Part 47
William Barrett, of the Life Guards, a middle aged, muscular man, of full habit, was wounded by a musket-ball at the battle of Waterloo; it fractured the third and fourth ribs behind on the left side, and broke the left arm. He was brought to Brussels, where the inflammatory symptoms were subdued by repeated general and local bleedings, and the other ordinary but strictly antiphlogistic means, during the first six weeks, by which time the external wound had nearly closed, and no trace of the ball could be perceived. At the end of this time, Staff-Surgeon Collier, now Inspector-General of Hospitals, under whose care he was, and who furnished me with these particulars of the case, which I saw in Brussels, finding that his symptoms became worse, that he had rigors and evening exacerbations, and that the difficulty of breathing had increased almost to suffocation, decided on opening into the cavity of the chest and following the course of the ball. This he did by a deep incision, which enabled him to remove some pieces of the ribs, which were denuded but not detached. A bag-like protrusion was then felt between the ribs near their angles, which was opened, and nearly two pints of thick, fetid pus escaped, the relief which followed being as complete as sudden. The wound was dressed from the bottom, and every means adopted, except introducing a tent, to prevent its closing, but in vain; the opening closed, and matter again collected, requiring a second incision for its removal. Between these two operations small bleedings were resorted to most beneficially. A short gum-elastic catheter was introduced into the cavity of the chest after the second incision; very little matter, however, was secreted. From this time he gradually recovered, and was sent to England, cured, in November.
347. The presence of a ball, rolling about on the diaphragm, can now be ascertained by means of the stethoscope at an early period, so as to admit of an operation being undertaken with confidence for its removal; while the knowledge acquired by auscultation or percussion, of the filling of the chest by fluid, whether serous, bloody, or purulent, is at the same time incontestibly demonstrated. The presence of a ball, or of any other foreign body, decides the question as to the place where the opening into the chest should be made. On this point the information derived from the practice of the French surgeons in Algeria is valuable.
M. Baudens, whose labors I again refer to with great pleasure, says that he has also seen splinters of bone and even a ball, surrounded by a cyst formed by the pseudo-membranes of inflammation, cut off from the general cavity, and confined in the angular space formed behind between the rib, the diaphragm, and the spine. In one case, M. Baudens introduced a _sonde à dard_, such as is used in the high operation for the stone, between the second and third ribs, and made it project behind between the eleventh and twelfth. He then cut down upon it, and extracted a ball and some splinters of the rib. The wound thus made was then closed, the upper one being sucked dry daily by a pump. The patient recovered in forty days.
A., 54th Regiment, was brought to the hospital at Algiers, on the 22d of October, 1833, wounded eleven days before by a ball, which, having broken the right clavicles was lost in the chest, without any sign of effusion having taken place; he appeared to be going on well, until suddenly he complained of pain about the middle of the sixth rib, which could not be removed by the means employed, and was accompanied by a great discharge from the wound. On the 10th of November he died. The clavicle and the first rib had been fractured, and an abscess had formed behind them, the size of a hen’s egg, containing several splinters of bone, which had stuck in and afterward separated from the lung. The ball had passed from above downward and outward, forming a sinus, which terminated at the middle of the sixth rib, to which this part of the lung was attached; the posterior three-fourths of this canal were closed; the anterior fourth contained two splinters of bone, one of which was about to fall into the abscess in front. The sixth rib was broken, although it had not been perceived during life; and a small digital cavity was formed at this part in it by the ball, surrounded by portions of lymph, floating loosely from its edges; from this the ball had been detached, and had given rise to the inflammation which destroyed him. The ball had fallen on the diaphragm, where it was lying loose, surrounded by a quantity of purulent matter.
M. Baudens says himself, and rightly, that the operation of opening into the chest should have been performed in the eleventh intercostal space, and that the wound in front should have been enlarged.
M. Baudens relates another case, in which the posterior wound, situated near the angle of the tenth rib, had healed, the anterior one, half an inch below the clavicle, giving issue to an abundant and weakening suppuration. The lung above this was permeable to air, but the respiratory murmur could not be heard below it. To draw off this offensive fluid, he adapted an empty caoutchouc bag to a gum-elastic canula, which he affixed against the orifice of the wound, and thus sucked out six pints in five days. Some days later the wound behind reopened, and a piece of bone was discharged from it, which saved the man’s life. Two years afterward he was seen in good health.
The desire to have as dependent an opening in the chest as possible in these injuries has been manifested by all surgeons of experience; and the interspaces between the ninth and tenth, and between the tenth and eleventh ribs, have been often selected for this purpose; but as the operation was formerly done with the trocar, the abdomen was as often opened as the thorax, and death was frequently thus caused, even if it would not have been occasioned by the disease. To prevent, or to avoid this evil, M. Baudens advises its being performed at three fingers’ distance from the spine, by incision, and he says he has frequently done it with success, although he does not give any circumstantial directions as to the operative method to be pursued. I therefore caused several experiments and dissections to be made in the workroom of the College of Surgeons by Mr. Quekett, with the following results:--
348.--1. That a trocar and canula pushed in between the eleventh and twelfth ribs, in a diagonal direction upward, on a line with the angle of the ribs generally, will in the _dead body_ invariably enter the cavity of the chest without injuring the diaphragm.
