallic substance at the bottom of the cavity of the chest, which he supposed to be the ball, nearly in the situation of the place where the operation for empyema is usually performed. This operation having been done, about twelve ounces of pus escaped, and the ball was discovered rather flattened. It was easily removed with the aid of a pair of polypus forceps. After this there was every prospect of recovery, until the patient, having unfortunately one day drank too much brandy, was attacked by enteritis, and died.