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and calomel with extract of hyoscyamus given. The food must be entirely fluid. Persons who have attempted self-destruction must be carefully watched, lest they disturb the bandages. This treatment must be persisted in so long as the inflammatory and convulsive state of the windpipe continues.
If union do not completely occur, the wound is to be covered with lappets dipped in lukewarm water. If the discharge be great, and the powers of the patient give way, Iceland moss, bark, and narcotic remedies must be used. The hoarseness which remains for the most part gradually subsides. ln injuries of the cartilaginous part of the windpipe, there sometimes remains for a long while a fistulous opening, which often closes of itself (2). When the bandage is removed, the patient must guard against a deep inspiration, and much drawing the head backwards (3).
[(1) If there be much inflammation and cough it is always best to remove the dressings, even though the breathing by the mouth may be comparatively easy, and allow the mucus or other secretion to be coughed through the wound, as their discharge by that passage is more easily effected than through the chink of the glottis, and consequently the necessary exertion and irritation are lessened. If the case proceed favourably, after a week or ten days the secretion from the lining membrane of the air-tube diminishes, it becomes less viscid, and is separated with less exertion; the granulations begin to close the aperture, and breathing begins to be performed through the laryngeal chink, and daily increases till the wound has entirely healed. ASTLEY COOPER mer tions an instance of ossification and exfoliation of the thyroid cartilage, in a case where the cure occupied several weeks (p. 246); but I believe such occurrences are rare...
I have had a case of fistulous wound between the thyroid and cricoid cartilage, which had been of some weeks' standing before I saw it, and the passage through the latter into the windpipe had become so narrowed, either by the falling together of the cricoid cartilage, of which the front had been perhaps cut off from the hind part, or by the adhesions which had formed between the lining membrane, that breathing was performed with extreme difficulty, and with a loud hissing noise. As these symptoms had been gradually increasing it was thought advisable to introduce a short silver tube, to do which it was necessary to enlarge the aperture with the knife, and the tube having been passed in the breathing immediately became easy, and the hissing ceased. She wore the tube for several weeks without inconvenience, and left the house with it still in. In this case, as might be expected, the voice was entirely lost.–J. F. S.
(2) These cases are very uncommon, ASTLEY COOPER says that in a wound upon the thyroid cartilage, which remained fistulous, he raised a piece of skin from the surface of the neck, above the opening, and turned it over it, having previously pared the edges, and it united extremely well.” (p. 246.)
(3) Sometimes after a cut has been going on well for some days, a sudden bleeding may come on, either during the exertion of coughing or any other effort, and it will be extremely difficult, if not impossible, to ascertain whether the blood come from an artery or vein. A case of this kind recently occurred in our hospital under my colleague MACKMURDO's care. A man cut his throat nearly from ear to ear, on the night of the 7th of July, 1845: he lost a large quantity of blood, but when he was found the bleeding had ceased. On examining the wound it appeared that he had cut between the hyoid bone and thyroid cartilage, separating with the former the epiglottis. The edges of the wound were brought together by bending the head down to the chest, and cold water dressing applied. On the next morning one suture was put through the lips of the wound, and on the day following other two. On the fourth day they were all removed, as there did not appear any disposition in the wound to union. On the afternoon of the 14th the sutures were again introduced. At 5, A.M., of the 15th, he had s violent fit of coughing, and, whilst trying to reach the chamber-pot from beneath bis bed, a sudden bleeding came on, said to be in a twisting stream. It was checked by pressure, but on the removal of the finger bleeding recurred, and he lost about halfpint of blood; but it was controlled by thrusting a piece of sponge into the bottom of the wound, which was left open, and cold water applied. No further bleeding having occurred, the sponge was removed on the 18th, and the wound has now (26th) filled with granulations, and the case has every appearance of doing well.-J. F. S.]
