Case 17. Thomas Smith, aged 26, 30th regiment, wounded on the 8th of September. Ball entered fleshy part of right thigh. Cut out. Another ball entered at acromial end of right clavicle. Exit at angle of ninth rib. Great depression: hæmoptysis.

12th. Sudden effusion of blood and serum into right pleural cavity: death almost instantly.

No post mortem.

On the contrary, it happens in many cases of wounds of the chest, that the serum escapes freely by one wound, or, if there be two wounds, by both. This will be an indication to the medical attendant, to assist nature's remedy by enlarging the wound; and if the complete evacuation of the fluid cannot thus be effected, to entertain the necessity of forming an artificial opening by paracentesis thoracis. Opinions as to the point of election for the introduction of the trocar vary. Baudens recommends the eleventh intercostal space close to the spine; but generally between the fifth and sixth rib, if it be the right side, and between the seventh and ninth, if it be the left side, are the points selected. The following case, given in the Director-General's Report, page 65, shows certain peculiar effects which may attend this otherwise simple operation ; and they ought to be held in remembrance by the medical attendant as a possible contingency.

John Carroll, aged 20, 97th regiment, wounded on the 8th of September. The ball appeared to

have entered and lodged in the chest. Urgent symptoms of pleuro-pneumonia were present. Calomel and opium were prescribed on the 22nd. At a spot close to the inferior angle of the right scapula, “ something was detected which had much the feel of a bullet. It was cut down upon, and found to be one end of a fractured rib, and it was now evident that the cavity of the chest had been unintentionally opened ; a considerable quantity of darkish bloody serum flowed through the wound. The operation was immediately followed by a most distressing and alarming dyspnea, as well as excessive increase of the pain. He tossed his arms wildly about, appeared to be quite unable to breathe, and death to be imminent. The wound was closed, and a bandage applied with some relief; but much pain and dyspnoa remained, and constantly increased if the bandage was relaxed. He died three hours and a half after the opening had been made. Two pounds of dark-coloured clotted blood, and a large quantity of serum, were found in the cavity of the chest. Three ribs were broken; the two upper very badly; the lower the one which had been cut upon. The lung was compressed, bloodless, and unwounded. The bullet (conical) was found lying on the crus of the diaphragm.”

The report goes on to observe : “ The suddenness of the death seems difficult to account for. He did not die of hæmorrhage. The blood found in the chest had not come from a vessel wounded in the operation. His appearance did not give the idea of blood-poisoning by asphyxia.”

A case similar in result, from opening the chest, is recorded by Dr. Hoadley, page 70, as having been seen by him in St. George's Hospital. “A girl, about three years of age, had a small swelling on the back, situated on the lower small ribs on the right side, about the bigness of a walnut. The swelling was soft, and plainly contained matter. .... Upon opening this tumour, there came out a surprising quantity of matter, the discharge of which affected the child's breathing so much, and occasioned such an alteration in the manner of performing it, that the surgeon was forced several times to stop the orifice with his finger to give her time to recover her breath.” In this, as in the former case, it is not easy to give an explanation of the cause of the urgent dyspnea induced, by that which is now known to be a very simple and, in general, a safe operation, unless the following will suffice. By a law of hydrostatics, the fluid in the thorax is pressing equally on all sides : and at the smallest removal of opposition to such pressure, such as cutting down upon a rib, a release will follow, and the constrained lung will rise to follow the expanding chest-wall, and urgent dyspnea will follow.

The following case, under the care of Dr. Ranke, presents subject for reflection connected with the

present point.' The bullet entered above the left clavicle, slightly splintering its upper edge. Supposed exit between sixth and seventh ribs. An elastic swelling, as large as a turkey egg, appeared at the supposed point of exit upon expiration and the act of coughing, and disappeared upon inspiration. Symptoms of pleuro-pneumonia, and also “ metallic tinkling,” are said to have been present. Recovery took place. It is doubtful whether the lung really was wounded. The ball may have passed between the pleuro-pulmonalis and costalis, and at the point where the swelling appeared, ruptured the fibres of the intercostals, thereby admitting a hernia of the lung. The ball must have lodged. See a resembling case by Sabatier. Dr. Halliday reports a similar case, page 26, and puts it down as emphysema. “The swelling,” he says, “ contracted on inspiration and expanded on expiration.” The question here arises, if an apparent necessity arises for opening a similar tumour, are we to be deterred from interference by a fear of inducing effects similar to those described in the two foregoing cases ? I think not; they were clearly exceptional, from a peculiar idiosyncrasy, or some physiological or physical influence.

CHAPTER XV.

ON THE GENERAL TREATMENT OF PENETRATING

WOUNDS OF THE CHEST.

In entering upon the general treatment of penetrating wounds of the chest, it is necessary, for a full comprehension of the subject, to premise that the circumstances in which the British soldier was placed in the Crimea were those of great hardship, arising from deficient and unwholesome food, inclement exposure, undue excitement, excessive and prolonged exertion: all of which tended to reduce him to a state of extreme moral and physical depression, and, in many instances, to a condition of positive anæmia and irrecoverable exhaustion. It is scarcely necessary to add, that in this condition men would be ill able to bear up against the ravages of disease and the destructive effects of wounds.

My observations on the general treatment will mainly apply to the non-utility of venesection in cases of lung wound; and in my endeavour to arrive at a useful and practical conclusion, the in

case

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