2. That the same operation performed on the _living body_ would, in all probability, if done at the moment of expiration, first enter the thorax, then pierce the diaphragm, and thus open into the cavity of the abdomen,--a difference in result to be explained by reference to the anatomy and physiology of the parts concerned; showing that this operation, when required on man, should always be done cautiously by incision, and not by puncture with the trocar and canula.
On examining the lower part of the chest from within, after removing the pleura, the diaphragm is seen forming the boundary between the thorax and the abdomen, commencing from the transverse process of the first lumbar vertebra, and forming an arch under which the upper part of the psoas muscle passes, (the ligamentum arcuatum proprium.) From this part extends another aponeurotic arch along the lower border, to the end of the last rib, called the _false ligamentum arcuatum_, (ligament cintré du diaphragme of Cruveilhier,) which is nothing more than the upper edge of the anterior layer of the aponeurosis of the transversalis muscle, folded upon itself in all its extent. The diaphragm is afterward attached to the lower border of the twelfth, and in succession to the eleventh, tenth, ninth, eighth, seventh, and sometimes to the sixth, ribs, counting from below upward. The external intercostal muscles are distinctly seen between the ribs, extending from the spine until they meet and are concealed by the fibers of the internal intercostal muscles, near the angles of the ribs. The vessels and nerves, after passing on the external intercostal muscles, subsequently run between them and the internal ones.
The lower intercostal arteries arise from the aorta on each side, and before they enter the space between the ribs give off a branch passing backward to the vertebral canal and the posterior muscles of the spine. The eleventh and twelfth intercostal arteries, covered at first by the pillar of the diaphragm, ascend on leaving the vertebræ to reach the under edges of the ribs, and are accompanied by a vein and nerve. The tenth intercostal artery, and those immediately above it, run almost horizontally, and nearly in the mid-spaces of the ribs, as far as their angles, at which part a small artery is commonly given off, which descends from the main trunk at an acute angle to the rib below, and may be injured in opening into the chest, and be perhaps mistaken, in operating, for the intercostal artery itself. From the angles each artery runs in a groove in the under edge of the rib as far as the anterior third, when they all become very much diminished in size, and, leaving the grooves, run in the middle of the intercostal spaces, until lost in their different anastomoses with the branches of the epigastric, phrenic, lumbar, and circumflexa ilii arteries.
In making an opening into the chest between the tenth and eleventh, or between the eleventh and twelfth ribs, the artery will not be injured, provided the opening be made below the middle of the intercostal space, which is wider between the eleventh and twelve ribs than between those above it. The vein is situated above the artery, and proceeds to the vena azygos major on the right, and to the smaller azygos vein on the left side.
The intercostal nerves are the anterior branches of the dorsal nerves, and lie below the arteries under the pleura upon the external intercostal muscles, until they approach the angles of the ribs, where they enter between the layers of the intercostal muscles.
It is worthy of observation that the pleura is necessarily continued over the inside of the twelfth rib to line the different attachments of the diaphragm, and that an incision may always be made into the chest above this point, if done carefully.
On removing the integuments of the back, covering the muscles and the lower ribs, the broad expanse of the _latissimus dorsi_ muscle is brought into view, extending from the ilium and spine upward and outward, and covering all the parts of importance beneath in the operation to be described. On the removal of the lower part of this muscle the _serratus posticus inferior_ is seen, of a somewhat quadrilateral form, arising by a thin aponeurosis common to it and to the latissimus dorsi, from the spinous processes of the three superior lumbar vertebræ and the two inferior dorsal, and proceeding upward and outward to be inserted by four flat, tendinous digitations into the four lower ribs.
If this muscle be separated from its origins and turned outward, or divided in the middle, and its two portions reflected, the posterior spinal or long muscles running in and filling up the groove or hollow of the side of the spine will now be distinctly seen, composed chiefly of the sacro-lumbalis and the longissimus dorsi muscles, sometimes called as a whole the _erector spinæ_ or the _sacro-spinal_ muscle. This, which forms a thick mass over the beginning of the tenth, eleventh, and twelfth ribs, is not to be divided or interfered with beyond a very few at most of its external fibers; the opening into the chest about to be made should begin at its external edge and go through the external intercostal muscle, which is now exposed on a plane below it.
