Part 43
323. Mr. J. Bell had so alarmed all military surgeons by stating, in his able discourses on the Nature and Cure of Wounds, that emphysema was “peculiarly frequent in gunshot wounds of the chest, both at the orifice of entrance and of exit of the ball,” that they thought of little else. They could not withstand the brilliant manner in which this remarkable error--for error it is--was expressed. To such of us as had served in the first part of the war in Portugal it was no longer a bugbear; we slept in peace after the battles of Roliça and Vimiera, of Corunna, of Oporto, and Talavera--laughing, perhaps, a little at the credulity of the surgical portion of mankind; for the opening made by a musket-ball rarely admits of emphysema. A slanting wound made by a pistol-ball may sometimes give rise to it. After long and tortuous wounds made by swords or lances it is seen more frequently, but then it takes place shortly after the receipt of the injury.
A soldier, at the battle of Albuhera, was wounded in the right side of the chest by a sword, which had passed slantingly under the shoulder-blade, from which injury he did not suffer much, until the whole side as well as the body and neck began to swell and impede his breathing, which was effected with some difficulty and with any ease only when sitting up. The external wound was enlarged until I could distinctly hear the air rush out and see the part where the weapon had penetrated between the ribs; upon which he declared himself relieved, when the wound was closed by compress and bandage. It did not unite, however; active inflammation of the cavity of the chest ensued, requiring frequent and considerable losses of blood for its suppression. At the end of three weeks the man was sent to Elvas, in a favorable state for recovery.
324. When an opening is made into the cavity of the chest in the dead body, the lung recedes from the pleura lining its wall, for some distance; it is said to collapse; but this does not take place in anything like the same extent in the living body; and if the continued admission of air through the wound be prevented, it scarcely takes place at all; or, should it have done so, the air is usually absorbed and the lung quickly recovers its natural dimensions and functions. Neither does a wound in the chest, when kept open, usually cause this collapse to the extent which it is generally supposed to do in the living body. The lung can be seen in motion and performing its office, although imperfectly, as it does not fill the cavity of the pleura. When the lung has been wounded by a ball actually going through its substance, it does not necessarily collapse; and abrasions or deeper injuries of its surface lead to no such result. To cause the complete collapse of a living lung, its surface must be compressed by a fluid, as in empyema, or by confined air, as in emphysema or in pneumothorax.
In extreme cases, when the patient can no longer lie down, but sits up, supported, in the greatest agony of respiration, approaching to suffocation, the face and lips swollen and blue, the pulse almost imperceptible and countless, an opening should be made into the chest by a small trocar and canula, for the purpose of evacuating the highly compressed and compressing air, and to allow the expansion of the lung after its evacuation. When this compressed air has been drawn off, as in the case of Lord Beaumont, the compressing power being removed, the lung expands in part, if not entirely, in spite of the breach in it, and the mediastinum and heart return to their natural situation, the distress in breathing is removed, the failing circulation is restored, and the opposite lung resumes its functions.
The course then to pursue in such extreme cases is merely to puncture the chest, evacuate the air, withdraw the canula, and close the opening. The life of the patient having been thus saved, time is given for the wound in the lung to heal under the usual inflammatory processes, provided it will do so without a recurrence of the mischief. This, if it should take place, must be met by another puncture, or the opening in the chest should be made permanent in order to equalize the pressure of the air in the cavity.
The incisions (the “_taillades_” of the French) into the cavity of the chest formerly recommended, should only be resorted to when the means indicated have failed, which they will rarely do when combined in the first instance with an antiphlogistic treatment, aided by sedatives, and if necessary by cordials.
The advantages to be derived from auscultation in these cases are evident. Its value has been sufficiently shown, and the ear or the stethoscope should be resorted to at least three times in every twenty-four hours, in every case, however trifling it may appear to be, until the absence of danger has been ascertained.
LECTURE XXII.
SIMPLE INJURIES OF THE CHEST, ETC.