470. In Stabs of the Windpipe, owing to the parallelism of its inner and
outer walls, the air readily escapes into the cellular tissue. If slight pressure upon the wound do not prevent the escape of the air, the outer wall must be enlarged with the bistoury, so that the air may more readily escape.
471. Bruised Wounds of the Larynx and Windpipe, Shot-wounds with loss of substance, require besides the general treatment already mentioned, a simple linen bandage spread over with a mild ointment.
If the edges of the wound skin over, and fistulous passage form, which, especially occurs in bruises and in wounds connected with the loss of substance, the edges must be refreshed, (re-pared with the knife,) and, if possible, united vertically with the twisted suture. Attempts have been made to close the opening by healing over it a flap of skin (a).
472. Wounds of the Gullet occur with an entirely, or, for the most part, divided windpipe, (in stabs only is injury of the former possible without that of the latter,) and the gullet is either cut into or cut through. Severe wounds of the gullet are usually accompanied with wounds of the larger vessels and nerves, and are then speedily mortal. Without this simultaneous injury, however, wounds of the gullet may be very large; it may even be entirely divided without the wound being absolutely fatal (6). Injuries of the gullet in large wounds can be ascertained by the eye, by examination with the finger, and also by the fluid swallowed by the wounded person, escaping through the wound, and exciting severe
473. When in wounds of the gullet the blood has been stanched, the same treatment is to be pursued as in wounds of the windpipe : the external coverings must be fixed, and the head bent towards the chest. If the wound be large, the patient must be supported with nourishing clysters, baths, or what is best by strong broths introduced by an elastic tube into the stomach. If the tube excite vomiting, coughing, or bleeding, it must be removed, and nourishing clysters and baths only used. The tormenting thirst of such patients is best relieved by putting into the mouth slices of lemon or Seville orange sprinkled with sugar. As the wound advances towards healing pappy gelatinous food must be cautiously given by the mouth.
The elastic tube kept in the gullet should be about as thick as the little finger, and provided with a valve at its top. It is introduced through the nose or mouth; it generally slips the first time into the windpipe, which must be ascertained by the motion of a taper flame held before the opening of the tube. In this case, the tube is to be drawn back, and attempt made to pass it more backwards into the gullet. It may remain many days, its outer end being fastened.
(1) ASTLEY COOPER “ objects entirely to the introduction of tubes into the pharynx and esophagus, as worse than unnecessary, for they are highly injurious by the cough which they occasion by their irritating the wound; and, if adhesion or granulation have taken place to close the wound, such tubes tear it open again and destroy the process of restoration." (p. 249.) The correctness of this opinion is fully borne out by the following case related by STARK (c):
CASE.-A man cut his throat ; " the external jugular veins on both sides were perfectly divided ; the carotid arteries laid bare; the trachea arteria divided from the larynx immediately above the pomum Adami ; the epiglottis and glottis, along with the os hyoides, perfectly detached from the rima glottidis; the pharynx cut through, except about a finger's breadth of the back part, which was very much stretched, for the trachea thus divided had retracted equal to the clavicles, as had also the fore part of the esophagus, which very much stretched the remaining fibres of the pharynx. "As the os hyoides was perfectly detached from the rima, consequently every muscle that arises from the
(a) La Lancette Francaise, 1831, 26 Nov.-Fro- in Bezug auf ihre Behandlung und ihr LethaliRIEP's Notizen, 1831. No. 692.
tätsverhältness, in his Magazin, vol. vii. p. 262. (b) Rust, Einige Beobactungen über die Wun (c) Medical and Philosophical Commentaries, by a den der Lufr und Speise röhre, mit Bemerkungen Society in Edinburgh, vol. iv. part i. London, 1776.
