Part 44
332. _The important question of hemorrhage_, in cases of incised wounds admitting of being accurately closed, remains for consideration. In many instances, the quantity of blood effused is trifling, and in others, although greater, it is absorbed without being productive of evil. In a third class, the quantity extravasated is larger than can be absorbed, although it does not flow in an inconvenient or dangerous manner through the wound, and may ultimately become coagulated and adherent to the diaphragm and spine in the angle between them, when the patient lies long on his back. In the worst or most alarming cases, the loss of blood is and has been so great that its suppression offers the only chance for the continuance of life. It is between these two last cases only that a difference of opinion exists as to the treatment to be pursued: one party desiring that the effused blood, if moderate in quantity, should be allowed to discharge itself, the wound being kept open; the other, that under all circumstances, whether the quantity of blood poured out be small or great, the wound should be closed, and the result awaited. The right course is, I apprehend, to remove all the blood which can be evacuated by position, provided it can be done without danger to the patient, rather than to allow it to fill the chest; but as the bleeding vessel in the lung cannot readily be got at, if seen, nor be secured by ligature with advantage, it is advisable, if the bleeding continue, to close the wound, and allow the cavity of the pleura to be filled, until the lung shall be sufficiently compressed to cause the hemorrhage to cease, if the person survive so long. The first object is to save life; after that, if time be given, the next will be to relieve the loaded cavity. After the wound has been closed, and the patient has so far recovered that reaction has begun to take place, it may be concluded that the bleeding has ceased. The chest should then be most carefully auscultated from day to day, so that its respiratory state may be known, particularly with regard to the increase of effusion, which will then be serous. This will not take place until after the third, and not perhaps before the fifth or sixth day, in any considerable quantity; when, if it should have occurred, the wound should be reopened, or another opening made at the most convenient place for the evacuation of the effused blood and serum. It is probable that the wound of the vessel in the lung which furnished the blood will be closed in five or six days: while it is of great importance that the lung should be early relieved from pressure, that it should be allowed to expand, and not be bound down by false membranes; which will be the case if the compressing fluid be not removed, and the inflammatory symptoms subdued. There is no object to be gained but the suppression of the hemorrhage by retaining the blood and serum within the chest; while the probability of a return of the bleeding is not great after an opening has been made, and the blood and serum have been evacuated, although much mischief will inevitably follow the effused fluids remaining too long.
Repeated observation has shown that in sabre-wounds penetrating the chest and lung, which have not united, and from which no excessive hemorrhage has occurred, a great discharge of serous fluid usually takes place from the cavity, which, gradually diminishing, becomes purulent, and at last ceases, without the function of the lung being destroyed; while, if the wound had been early closed, and the fluid collected too long retained, the functions of the lung would be impaired, and a counter-opening, for the relief of the resulting empyema, may be unavailing. Whenever, therefore, the adhesive process between the pleuræ has failed, and great effusion has taken place, the sooner it is discharged the better.
In addition to the closure of the wound, it is desirable to arrest the hemorrhage by other means, if possible, such as the abstraction of blood from the arm to such an extent as it may be considered the patient can bear, the administration of the acetate of lead with opium, turpentine, matico, or the mineral acids; and the external and internal use of cold or iced water, if it can be borne. If there be reason to believe that a rib or ribs have been injured--that any extraneous body is inclosed in the wound--or, from its appearance, that it will certainly reopen, an incision should be made in the part injured, for the purpose of giving the necessary assistance. The cure, however, will not only be assisted, but mainly effected, by procuring a depending opening by means of the small trocar and canula introduced as low down as auscultation will authorize; the introduction of this instrument will give the desired information on the one hand, and do little or no harm on the other.
A soldier of the 3d Regiment of Infantry was wounded by a lance at the battle of Albuhera, in the left side, between the fifth and sixth ribs; and was thrown down, bleeding from the mouth and from the wound, which was afterward closed by his comrades, by confining upon it a piece of his shirt folded up for the purpose. Brought to the hospital, at the village of Valverde, he appeared ten days afterward to be dying from difficulty of breathing. On enlarging the opening in the integuments, a quantity of blood, partly fluid, partly coagulated, issued from the cavity of the chest. The wound was kept open to allow the discharge of this, and of a reddish, watery fluid, which, after a few days, became purulent. At the end of three weeks I sent him to Elvas, doing well, and with but little discharge from the wound.
