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

HERNIA OF THE LUNG, ETC.

350. Hernia of the lung, as a consequence of a wound in the chest which has healed, is a complaint of rare occurrence. It appears to take place when the intercostal muscles have been much injured and are deficient, the opening through them being merely covered by the common integuments which have yielded to the pressure exerted from within. It has been supposed that it might be mistaken for the thinning of parts from the formation of matter within, or empyema. The early occurrence of the abscess after the receipt of the injury forbids the supposition, while the ear, applied to the protruded part which is most prominent during EXPIRATION or coughing, perceives not only a crepitation, felt equally by the touch, but the natural respiratory murmur stronger, softer, but less vailed and more like the sound given out by a pulmonary lobule inflated close to the ear, but without enlargement of the part.

A portion of lung will sometimes protrude during the efforts made by the sufferer to breathe, particularly in expiration, when the wound is left open and the lung is sufficiently free to admit of it. When protruded, it sometimes happens that the efforts of nature are not sufficient for its retraction, and it remains filling up the opening into the thorax. A large portion of lung is rarely protruded, except through an opening which readily admits of its return; but when the wound is small, the return of a portion of protruded lung, when it is not positively strangulated, should not be interfered with. The surface of the lung is but little sensible; touching it causes no apparent pain, and its adhesion to the edges of the cut pleura is more advantageous than its separation from it. It should, therefore, be allowed to remain or be only so far returned, if it can be so managed, as to rest within the edges of the divided pleura and fill up the gap made by the incision, over which the integuments should be accurately drawn and retained. The adhesion of the lung to the pleura costalis arrests the inflammation, and may prevent its progress to other parts of the cavity. That the inflammation may extend farther into the substance of the lung, is possible, but when the sufferers are otherwise healthy, the chance of evil from pneumonia is less than from inflammation of the general cavity. Whenever the protruded lung has been completely returned, more inflammation has followed than where it has been allowed to remain under the precautions recommended. Three cases were brought under my notice at Brussels, after the battle of Waterloo, which were not interfered with, greatly to the advantage of the patients. It is rare, however, to see a protrusion of the lung after a gunshot wound.

The protruded lung, when left uncovered and unprotected, soon loses its natural brilliancy, dies quickly, shrinks, and becomes livid, without being gangrenous. In such cases the protruded part may be removed, but it should never be separated at its base from its attachment to the pleura costalis by which it is surrounded.

351. Wounds of the diaphragm were known to the older surgeons from the time of Paré; they were aware that these wounds were not immediately, although generally, mortal. They knew that the viscera of the abdomen did sometimes pass through such wounds into the cavity of the chest, but they did not know that a wound of the diaphragm never closes, except under rare and particular circumstances; that it remains an opening during the rest of the life of the sufferer, ready at all times to give rise to a hernia which may become strangulated and destroy the patient, unless relieved by an operation as yet unperformed, but to which attention is especially directed—a fact first pointed out by me early in the war in the Peninsula.

A soldier of the 29th Regiment was wounded at the battle of Talavera, and died in four days after the receipt of the ball, which went through the chest into the liver. I found, on examining the body, an opening in the central part of the diaphragm of an oval shape, the edges smoothing off as if they were inclined to become round; this opening was nearly two inches long, evidently ready to allow either the stomach or the intestines to pass through it on any exertion.

Captain Prevost, aid-de-camp to Sir E. Packenham, was wounded by a musket-ball, on the 27th September, 1811, on the heights of Saca Parte. It penetrated the chest from behind, splintering the ninth and tenth ribs of the left side, and made its exit a little below and to the right of the xiphoid cartilage. A good deal of blood was lost from the posterior wound, but he did not spit up any. He was carried to Alfaiates, and there he threw up a small quantity of bloody matter by vomiting. The posterior wound was enlarged and continued to discharge some blood, the intercostal artery being in all probability wounded. Sixteen ounces of blood were taken from the arm, giving great relief, and the bowels were opened by the sulphate of magnesia.

Sept. 29th.—Bleeding to eighteen ounces; on the 30th he was bled again to thirty-two ounces, from which great relief was obtained; he fainted, however, on making a trifling exertion to relieve his bowels.

Oct. 1st.—Accession of symptoms as yesterday, relieved by bleeding in a similar manner; bowels open.

3d.—The inflammatory symptoms recurred this morning, and were again removed by the abstraction of sixteen ounces of blood. Beef-tea.