different cartilages, &c. of the windpipe, and which are inserted in the os hyoides, Fere cut through. * * * I endeavoured to attach the fore part of the Esophagus to the pharynx with needles and waxed thread; but it was found very difficult to accomplish, as the wound was very jagged, the patient averse to have any thing done for him, and the pricking of the needles brought on violent retching to vomit, so that the contents of the stomach were evacuated by the wound. I next endeavoured to attach the tracked to the larynx, which was likewise difficult, on account of the constant convalsive congbing; however, it was at last done, and the patient in this situation could swallow a little water, though the greatest part still ran out by the wound.” Some adhesive straps were afterwards applied. His bowels were kept open with clysters. No nourishment given by the mouth, but nutritive clysters thrown up every two hours. He went on very well till the sixth day, when he became very feverish; the discharge ichorous and oftea. sive; the breathing quick and difficult, with a loud rattling noise. Hot dressings were applied to the wound. On the ninth day the fever had subsided, and the discharge from the wound thick and hardly in any degree offensive. On the following day, when the dressings were removed, “all the stitches had given way, and the windpipe and gullet had retracted as before. *** Between the os hyoides and the clavicles there was only oce continued gash, which looked as if the windpipe and the gullet had been cut out entirely." As he was now very much reduced, and both very thirsty and hungry, attempts weit made “ to introduce nourishment by the external wound, by means of a bent catheter that had a bladder tied to it; but the catheter had no sooner touched the top of the gullet than it produced violent efforts to vomit, and convulsive coughing, which tore the wound quite open. Finding this method would not succeed, I laid it aside, and trustad to strong nutritive injections only. I again put in a stitch or two into the fore part of the windpipe, but soon found they could be of no service, for they not only prevented reunion, but kept up a constant irritation on these sensible parts. I therefore next ds removed them, and only continued the stitches in the external wound, for the metas and matter now prevented adhesive plaster from sticking; and in order that there might be very little stress on the external stitches, I kept his chin confined close to his breast by means of pillows under his head, and a night-cap with straps that tied under the am pits. About this period small granulations of flesh made their appearance on the wound.” On the twenty-fourth day he was “sitting up in bed with a plate before hin containing boiled rice. I asked if he had swallowed any, to which he made sigus that he had, by patting bis belly, and expressing great joy of countenance. I desired be would make another attempt, and found, to my great astonishment, that he could swallow some, though by much the greatest part came out by the wound." He continued to mend, and about the end of six weeks from the accident, the external wound healed op entirely, except over the pomum Adami, which, by being a little hurt, gradually seps; rated; and as the separation was very slow, a small part of the external wound turned fistulous, and so left a passage into the windpipe, through which he could breathe st pleasure, though he generally breathed by the mouth as before, and could swallow either liquids or solids without any part coming by the wound.” A fortnight after, he went out, got drunk, and vomiting the following morning, “ some of the remains of the lique probably got into his windpipe, for he fell back on his bed and expired in an instant." On examination, there was found a perfect reunion of all the injured parts; the # hyoides was rejoined to the windpipe in the fore part by means of a soft but tough substance, which occupied the place of the scutiform and thyroid cartilage. The Time glottidis was attached to the sides of the os hyoides by a tough membranous cicatria. which marked the extent of the wound in its first state. All the muscles inserted into the os hyoides and originating from the cartilages, &c., had, after being cut through in the accident, retracted, and on one side formed a large and hard substance, about twice the size of the pomum Adami.” (p. 434-443.)
Dr. Ryan also relates (a) another, and very similar, case, in which, as in the formet nature seems to have had most to do with the cure.