A heavy dragoon, of the German Legion, was wounded at the battle of Salamanca by a sword, which penetrated the cavity of the right side of the chest, between the sixth and seventh ribs. He fell from his horse, and lost a considerable quantity of blood from the mouth and from the wound. On examining the wound next day, a black coagulum was seen filling up the orifice, the cellular membrane around being considerably ecchymosed, and little doubt existed that the oppression in breathing under which he labored was caused by blood effused into the cavity. On separating the edges of the wound with a director, several ounces of blood, half fluid, half coagulated, were evacuated by making the external opening, which was enlarged, quite dependent. The lung was then seen in contact with the external opening of the wound, having expanded as the pressure of the blood was removed from it. The wound was closed simply by lint, compress, and adhesive plaster, without bandage; the man was largely bled, and placed upon his wounded side on the ground, being the most comfortable position, in some degree relieved from the oppression in breathing. Two days after, the wound discharged freely a reddish-colored watery fluid, evidently from the cavity of the chest, the exit of which was aided by keeping the wound generally dependent. This continued for several days, the fluid gradually becoming less in quantity, and purulent; under careful management he was able to go to the rear, nearly well, by the end of October.
333. On the subject of the ecchymosis, which Valentin considers to be a pathognomonic sign of effusion of blood within the chest, he says: “It is very dissimilar to that which occurs after a blow or wound, and which takes place shortly after the accident, beginning around the wound, if there be one, and extending from it. The patient also complains of pain when the bruised part is pressed by the fingers. These characters are not observed in the ecchymosis, the sign of effusion, which always takes place near the angles of the lower or false ribs descending toward the loins. Its color is identical with that which appears on the abdomen of persons some time after death, a bright violet, (_violet très éclairci_.) It appears about ten days after the receipt of the injury, sometimes later.” The same sort of thing, he thinks, takes place when the cavity of the chest is filled with pus, but that edematous swelling is without discoloration.
334. In order to be explicit on points so important as those of which I have treated, I have thought it right to lay down certain general conclusions, subject to occasional deviations:--
_a._ All _incised_ or _punctured wounds_ of the chest should be closed as quickly as possible by a continuous suture through the skin only and a compress supported by adhesive plasters, the patient being afterward placed on the wounded side--a precept which is absolute only with respect to _incised_ wounds capable of being united by suture in the manner directed.
_b._ As soon as the presence of even a serous fluid in the chest is ascertained to be in sufficient quantity to compress the lung, a counter-opening should be made in the place of election for its evacuation by the trocar and canula, which may be afterward enlarged; unless the reopening of the wound should be thought preferable, which will not be the case unless it should be low in the chest.
_c._ If blood flow freely from a small opening, the wound should be enlarged so as to show whether it does or does not flow from within the cavity. If it evidently proceed from a vessel external to the cavity, that vessel must be secured by torsion or by a ligature applied on it, all the other methods recommended being simply surgical absurdities.
_d._ If blood flow from within the chest in a manner likely to endanger life, the wound should be instantly closed; but as the loss of a reasonable quantity of blood in such cases, say from two to three pounds, will be beneficial rather than otherwise, this closure may be delayed until syncope takes place or until a further loss of blood appears unadvisable.
_e._ If the wound in the chest have ceased to bleed, although a quantity of blood is manifestly effused into the cavity of the pleura, the wound may be left open, although lightly covered, for a few hours, if the effused or extravasated blood should seem likely to be evacuated from it when aided by position; but as soon as this evacuation appears to have been effected, or cannot be accomplished, the wound should be closed. It must be borne in mind that the extravasation which does take place is usually less than is generally supposed--a point which auscultation will in all probability disclose.
_f._ If the cavity of the pleura be full of blood, and the oppression of breathing and the distress so great as to place the life of the patient in immediate danger from suffocation, the wound should be reopened, if it have been closed, or freely enlarged, if small, to such an extent as will allow a clear evacuation of the effused blood. It has been supposed that in such a case the lung does not sufficiently collapse, and the bleeding is therefore continued because the vessel cannot contract; but the lung will usually collapse under pressure of the air, unless prevented by previously-formed adhesions, when the hemorrhage may possibly cease--instances of which are said to have taken place, and the practice should therefore be borne in mind.
LECTURE XXIII.
WOUNDS OF THE CHEST, ETC.