The eleventh and twelfth ribs, unlike all those which precede them, except the first, have only one surface of articulation with the corresponding vertebræ, to which they are attached, instead of two facettes articulating--one with the body of the vertebra above, the other with that below. They form, particularly the twelfth, a more acute angle with the spine than the other, which gives to them their greater degree of obliquity, while the freedom of their cartilaginous extremities enables the twelfth, particularly, to be depressed or separated by a moderate force from the rib above to a greater extent than at any other part, by which means a foreign body of larger size may be removed from between them more readily than elsewhere.
349. _Operation._--The eleventh and twelfth ribs having been distinctly traced, and the obliquity of their descent from the spine having been clearly made out, the patient ought, if possible, to be placed on a stool, with the upper part of the chest supported by a pillow on a table before him. An incision should then be made over the intercostal space between these ribs, three inches long and slightly curved, through the integuments down to the latissimus dorsi muscle, and as the mass of long spinal muscles is usually three inches in width, and can in general be seen, the incision should commence two inches from but between the spinous processes of the eleventh and twelfth vertebræ, and be continued obliquely or diagonally downward in the course of the interspace between these ribs. The latissimus dorsi and the serratus posticus inferior muscles having been divided at the upper part where they cover the longissimus dorsi or the long spinal muscular mass alluded to, its edge becomes apparent; from this point the latissimus and the serratus are to be further divided downward. The external intercostal muscle being thus exposed, its fibers should be scratched through or separated in the middle of the interspace between the ribs, which can now be seen as well as felt. A director should be introduced below the muscle, on which it may be carefully cut through, as well as any fibers of the internal intercostal muscle which may extend as far as the wound thus made. The pleura will then be exposed, and if the cavity of the chest contain fluid in any quantity, it can scarcely fail to project in such a manner as to convey to the finger the assurance of its being beneath. An opening may then be carefully made into it at the upper part of the incision close to the external vertical fibers of the spinal mass of muscles, _at the moment of inspiration_, and on the existence of fluid being ascertained by its discharge, the opening should be enlarged by a director previously introduced under the pleura, the patient being desired to draw a full breath at the time, in order that the diaphragm may descend as low as possible. If there should not be any fluid in the chest, the diaphragm, in ascending during expiration, may be applied to the inside of the pleura lining the chest as high even as the fifth rib, counting from above, and might easily be divided with the pleura, if great care were not taken to make the opening during the process of inspiration.
In all cases of wounds of the chest, in which auscultation points out the presence of a ball rolling loose on the diaphragm, this operation should be performed for its removal, and may save the life of the sufferer. It would, perhaps, have done so in the case of Sir Robert Crawford. At a later period the presence of a foreign body, perhaps, can only be known by the sounds or defect of sounds which may be observed at the back part of the chest, in which the ball or other foreign bodies lodge or become enveloped by matters confining them in that situation.
LECTURE XXV.
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.
5th.--Passed a sleepless night, and was evidently suffering from considerable internal mischief; wandered occasionally; pulse quick, 120, and small; felt very weak and desponding. A little light, red wine given, with beef-tea and bread; opium night and morning.
6th and 7th.--Much the same; pulse always quick, with much general irritability.
15th.--The wounds discharged considerably, particularly the posterior one; has a little cough; pulse continues very quick; spasms of the diaphragm troubled him for the first time, and caused great pain and uneasiness; they were relieved by opium in large and repeated doses.
On the 18th the spasmodic affection of the diaphragm and the pain returned with great violence, so as to threaten his dissolution, which took place on the 20th.
On examination, I found that the ball had passed through the under part of the inferior lobe of the left lung, and through the pericardium under the heart, through the tendinous part of the diaphragm, and into the liver, before it made its exit. The wound in the lung was suppurating; the matter and fluid from the cavity of the chest had a free discharge by the shot-hole; the edges of the wound in the diaphragm were smooth as if cicatrized, leaving between them an elliptical opening an inch long. The injury to the liver was through the substance of the anterior part of its right lobe; the matter having a free discharge, and generally slightly yellow, as if tinged with bile in small quantity. The skin did not show a yellowish tinge, neither were the conjunctivæ discolored.
A soldier of the 23d Regiment was wounded at the same affair, by a musket-ball, on the right side; it fractured the sixth rib, from three to four inches from the sternum, and passed out behind, between the ninth and tenth ribs, near the spine. The rib being fractured, the splinters were removed after an enlargement of the wound by incision, when the opening into the cavity of the chest was manifest, air being discharged freely from it. The shock in the first instance was great; but after a time reaction took place, and he lost a considerable quantity of blood in six bleedings during the first sixty hours. The discharge, at first serous and bloody, gradually became purulent, and the occurrence of jaundice showed that the diaphragm and liver had in all probability been injured. Under the administration of calomel, antimony, and opium, this symptom was gradually disappearing, when I left him to rejoin the army. He was sent to the rear at the end of ten weeks nearly well.