CASE.-A negro received several wounds in the neck, which, when seen some time after the accident, appeared to be “ thrusts or incisions with a knife between the upper edge of the right side of the thyroid cartilage and the os hyoides ; one incision was made transversely, it began below and opposite the middle of the base of the os hyoides, and extended almost as far as the right carotid ; it seems to have totally divided the sternohyoid and hyo-thyroid muscles. This incision was crossed by another, which was made in a longitudinal direction.” When first found, “they gave him some drink, but it all came out through the wound; and they, as well as he himself, declared, that till the thirteenth day after the attack he swallowed nothing whatsoever. Hence he was almost
(a) Duncan's Medical Commentaries, vol. viii. London, 1783.
exhausted, and his situation thought so desperate that recourse was had to none of the meaus usually employed in such circumstances in order to support life. From the time he began to swallow he has gradually recovered some strength, and he can now eat plantains, the chief fare of the negroes."' When Ryan had removed the dressings, “ on his attempting to drink some water, the most part rushed out by the orifice; but when it was closely stopped up by the application of another's hand, he swallowed pretty freely, though not without some coughing. It is always necessary to make a pressure of this kind when he takes any food. I had his mouth and nostrils closed for some time, but he breathed through the wound.” (p. 319-21.)
HENNEN has mentioned a case in which the larynx was completely severed between the thyroid and cricoid cartilages, and the æsophagus laid open throughout half its calibre. * * * I confess we were at a loss what to do; for when we attempted to close the wound he could not breathe at all. We therefore left it open, keeping his head reclining forward, and expecting that he would soon be suffocated. This did not happen, however, for he breathed very well through the wound; but his greatest suffering proceeded from thirst, as every thing he attempted to swallow came through the opening. We tried to introduce liquids through a flexible tube, but we succeeded very badly, on account of the great irritability of the fauces, trachea, and esophagus. As there was great abundance of milk to be had, he was put in a bath of this fluid several times a day, and clysters of various nutritious fluids were assiduously thrown up. By these means he was entirely supported during the space of eighteen days, and nothing but common dressings applied to the wound. At the end of this period, the æsophagus became retentive when liquids were taken, and the breathing was beginning to be partly carried on through the mouth. From this time he rapidly recovered, excepting a considerable loss of voice and power of articulation.” (p. 364.)]
474. As wounds of the gullet very rarely heal by perfect agglutination of their edges, but the interspace is filled by the neighbouring parts, there usually remains some contraction at this part, or it bulges like a bottle, in either of which cases swallowing is difficult.
475. Stabs of the Gullet, if there be no accompanying severe injury, often heal without any symptoms. If the gullet be wounded at the lower part, the food that is swallowed may pass into the cavity of the chest.
476. Deep wounds at the back of the neck often produce a palsied condition, and also frequently a wasting, of the lower limbs. Wasting of the testicle and loss of the generative power have also been observed in these cases.
[Of the severe nervous symptoms occasionally following gun-shot wounds of the throat. HENNEN mentions an instance in an officer who received a ball in " the sternal portion of the m. sterno-cleido-mastoideus, about an inch above its origin, which passed inwards towards the thorax, but no trace of its route could be discovered. On receiving the shot, he instantly dropped, not, however, perfectly senseless, but very much stunned. He felt as if he had received three distinct wounds, the most severe of which he referred to the arm of the wounded side, the two others, of nearly similar severity, to his throat and stomach.” He lost “an enormous quantity of blood, which also gushed copiously from the wound at every effort to cough or vomit. * * * His left arm hung nearly lifeless, with a pulse scarcely perceptible; that of the sound arm was excessively quick, 120 in a minute, and very feeble. On the following day he was better, but had such an oppression along the course of the diaphragm, that he urged HENNEN to cut for the ball, as he was certain, he said, it was the source of this pain. * * * He spat up a florid frothy blood very copiously, and the same issued occasionally from the wound. The efforts to vomit, and spasmodic catchings of the throat with globus and hiccup were very severe. On the third day the dyspnea was almost suffocating, and the nervous symptoms ran very high. On the fourth day his voice was entirely lost, till the sixth, when it began gradually to return. On the thirtieth day, after severe spasmodic bilious vomiting, the speech was again affected suddenly. His arm, which had, after the first twenty-four hours, given him occasional uneasiness, and in which he felt a prickling sensation on the inner side, was particularly painful at the period of this spasmodic attack. It had been wrapped in flannel, and gentle friction had been employed to it; but upon examining it more particularly, it was found somewhat shrunk, and the fingers cold and nearly insensible to pressure. In about six weeks he went home to England, and continued improving.” (p. 358-61.)