335. Gunshot wounds of the chest, penetrating the cavity, are always exceedingly dangerous. After the battle of Toulouse, on the 10th of April, 1814, one hundred and six cases of wounds in the chest in officers and soldiers, in all of whom the cavities were not penetrated, were received into hospital. Between the 12th of April and the 28th of June thirty-five died, fourteen were discharged to duty, and fifty-seven were transferred to Bordeaux to proceed to England, some to die, some to be pensioned, but few in all probability to return to the service--being an ultimate loss of nearly one-half, if the fifty-seven cases sent to England could be traced. M. Menière, in giving an account of the wounded carried to the Hôtel-Dieu of Paris, in the three remarkable days of July, 1830, where every case was immediately taken care of, says forty cases were received into the hospital; of these twenty died; he states the case of ten more, seriously wounded, who recovered; and he gives the names of seven more, in six of whom the cavity of the chest was not perforated, and alludes to three wounded by small-swords, who recovered--the loss being thus one-half, even if the rest happily and perfectly recovered, which may be doubted, thus showing that with the ablest assistance the Hôtel-Dieu of Paris could afford the loss was one-half. After the battle of Waterloo the loss was much greater; with the army on the Sutlej the loss was deplorable, in consequence of the want of a sufficient number of medical officers and of means--a state of destitution to which I have drawn the attention of the directors of the East India Company in the strongest possible terms, but which they will not rectify, but which will some day, I hope, become the subject of Parliamentary discussion, and, I doubt not, of public reprobation. That the wounds of the chest with the army in the Crimea will afford a more satisfactory result, cannot, I fear, be expected, and for similar reasons.
336. When a musket-ball fairly passes through the cavity of the chest, the orifice of entrance is round, depressed, dark colored, and more or less bloody in the first instance; the orifice of exit is generally more of a rugged slit or tear than a hole. The alarm is great, and the powers of life are much depressed. The wounds may or may not bleed; the sufferer may spit up more or less blood; respiration may be difficult, countenance pale, extremities cold, pulse variable--symptoms dependent on particular constitutions and circumstances connected with the extent of the injury.
It has been said that balls are apt to run round the body, coming out at a point opposite to that at which they entered, without penetrating the cavity of the chest; this, whenever it does take place, is a rare exception to a general rule, dependent on the ball being reflected from something solid which it cannot penetrate, such as a button, a piece of money, a rib, etc. If the ball run under the integuments exterior to the fascia covering the intercostal muscles, it is usually marked by a tenderness in its course on touching the part and a discoloration of the skin. A ball may, however, run between two ribs for some distance, injuring the muscular structures between them without penetrating the cavity, in which case, after the first moments of alarm have passed away, the symptoms indicative of a penetrating wound either cease or do not occur, although those of inflammation of the pleura or lung may and often do follow to a considerable extent.
When the ball cannot be traced, the absence of symptoms, after the first period of alarm has subsided, will enable the surgeon to form the surest prognosis; their absence, however, cannot too certainly be relied on.
A ball will occasionally rebound from the sternum, leaving merely a black mark; from the spongy nature of that bone in which they frequently lodge, they require the application of the trephine. If a ball should be felt through a wound in the sternum, the broken portions of bone should be removed by the small saw or by the trephine, and the ball extracted.
337. An enlargement of the wound, the “_debridement_” of the French, does no harm beyond the pain it occasions, unless there be something to be removed, when an incision becomes necessary, in many instances, for the removal of extraneous bodies or for the evacuation of blood, etc. When a wound from a musket-ball appears likely to have penetrated the cavity of the chest, and is too small to admit the end of the finger, the opening ought to be enlarged so as to allow its introduction as far as the ribs, in order to ascertain whether those bones have sustained any injury, or whether anything is lodged exterior to or within them. It is not necessary that a man should be cut simply because he has been shot; and an enlargement of the wound should be of no greater extent than is absolutely necessary for the purpose intended. When pieces of shell, or of a sword or lance, are broken off and partly lodged in the cavity of the thorax, which is more likely to happen when they enter through the large muscles of the back, they will require larger incisions to give room for their removal. Great praise was given of old to Gerard, surgeon-in-chief of La Charité in Paris, who, having perceived that a small sword, after going through a rib, was broken off close to it, thought it advisable to make an incision through the intercostal muscles into the chest, and then to introduce his forefinger, armed at the end with a thimble, with which he pressed back the point of the broken blade. In a case of this kind, the surface and outer edge of the bone should be removed, until the piece of steel can be firmly seized and withdrawn by a fine pair of pincers or pliers.
When a ball sticks firmly between two ribs, it requires some care to remove it, as the rib both above and below may be more or less interested, although not actually fractured. The attempt should be made during inspiration, when the lower rib should be depressed, and some thin but not sharp-pointed instrument like an elevator should be gently pressed around and under the looser edge of the ball, in order to extricate it.