325. The most _simple injury_, perforating the wall of the chest, is a stab by a triangular sword, a small knife, or other weapon, which may or may not abrade the surface of the lung, and which is usually attended by little pain, although it often gives rise to considerable alarm. It might be supposed that a very slight wound of the lung would be followed by some expectoration of blood, but this does not always take place; and although its presence may be considered demonstrative of the injury, its absence is no proof of the contrary; for a considerable injury from a stab or from a musket-ball may be inflicted, with scarcely any sign of blood in the matter expectorated. If the pleuræ are in their natural state, a small quantity of air may enter the chest, but the opening will require to be direct and tolerably large before the lung will separate or shrink from the wall on that account; if adhesions should have been previously formed between the pleuræ preventing it, they will be for the advantage of the sufferer.
In a simple incised wound, injuring the lung perhaps extensively, as supposed from the bleeding from the mouth, no examination by probes or other instruments need or ought to be made as a general rule; but the wound should be immediately closed by sutures after the external parts have been sufficiently examined to satisfy the surgeon that no portion of the offending instrument has been broken off, or other extraneous matters are sticking in the part.
The advantages derived from the closure of punctured wounds of the chest in former times led to the practice of sucking them by the mouths of irregular practitioners, generally the drum-major of the regiment, when the patient was a soldier; and the consequences, although in some instances apparently miraculous, were in others quite as unfortunate.
That bleeding may take place from the lung into the cavity of the chest is indisputable, but little or no blood will escape through a small wound; and its continuing to flow from such a wound will be a presumptive if not a conclusive proof that some artery external to the pleura has been wounded. Sucking, under ordinary circumstances, of a small wound, unattended by bleeding, does good by attracting the natural fluids to the parts, and thus causing them to swell so as to be placed in apposition in the most advantageous manner for their reunion. Punctured wounds of small size, therefore, may be sucked chirurgically if any one be willing to do it, after which a bit of gold-beater’s skin, or dry lint, should be placed upon the wound, supported by a compress covered by adhesive plaster; these dressings should not be removed for several days.
326. The patient should lie on the wounded part, as a general rule, if he can conveniently bear it, not for the purpose of allowing any effused blood or fluid to flow out, unless some particular reason require the precaution of keeping the wound open, but to allow the pleura covering the lung to be as closely applied as may be to the pleura lining the wall of the chest, with the hope that the adhesive process may take place between these parts, and by this means cut off the wound from the general cavity of the pleura, a proceeding due to the practice of the Peninsular war, yet so little attended to at the present time by some teachers of surgery, who seem to confound the practice thus recommended in incised wounds penetrating the cavity of the chest with that which should be adopted in gunshot wounds, that few students obtain even a reasonable degree of knowledge on this subject. Teachers are entitled to prefer any mode of treatment they please, but they should be careful not to neglect the opinions of others, whose authority, derived from experience, they are bound at least to notice, even if it should be to disapprove.
327. _Incised_ wounds of even greater extent ought not to be examined by the probe or finger; no disturbance of any kind should be permitted unless the cartilage or bone be injured. The external parts should be brought together as closely as possible, so as to facilitate in every way their union, and the processes which it is desirable should go on within. The external parts or skin and cellular membrane cannot be kept in perfect and continued apposition without sutures, and the proper method of proceeding is to sew up the wound in the skin with a needle and fine silken thread in a continuous manner, including absolutely nothing but so much of the cut edges as will retain the thread; a small piece of gold-beater’s skin or lint should then be laid over the stitches and retained by a compress and adhesive plaster.
In a _simple_ case of this kind little or nothing is effused into the cavity or secreted from the membranes of the chest, which will interfere with the processes which may have happily begun, and which it is desirable should be aided by the absolute quiescence of the patient, to whom no medicine should be given which may render any movement of the body necessary. It was formerly supposed that the greatest object to be attained was the prevention of inflammation, and a man was no sooner stabbed by his opponent than he was blooded and purged by his surgeon, regardless of the necessity which existed for perfect rest and the presence of a certain amount of inflammation, in order to enable nature to carry on those processes which are essential for the restoration of the injured parts. This inflammation should be allowed to commence without interference and to continue in a moderate degree until the object shall have been effected. It should only be interrupted or subdued when it is supposed to be about to exceed that degree which experience has pointed out as likely to be useful.