A case is related by KENNEDY (a) of a man wounded on the right side of the thyroid cartilage by bullet, which, passing behind the m. sterno mastoideus, was next day found lodging a little above the superior costa of the scapula, and when cut upon two bullets joined by a neck were removed. The wound healed kindly in five weeks. "Immediately upon the patient receiving the shot, his right arm, from a little below the neck to the finger-points, became pale, quite cold and benumbed.” Aromatic and spirituous fomentations were used, and the arm covered with bags. “In about twelve hours after the arm recovered some heat; but the thumb of that hand was seized with violent pain, which kept him all night from sleep; and the next day the pain was so unsupportable, that he was in danger of turning delirious, though his pulse was scarce quickened and he had no thirst or other sign of fever.” Blood was taken from the arm again, (he having been bled also on the day previous,) clysters thrown up, and anodyne fomentations and poultices employed without relief. Some laudanum was given, which relieved the pain, but did not cause sleep, and the pain recurred next morning. The quantity of laudanum was therefore increased, and on the third night he had sleep; and after. wards it was given also in the morning, but in smaller quantity. As the effect of the opium diminished its quantity increased, till in the course of six or seven months the opium amounted to 250 drops of laudanum. Two months after he had received the wound, not only his thumb was pained, but such another pain was felt, at the joint of the elbow, without either swelling or hardness in the pained parts, or in the parts between them, and the fore-arı remained free from pain.” At the end of seven months the pain began to abate, “but as the pain became less uneasy the feebleness of the member increased ; and in twelve months the pain was gone, and the use of the arm entirely lost. About two years and a half after receiving this wound he went to Bath and used the waters for a season : when I saw him after that time at London, he told me he had recovered the full use and strength of his arm.” (p. 167–70.)
IV.-OF WOUNDS OF THE CHEST. VERING, über die eindringenden Brustwunden. Wien, 1801. 4to. HEROLD, über die Behandlung trefer Wunden der Brust. Kopenhagen, 1801. 8vo.
LARREY, Mémoires de Chirurgie Militaire, vol. ii. p. 150; and in the Mémoires de l'Académie Royale de Médecine. Paris, 1828. Vol. I.
RUMEBE, E., Dissertation sur les Plaies d'Armes à feu pénétrantes dans la Poitrine. Paris, 1814. 4to.
HENNEN’s Principles of Military Surgery. 2d Edit. MAYER, C., Tractatus de Vulneribus Pectoris penetrantibus imprimis cum Hæmor rhagia conjunctis. Heidleb., 1823. 4to. Heidelberger klinische Annalen, vol. i. part iii. p. 365.
REYBARD, J. H., Mémoires sur le Traitement des Anus artificiels, des Plaies des Intestins, et des Plaies pénétrantes de Poitrine. Paris, 1827. 8vo.
477. Wounds of the Chest (Vulnera Thoracis) are either superficial or may penetrate into the cavities of the chest.
478. Superficial Cut and Sabre Wounds require the same general treatment, and their union can always be produced by sticking plaster. Superficial Stabs (of which we satisfy ourselves by their direction, by the depth to which the injuring instrument has penetrated, and by examination with the probe, after placing the patient in the same position he was at the moment of the injury, and by the absence of the symptoms to be described in penetrating wounds of the chest) are also to be treated, according to the general rules, although the more active inflammation, which usually occurs in these wounds, requires a stricter antiphlogistic treatment. But when extravasation of blood takes place in the cellular tissue, and compression is not sufficient to stanch the bleeding, or when in (a) Medical Essays and Observations, published by a Society in Edinburgh, vol. i. Edinburgh,