Part 45
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.
H. G. Broke, _Major-General_.
He is now, in 1855, in perfect health, the respiratory murmur being free all over the chest.
The Duke of Richmond, then Earl of March, was wounded by a musket-ball at the battle of Orthez, while at the head of his company in the 52d Light Infantry. He was standing at the moment with his right face toward the enemy. The ball entered that side of the chest, between the fourth and fifth ribs, nearly in a line with the lower edge of the scapula. He fell to the ground with great violence, and was speechless for some time. He stated to me at a subsequent period that the sensation he felt at the moment was as if he had been “_cut in two_.”
On immediate examination there was no other opening to be found but the _one_ where the ball had entered; nor were the medical officers able to feel the ball anywhere under the skin or under the muscles.
The wound having been dressed he was laid on a door and removed to Orthez, about three miles from the scene of action, during which he complained of excruciating pain, extending from the wound to the top of the os ilii on the same side, the pain being much aggravated by frequent and severe cough, with copious expectoration of frothy mucus, and much florid blood; respiration hurried; countenance pale.
The moving him to Orthez occupied nearly three hours; a great part of the ground being very rough and broken, the men could not well step together, and the consequent unavoidable shaking and jolting caused him much pain. On his arrival at Orthez, he was extremely languid, with a tendency to syncope. Pulse feeble; extremities rather cold.
Seven in the evening: After having been faint for an hour, he became hot and restless; pulse 108, and full; skin more hot, and the respiration short and more hurried. After he was placed in bed hemorrhage from the wound took place to a very considerable extent. Eight ounces of blood were taken from the arm. (Could bear no more.)
15th inst., nine A.M.: After the bleeding he became more quiet, and had less pain; but he has since become very restless, and the pain returned, with a full, hard, and frequent pulse. The wound has again discharged a very considerable quantity of blood. Bleeding repeated as before.
Nine P.M.: Deputy-Inspector Thomson and Staff-Surgeon Maling examined the wound. Mr. Maling introduced his finger (the whole length) between the ribs into the wound without any interruption to its progress, and without being able to reach the termination of the passage of the ball; and Dr. Thomson then passed a probe (its whole length) straight into the chest, with a similar result; thus leaving no doubt on the minds of all present that the ball had passed directly into the posterior part of the chest.
Midnight: The blood last taken is very buffy; and there has again been an _immense discharge_ of blood, etc. from the wound; the sheets, mattresses, etc. are saturated with it; and on the floor, under the bed, there is a large pool of blood which had soaked through the bedding. Pulse 114, low and frequent; cough and expectoration as before; pain violent, and great restlessness. Repeat the bleeding.
_Mem._--Perhaps enough has now been stated to show the nature of the wound; and any further detailed statement of his lordship’s sufferings, or the treatment of his case, would be unnecessary. On the latter point, however, it may be mentioned that, exclusive of the _general treatment_, he was bled _seven times_ between the evening of the 27th of February and the morning of the 2d of March, the _cough_, _expectoration_, _breathing_, _pain_, _etc._ being much relieved by each bleeding.
A. Hair, M.D.
Mr. Guthrie saw the Earl of March on the same day as Colonel Broke, and suggested that no further efforts should be made to find the ball, while the treatment adopted should be steadily pursued; and in 1846, he pointed it out lying under the edge of the base of the scapula. His grace is now, 1855, in good health, and the chest, well formed, sounds clearly and healthily in every part, even at the point injured.
341. The ball in passing through the lung, in these cases, destroyed the life of that part only which it touched; and although air would pass out at the time, this would not be of long continuance. The wounds being kept covered, the lung did not and does not usually, in similar instances, collapse or recede from the wall of the chest, but quickly recovers its state of expansion, however impaired it may be at the moment by the injury. The track made by the ball gradually suppurates and heals, leaving merely a depression or cicatrix on the surface attached around or in part to the wall of the chest by adhesion. The track through the lung may be readily seen in such cases after death; although during life it interferes so little with the respiratory murmur as not to be observable, unless by its greater distinctness, from the thinness of the intervening parts.
Mrs. M. was wounded by a small pistol-ball, which entered on the right side from behind, between the seventh and eighth ribs, just under the arm when hanging down, and passed out in front over the cartilage of the sixth rib, more than an inch from the pit of the stomach. She had not spit blood, and the ear declared the lung to be pervious to air at the wounded part, which raised a hope that the ball might not have penetrated the cavity, although it might have injured the pleura. As she suffered great pain twenty-four hours after the injury, the breathing being oppressed, Mr. Adams bled her into a hand-basin, until about to faint. She lost nearly thirty ounces of blood, but her symptoms were quite relieved, so as to render any other bleeding during her treatment unnecessary. At the end of the third day she spat a very little blood after removal in a carriage to another lodging, and then gradually recovered. After four different stethoscopic investigations, I came to the conclusion that the ball had not struck the lung in the first instance, although the lung adhered to the pleura costalis, and suffered from some abrasion or ulceration at that point, which gave rise to the expectorated blood.