328. When the most courageous persons are wounded in parts essential to life, there is more or less alarm or shock created by the injury; although it has been gravely argued that a man does not always know when he is actually shot or run through the body. A continued state of anxiety and depression after an accident of this kind is a disagreeable accompaniment of the injury, during which little should be done beyond the giving a little cordial, and quieting the apprehensions of the patient, leaving him to rest, if possible, after the necessary applications have been made. If a gradual improvement take place, if the pulse rise, if the patient resume more of his natural appearance, and that state of commencing excitement which is denominated reaction follow, hope may then be entertained. The general symptoms, as long as they continue within ordinary bounds, are of little importance; the local ones, significative of action commencing in the injured part, are, however, to be carefully watched. They are those of inflammation of the pleura, and it may be of the lung. This inflammation begins slowly, and a day may elapse before it is well marked; for, when persons have died within the first few hours after such injuries, the pleura has often shown but little sign of inflammatory action. Auscultation should always be resorted to from the moment of injury, and constantly used throughout the treatment. Whenever it is concluded that adhesion between the two pleuræ has failed to take place, the direction to lie on the wounded side ceases to be of importance. Until this period no food whatever should be allowed, and thirst should be allayed by small quantities of water.
329. A punctured, incised, or gunshot wound, going fairly through both cavities of the chest, is usually believed to be quickly if not immediately mortal--an opinion generally correct with respect to wounds made by musket-balls, although it is certainly not the case with regard to punctured wounds, and does not always occur in those made by pistol or musket-balls.
Sergeant-Major Richards, of the 29th Regiment, received thirteen sword or bayonet wounds, and other injuries, on the heights of Roliça, on the 17th August, 1808--one particularly through each side of the chest, between the ribs, as if the small-sword had made a wound of larger size than usual. He had distinguished himself greatly in covering the body of his commanding officer, and was beaten down before the British column, which had been repulsed, could rally and recover its ground. He was an object of particular attention to me, for the few minutes he lived after I saw him; he had coughed up a little blood, and died gasping, as if suffocated, the chest laboring on each side to do its work in vain. His commanding officer, Colonel the Hon. George Lake, lay dead by his side, killed instantaneously by a musket-ball, which passed from the upper part of the left through the right side of the chest.
A French gentleman, fencing with his pupil in July, 1834, received a blow under the right axilla in a very violent lunge, whereby the button of the foil was broken off, and the foil itself passed into and through the back part of the thorax, the point coming out between the sixth and seventh ribs on the left side near the angles. There was but little bleeding. The chief symptoms were those of great inflammation of the contents of the cavity, which gave way to full and repeated bleeding from the arm, with perfect rest and almost starvation. He recovered very favorably, and was quite well in about eight weeks. He remains well, and is following his profession as a teacher of fencing.
330. When an incised wound into the chest is large and direct, injuring the lung, two very important points usually demand immediate attention. The first is to relieve the oppressed state of the breathing; the second, to suppress the bleeding.
In large penetrating wounds of the chest, with injury of the lung, it has been observed that the patient has breathed most easily when the external wound has been covered; and has been hardly able to breathe when it was opened, which is attributed to the air getting into that side of the thorax in inspiration, instead of entering the lung by the trachea. If the wound admit of being well closed, the difficulty of breathing diminishes; adhesion may take place, and the inflammatory action within the chest may terminate; but if the inflammatory symptoms continue, adhesion does not take place, and the secretion and effusion of a quantity of serous fluid are the consequence. This secretion of fluid is the natural consequence of inflammation which has passed the stage of adhesion, whether the injury of the chest have occurred from a stab or from a gunshot. It is the leading fact in the treatment of these injuries, hitherto disregarded by writers on this subject, but on the proper management of which, in both instances, a successful result principally depends. If the closure of the wound lead, in the course of a few days, to the re-establishment of the breathing, and the antiphlogistic means employed to the cessation of all urgent inflammatory symptoms, adhesion has most likely taken place, or is about to take place, in the neighborhood of the wound, and the patient will in all probability recover without much further suffering. If this should not occur, and effusion take place, the wound should be reopened, or the fluid otherwise evacuated.
A soldier of the 9th Regiment was wounded at Roliça, in 1808, by the point of a sword in the left side; it penetrated the chest, making a wound somewhat more than an inch long, through which air passed readily, accompanied by a very little frothy blood, which was also spit up on any effort being made to cough, leaving no doubt of the lung having been injured, that viscus appearing to be retained against the wall of the chest. As the edges of the wound could not be accurately kept in apposition by adhesive plaster, two sutures were applied through the skin, and the man was desired to lie on the injured side, with the hope that adhesion might take place, as there appeared to be no effusion of blood into the cavity. He was freely bled on each of the two days following the receipt of the wound, and gradually recovered.
