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

William Barrett, of the Life Guards, a middle aged, muscular man, of full habit, was wounded by a musket-ball at the battle of Waterloo; it fractured the third and fourth ribs behind on the left side, and broke the left arm. He was brought to Brussels, where the inflammatory symptoms were subdued by repeated general and local bleedings, and the other ordinary but strictly antiphlogistic means, during the first six weeks, by which time the external wound had nearly closed, and no trace of the ball could be perceived. At the end of this time, Staff-Surgeon Collier, now Inspector-General of Hospitals, under whose care he was, and who furnished me with these particulars of the case, which I saw in Brussels, finding that his symptoms became worse, that he had rigors and evening exacerbations, and that the difficulty of breathing had increased almost to suffocation, decided on opening into the cavity of the chest and following the course of the ball. This he did by a deep incision, which enabled him to remove some pieces of the ribs, which were denuded but not detached. A bag-like protrusion was then felt between the ribs near their angles, which was opened, and nearly two pints of thick, fetid pus escaped, the relief which followed being as complete as sudden. The wound was dressed from the bottom, and every means adopted, except introducing a tent, to prevent its closing, but in vain; the opening closed, and matter again collected, requiring a second incision for its removal. Between these two operations small bleedings were resorted to most beneficially. A short gum-elastic catheter was introduced into the cavity of the chest after the second incision; very little matter, however, was secreted. From this time he gradually recovered, and was sent to England, cured, in November.

347. The presence of a ball, rolling about on the diaphragm, can now be ascertained by means of the stethoscope at an early period, so as to admit of an operation being undertaken with confidence for its removal; while the knowledge acquired by auscultation or percussion, of the filling of the chest by fluid, whether serous, bloody, or purulent, is at the same time incontestibly demonstrated. The presence of a ball, or of any other foreign body, decides the question as to the place where the opening into the chest should be made. On this point the information derived from the practice of the French surgeons in Algeria is valuable.

M. Baudens, whose labors I again refer to with great pleasure, says that he has also seen splinters of bone and even a ball, surrounded by a cyst formed by the pseudo-membranes of inflammation, cut off from the general cavity, and confined in the angular space formed behind between the rib, the diaphragm, and the spine. In one case, M. Baudens introduced a sonde à dard, such as is used in the high operation for the stone, between the second and third ribs, and made it project behind between the eleventh and twelfth. He then cut down upon it, and extracted a ball and some splinters of the rib. The wound thus made was then closed, the upper one being sucked dry daily by a pump. The patient recovered in forty days.

A., 54th Regiment, was brought to the hospital at Algiers, on the 22d of October, 1833, wounded eleven days before by a ball, which, having broken the right clavicles was lost in the chest, without any sign of effusion having taken place; he appeared to be going on well, until suddenly he complained of pain about the middle of the sixth rib, which could not be removed by the means employed, and was accompanied by a great discharge from the wound. On the 10th of November he died. The clavicle and the first rib had been fractured, and an abscess had formed behind them, the size of a hen’s egg, containing several splinters of bone, which had stuck in and afterward separated from the lung. The ball had passed from above downward and outward, forming a sinus, which terminated at the middle of the sixth rib, to which this part of the lung was attached; the posterior three-fourths of this canal were closed; the anterior fourth contained two splinters of bone, one of which was about to fall into the abscess in front. The sixth rib was broken, although it had not been perceived during life; and a small digital cavity was formed at this part in it by the ball, surrounded by portions of lymph, floating loosely from its edges; from this the ball had been detached, and had given rise to the inflammation which destroyed him. The ball had fallen on the diaphragm, where it was lying loose, surrounded by a quantity of purulent matter.

M. Baudens says himself, and rightly, that the operation of opening into the chest should have been performed in the eleventh intercostal space, and that the wound in front should have been enlarged.

M. Baudens relates another case, in which the posterior wound, situated near the angle of the tenth rib, had healed, the anterior one, half an inch below the clavicle, giving issue to an abundant and weakening suppuration. The lung above this was permeable to air, but the respiratory murmur could not be heard below it. To draw off this offensive fluid, he adapted an empty caoutchouc bag to a gum-elastic canula, which he affixed against the orifice of the wound, and thus sucked out six pints in five days. Some days later the wound behind reopened, and a piece of bone was discharged from it, which saved the man’s life. Two years afterward he was seen in good health.

The desire to have as dependent an opening in the chest as possible in these injuries has been manifested by all surgeons of experience; and the interspaces between the ninth and tenth, and between the tenth and eleventh ribs, have been often selected for this purpose; but as the operation was formerly done with the trocar, the abdomen was as often opened as the thorax, and death was frequently thus caused, even if it would not have been occasioned by the disease. To prevent, or to avoid this evil, M. Baudens advises its being performed at three fingers’ distance from the spine, by incision, and he says he has frequently done it with success, although he does not give any circumstantial directions as to the operative method to be pursued. I therefore caused several experiments and dissections to be made in the workroom of the College of Surgeons by Mr. Quekett, with the following results:—

348.—1. That a trocar and canula pushed in between the eleventh and twelfth ribs, in a diagonal direction upward, on a line with the angle of the ribs generally, will in the dead body invariably enter the cavity of the chest without injuring the diaphragm.

2. That the same operation performed on the living body would, in all probability, if done at the moment of expiration, first enter the thorax, then pierce the diaphragm, and thus open into the cavity of the abdomen,—a difference in result to be explained by reference to the anatomy and physiology of the parts concerned; showing that this operation, when required on man, should always be done cautiously by incision, and not by puncture with the trocar and canula.

On examining the lower part of the chest from within, after removing the pleura, the diaphragm is seen forming the boundary between the thorax and the abdomen, commencing from the transverse process of the first lumbar vertebra, and forming an arch under which the upper part of the psoas muscle passes, (the ligamentum arcuatum proprium.) From this part extends another aponeurotic arch along the lower border, to the end of the last rib, called the false ligamentum arcuatum, (ligament cintré du diaphragme of Cruveilhier,) which is nothing more than the upper edge of the anterior layer of the aponeurosis of the transversalis muscle, folded upon itself in all its extent. The diaphragm is afterward attached to the lower border of the twelfth, and in succession to the eleventh, tenth, ninth, eighth, seventh, and sometimes to the sixth, ribs, counting from below upward. The external intercostal muscles are distinctly seen between the ribs, extending from the spine until they meet and are concealed by the fibers of the internal intercostal muscles, near the angles of the ribs. The vessels and nerves, after passing on the external intercostal muscles, subsequently run between them and the internal ones.