These cases are instances of wounds of the upper part of the lung, which are in general more dangerous than those of the lower, from the vessels being larger, and from the greater difficulty with which any extravasated blood or fluids can escape. They also prove that when blood is poured out in small quantity, it may be absorbed, but what that quantity may amount to is doubtful.
342. In cases in which the external opening or wound does not communicate freely with the cavity of the chest, the principal danger arises from the inflammation of the pleura ending in effusion, which, if not evacuated, leads to the loss of the individual. _It is the great fact to be attended to in the treatment of pistol wounds of the chest, or those made by small balls which do not pass out._ All the persons I have seen die from small balls have died with the affected cavity more or less full of fluid. The post-mortem reports of all persons killed in England in duels by wounds through the chest, unwittingly attest this fact, as well as the insufficiency of the surgical treatment they received; and the necessity, for the future, for its amendment. It is in these cases that the stethoscope is most valuable--its frequent use indispensable. When the respiratory murmur ceases to be heard except at what is the upper part of the chest, whatever the position of the patient may be, it is full time to enlarge the original opening, or to draw off the fluid by the trocar and canula.
Laennec thought that when a considerable effusion took place in pleuro-pneumonia, filling the posterior part of the chest when the patient lay on his back, it nevertheless diffused itself over the whole surface of the lung; but dissection has shown, in cases of wounds, that the fore part of the lung may be applied to the anterior part and sides of the ribs, while a serous effusion fills the hollow behind, the respiratory murmur being distinctly heard above it. It is the most important fact to ascertain, particularly in pistol or small penetrating wounds of the chest, in which the opening is not sufficiently large to allow any fluid effused to run out.
Sir C. B. was wounded by a pistol-ball in the back, which passed into the chest through the lower part of the lung of the right side, and lodged on the inside of the wall of the chest in front of the same side, sticking in and against a rib, but giving rise to no external marks or signs of mischief at that part, so as to admit of an operation for its removal. The inflammatory symptoms having been restrained, it was nevertheless obvious that the cavity of the chest was full of fluid, and that the oppression in breathing arose from it, and not from the injury done to the lung. The stethoscope was then unknown, the ear was not in use; my older colleagues were obstinate; they would not hear of an operation for enlarging the wound into the chest; and as our patient was, unfortunately for him, shot in London, instead of at the pass of Roncesvalles, or on the bridge over the Bidassoa at Irun, we let him die on the eighth or ninth day, without all the aid which surgery might have given him. It is possible he would not have recovered under any circumstances, from the ball having lodged, and from his advanced age.
A soldier of the Fifth Division of Infantry was wounded at Toulouse by a musket-ball, which entered between the fourth and fifth ribs of the right side, near the sternum, and came out behind nearly opposite, fracturing the ribs, the splinters of which were removed. The first symptoms of inflammation, having been in some degree subdued by the sixth day, were followed by those more immediately indicating effusion; such, particularly, as great oppression, difficulty of breathing, and inability to lie in the recumbent position, which induced me to introduce, after a little pressure, a gum-elastic catheter into the posterior wound, through which a quantity of red, serous fluid was withdrawn, exceeding, perhaps, three pints by measure. On the removal of the catheter the discharge of fluid ceased, and, under a strict antiphlogistic treatment, the man gradually recovered, so as to be sent to England in the following June. If the symptoms of oppression had returned, I should have repeated the operation perhaps lower down. Auscultation, if it had been then known, would have smoothed away many doubts and difficulties.
A soldier of the 40th Regiment was wounded at Toulouse on the 10th of April by a musket-ball, which entered about two inches below the nipple of the right breast, passed through the cavity and the lung, and came out behind at a nearly opposite point, injuring the ribs above and below, without entirely destroying their continuity. He was bled largely on the morning of the 11th, and again at night. On the 12th the bleeding was repeated; some small pieces of ribs were extracted from both orifices, and some part of his dress from the anterior one. He spat blood when he coughed, and respiration was difficult. Calomel, opium, and antimony were given in pills every six hours, and the bleedings were repeated daily, and sometimes oftener, for the first eight days, during which time a free discharge, at first serous, afterward purulent, took place from the wound, after which the inflammatory symptoms subsided; the cough became easier, the expectoration less, and free from blood; breathing easy. The calomel was omitted; a mild farinaceous diet was allowed instead of a little gruel, and a very little bread and milk. In a fortnight the wounds began to heal. On the 1st of May, some small pieces of rib were removed from the anterior wound, after which both gradually closed, and he was forwarded to Bordeaux on his way to England in the beginning of June, cured.