When a musket-ball fractures a rib, there ought to be no hesitation about the propriety of enlarging the wound, to allow the splintered portions of bone to be removed. It is possible that in doing this some pieces of cloth or other matters may be extracted, which might else glide into the cavity of the thorax, or stick in the lung itself.
A soldier of one of the regiments on the left of the position of Talavera was brought to me, wounded by a ball in the left side of the breast; it had struck the sixth rib, and passed out about four inches nearer the back. As the point of the finger indicated the presence of broken bone, I enlarged the anterior wound, and then found that the ball had driven some spiculæ of bone into the surface of the lung, which appeared to have been previously attached to the pleura costalis at that part. These having been removed, together with a piece of coat which had been carried in with the ball, a small, clean wound was left, which gradually healed up, the man accompanying me on the retreat over the bridge of Arzobispo.
338. When a ball impinges with force on the center of one of the ribs, and passes into or through the chest, the bone is usually broken into several splinters of different lengths, some of which frequently accompany the ball in the commencement of its course, or are even carried into the substance of the lung, together with a part of the wadding of the gun, or of the clothes of the patient. These should if possible be extracted if they can be seen, and the sharp ends of the rib rounded off. When the ball fractures a rib on passing out of the chest, the splinters are driven outwardly, and should be removed by incision.
339. When a ball strikes a cartilage of one of the ribs, it does not punch out a piece as it were, but merely divides and passes through it, bending it inward, rarely tearing away a portion. The parts of the cartilage thus bent and turned inward are to be drawn outward, and replaced by the end of the finger, a bent probe, or other curved instrument.
A ball, when striking obliquely but with force on the chest, will frequently penetrate, and then run round, between the lung and the pleura lining the wall of the chest, for a considerable distance, before it makes its exit. In this case the lung may be only slightly bruised, without the pleura pulmonalis or costalis being more than ruffled. In others the lung shows a distinct track or hollow made by the ball. A shade deeper, and the ball penetrates, and forms not a hollow, but a canal. The patient in all these cases spits blood, and the first symptoms are severe; they frequently, however, subside, and are not always followed, under proper treatment, by effusion, although it may always be expected.
340. When a ball fairly passes through the lung, it leaves a track more or less bruised, which continues for a time to bleed according to the size of the vessels which are injured, thus making a wound more dangerous as it approaches the root of the lung where the vessels are largest. More or less blood is spit up, or, if effused, it gravitates in the chest, until it rests on the diaphragm or other most depending part, according to the position of the patient. If it should be in quantity, the filling up of the chest may be ascertained by auscultation, if the wound be closed. As the quantity of effused blood increases, the lung becomes more and more compressed, until at last the hemorrhage ceases under pressure, if the wound be covered; and the patient is saved for the moment, unless he should die of asphyxia, from the lung on the other side being also compressed through the bulging of the mediastinum on it; to prevent which, if possible, the wound should be reopened or enlarged, so as to take off the pressure of the effused and perhaps coagulated blood. If the person wounded shall have suffered formerly from inflammation, and the lung has adhered in consequence to the wall of the thorax, at the parts where the ball enters and goes out, the cavity of the chest will not be opened, and the track only of the ball will communicate with the external parts, unless the ball shall have perforated some of the large vessels, when he will continue to bleed by the mouth. The pressure of the blood effused into the track of the ball, which may become coagulated, will sometimes suffice, under even these circumstances, to effect the suppression of the hemorrhage which the loss of blood, the faintness of the patient, and the weakness of the circulation, under proper treatment, will materially assist in rendering permanent.
General Sir G. Lowry Cole, G.C.B., was struck at the battle of Salamanca, on the 22d of July, 1812, by a musket-ball, which entered immediately below the clavicle, fractured the first rib, and, inclining inward, came out through the scapula behind; as he spat blood for three days, the upper part of the lung was shown to have been injured. The ball appeared to have passed so close to the under part of the subclavian artery that the greatest fears were entertained for his safety; more particularly as a marked difference in the size of the pulse was perceived in the left arm, which did not exist before. He remained three days on the field of battle, in a Portuguese officer’s tent I always carried with me. Under repeated bleedings, and the strictest antiphlogistic treatment, several splinters having come away, and a large piece of the rib and of the scapula having exfoliated, he gradually recovered, so as to be able to resume the command of the Fourth Division in October at Madrid. The subclavian artery never resumed its power, and the radial always beat less forcibly on the left side. He perfectly recovered his health, the respiratory murmur of the lung being natural. He died suddenly in 1844, from rupture, I believe, of an aneurism of the abdominal aorta.