A French soldier was brought into the village after the battle of Vimiera, wounded by a sword in the right side of the chest. He said he had lost a good deal of blood; was very pale; pulse small; extremities cold; breathing hurried and oppressed; had spit up some blood. On removing the handkerchief, a gaping wound presented itself, an inch and a half long, through which the cavity of the chest could be seen, the lung having receded. The wound did not bleed. As adhesive plasters would not keep the edges of the skin in perfect contact if he attempted to move, they were sewn together, and after the application of a compress he was much relieved. The next day all the symptoms were alleviated, and after the supervention of some serious inflammatory symptoms, he was forwarded to Lisbon, for embarkation for France, in a fair state of recovery.
It was the successful results of these cases which led to the closure of all such wounds in the first instance, with the hope of preventing thereby the extension of the inflammation to the whole sac of the pleura, which in many instances it succeeds in doing; and thus that which was done in the first instance from apparent necessity, rather than scientifically adopted, became a rule of practice, which may be laid down as a principle to be followed in similar cases. When persons thus wounded are neglected, the wound remains open, and the cavity of the pleura passes into a state of suppuration, after all the symptoms of acute pleuritis or of pleuro-pneumonia have taken place.
331. If the union of a large incised or other wound by the adhesive process does not take place, a bloody, serous fluid oozes out from under the dressings, if the oppression of breathing should not have led to their removal; the patient is relieved by the discharge, which, after a time, as the case proceeds toward recovery, will become less in quantity and more purulent in quality.
If the union of the divided parts should take place externally, and the general as well as local symptoms become more urgent, there can be little doubt of a collection of some kind having taken place, and then auscultation and percussion, if the latter can be borne, become of the greatest importance. From the moment the wound is closed the ear becomes the most important guide; the only one in fact to be depended upon as to what is going on within the chest. The case is one of pleuritis, perhaps of pleuro-pneumonia, and hence the reason that the symptoms and treatment of these complaints have been more fully noticed than might be considered to appertain to the province of surgery. The effusion of a bloody, serous fluid comes on, after a penetrating injury, from the third until the seventh or ninth day, by which time the cavity of the pleura may be filled; puncturing the chest between the sixth and seventh ribs at the point of election, or reopening the wound, should be early resorted to for its evacuation.
A picket of Portuguese infantry being surprised by a sudden rush of French cavalry from the town, during the first unsuccessful siege of Badajos, were nearly all sabred. The survivors were brought to me. Two had been run through one side of the chest, and one through both sides; the last died a few minutes after I saw him. The other two seemed to be nearly in a similar situation from loss of blood by the mouth and from the wounds. These were immediately closed by stitches, compresses, and adhesive plasters. A little hot brandy and water was given to each, and they were laid aside without hope of recovery. They did not die, however; the breathing became more easy, the distress less, and the pulse more distinct; reaction after a time took place. The next morning, the siege being abandoned, they were removed to Elvas, where I afterward heard they were doing well.
A soldier of the Third Division of Infantry, under the command of Sir James Kempt, was wounded at Waterloo, by a straight sword or sabre, which penetrated the left side of the chest. He fell, and lost a considerable quantity of blood from the mouth as well as from the wound, and was supposed to be dying. On showing some signs of life, the wound was covered by a part of his shirt; and on his arrival at the Elizabeth Hospital in Brussels, four days afterward, it was closed. On the ninth day, when my attention was drawn to him, he was sitting up in great distress, from difficulty of breathing, his hand pressed upon the wounded part, the cicatrix of which was red, swollen, and projecting. I recommended the assistant-surgeon in charge to open this with an abscess lancet, which he did, giving vent to a very large quantity of bloody and purulent matter, to the great relief of the patient for several days, although he did not ultimately recover.
The advantage derived from the closure of the wounds in these cases was manifest. It relieved the breathing, and caused the hemorrhage to cease, aided, in all probability, by the exhausted state of the patients. The relief to the breathing was at the moment the most essential point, the wounds of entrance being nearly two inches long, and the free admission of air quite unopposed; the lung had receded from the opening.