Corporal Dunleary, of the 69th Regiment, was wounded on the 16th of June, 1815, at Quatre Bras, by a musket-ball, which entered the thorax, fracturing the seventh rib on the fore part of the right side, and lodged. He said he had lost a large quantity of blood from the mouth, and some from the wound, between that and the 19th, when he was brought to the hospital in Brussels. The pulse was then quick and hard, respiration difficult and anxious, and a bloody discharge issued from the wound on every respiration; bowels confined since the accident; was bled to forty-four ounces; saline purgatives, with calomel, antimony, and opium, were given until the 29th of June, when the wound discharged good pus. From this time, at different periods for six weeks, he lost ninety-two ounces more blood, being strictly placed on milk diet. Several pieces of rib exfoliated. He was sent home on the 31st of August, declaring himself quite as well as ever he had been in his life; the ball remaining undiscovered.
A soldier of the Fusilier Brigade was struck by a musket-ball on the right side of the front of the chest, at the battle of Albuhera; it entered between the fifth and sixth ribs, passed through the lungs, and lodged. Three days afterward, when the first symptoms were in part subdued, he complained of pain in a particular spot, nearly opposite to where the ball had entered, at which part something could be felt deeply seated. An incision being made, the ball was found lodged in the intercostal muscles between the ribs, whence it was easily removed. A considerable discharge of reddish-colored serum followed, with great mitigation of the symptoms, after which, under strict treatment, the man recovered, and was sent to Elvas with every prospect of a cure.
Lieutenant-Colonel Harcourt and Major Gillies, of the 40th Regiment, were both shot through the chest, at the head of the regiment, at the successful assault of Badajos; the wounds were as nearly similar as possible, from before directly backward. They were taken to the same tent, and treated alike with the same care by the late Mr. Boutflower, the surgeon of the regiment, with whom I saw them daily. The inflammatory symptoms ran high in both. In Major Gillies, a tough old Scotchman, they could not be subdued, and he died, at the end of a few days, of pleuro-pneumonia. Colonel Harcourt slowly recovered, and died Marquis d’Harcourt, near Windsor, more than twenty-five years afterward, suffering little or no inconvenience from his chest, when I last saw him.
Captain Cane, 23d Fusiliers, was wounded at the affair of Saca Parte, in front of Alfaiates, in 1812, by a musket-ball, which struck him below and a little to the outside of the left nipple, fractured the rib, and entered the chest, giving rise to the sensation as if the ball had passed diagonally downward and backward to the loins of the same side. He spat blood, and was very faint. The next day he could scarcely breathe, was in great pain, continued flushed and anxious; pulse 100. He was bled into a washhand-basin until he fainted, and every day afterward, some days twice, to a less extent, for ten days, and once again until syncope was induced, on an accession of symptoms after an imprudence in taking a little wine, which nearly smothered him, he said. Some pieces of flannel shirt, of braces, coat, etc. were removed from the wound, and several portions of bone gradually followed, together with a quantity of matter, which continued to flow from May until the end of the following September, when the wound healed.
On the 23d Jan., 1821, I had an opportunity of examining this gentleman. My report says, he is never free from a little pain in the loins, where the ball is supposed to be, and cannot take a full inspiration without pain in the chest; expectorates more or less constantly, and occasionally a little blood about once in three or four months in half congealed lumps. Cannot ride or take any exercise because it brings on the pain. The cicatrix shows a large, deep hole, and the deficiency of the rib is well marked. The side of the chest is altogether contracted and flatter; the heart has been moved behind the sternum; the beat of the apex being on the other side of the xiphoid cartilage, and that of the heart, as a whole, is more indistinct than usual. In other ways in good health. It is possible that the ball may be lodged in or be retained by layers of coagulable lymph in the angle formed between the diaphragm, the ribs, and the spine.
William Downes, of the 11th Regiment of infantry, aged thirty-three, was wounded by a musket-ball, on the 31st of August, 1813, in the Pyrenees; it fractured the fourth rib of the left side, passed through the chest, and came out behind through the scapula. He spat a good deal of blood, although little flowed from the wound. The next day he was bled largely twice, to relieve the bleeding from the lung, and was sent to Passages, where he was bled daily; and thence, a ship being ready, to Santander, where he arrived on the 14th of September. A free, bloody, purulent discharge took place from the anterior wound, but little from the posterior, and he expectorated a bloody, purulent matter, and occasionally a little blood. Toward the end of September the sanguineous expectoration ceased; but the soft parts of the chest had sloughed and separated under an attack of hospital gangrene, from which he had a narrow escape during the month of October. The wound in the chest gradually closed during the month of November; and on the 14th of December he was discharged convalescent, his health tolerably good, but his breathing by no means free; no expectoration. The left arm was impaired in power, in consequence of the mischief done to the muscles of the fore part of the chest and shoulder by the hospital gangrene. The chest was altogether somewhat flattened and shrunk, but there did not seem to be any diseased action going on within.