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the after-course of the wound a collection of pus takes place, and difficulty of breathing and so on occurs, the wound must be enlarged, the bleeding stanched, or a proper opening made for the escape of the pus.
Bruises and shot-wounds of the coverings of the chest may produce large outpourings of blood in the external parts, inflammation of the pleura and lungs, difficult breathing, spitting of blood, and so on, and require a strict antiphlogistic treatment, repeated bleedings, and cold applications to the chest.
479. Penetrating Wounds of the Chest ( Vulnera Thoracis penetrantia) either simply open the cavity of the pleura, or at the same time wound the viscera lying within the chest. Their danger depends generally on the bleeding which comes out of the walls of the chest, or from the viscera contained in its cavities, from compression of the lungs and heart by the collected fluids, from inflammation of the viscera of the chest, and their passages.
480. We ascertain that a wound of the breast actually penetrates into the cavity of the chest, or even injures the viscera contained therein, by the depth and direction to which the injuring instrument penetrates ; by the careful examination of the wound with the finger or with the probe, the patient being put in the same position as at the injury; by the influx and efflux of the air through the wound in inspiration and expiration ; by an air-swelling (emphysema) which forms around the wound; by difficult respiration, in consequence of the air which enters the cavity of the chest compressing the lung and preventing the flow of the blood. In simultaneous injury of the lungs the patient suffers deeply fixed pain ; breathing, especially inspiration, is very difficult; a frothy, pale-red blood pours in an unbroken stream out of the wound (1); the patient spits blood (the absence of spitting of blood is, however, no proof of the lungs being uninjured); sometimes also there are symptoms of internal bleeding and compression of the lungs, which are hereafter to be considered. The distinction of these wounds is more or less difficult according to their various size and direction (2).
Examination with the probe is, in most cases, illusive and uncertain; it may be very injurious, from the irritation connected with it, and is, in most cases useless, because the diagnosis is determined by other symptoms; and in a simple penetrating wound scarcely any other treatment is employed than in a wound that does not penetrate. The examination by injection, as advised by many, is still more unsatisfactory, and always dangerous.
The air passes freely in and out only when the wound is direct. The lungs do not always collapse, or fall together, when the cavity of the chest is opened, but remain in contact with the pleura costalis, which, in some cases, may depend on adhesion between the lungs and the pleura, but in others, is not to be explained. The opening, therefore, of both cavities of the chest is not directly mortal." WILLIAMS concludes from his experiments, Ist, that a lobe of the lung when exposed to the air does not collapse, so long as the functions of the other lobe and of the assistant organs continue undisturbed in respiration ; 2nd, that one lobe of the lung possesses a peculiar power of moving for some time, entirely independent of the diaphragm and intercostal muscles, when, indeed, the other lung respires: the origin of this power WILLIAMS cannot determine ; 3rd, that a sound lung recovers its natural expansive power when the pressure of the external air is removed ; 4th, that although the external air passes freely and uninterruptedly at the same time through tubes of the same size into the cavities of the chest, the lungs, however, do not collapse, if the assistant respiratory organs have their activity still unrestrained, 5th, that a healthy lung never completely fills the cavity of the chest, at least in natural respiration. In my experiments on dogs, I always found great collapse of the lungs, and the motions which I noticed in them seemed to me less dependent on a distinct expansive power in the lungs themselves, than much rather on elevation and
depression of the collapsed lungs in the laborious inspiration and expiration of animals, as will be described in accidents of the lungs.
[(1) To these symptoms AsTLEY COOPER adds " considerable irritation and tickling in the larynx." (p. 230.)
(2) In endeavouring to determine the course which balls take when wounding the chest, HENNEN's observation must not be forgotten, that “a ball striking the body or a limb will run round under the skin, and appear to penetrate right across the member or the cavity. By the deep-seated course which balls sometimes take, the deception is rendered still greater. Thus I have traced a ball by dissection, passing into the cavity of the thorax, making the circuit of the lungs, penetrating nearly opposite the point of entrance, and giving the appearance of the man having been shot fairly across, while bloody sputa seemed to prove the fact, and in reality rendered the same measures, to a certain extent, as necessary as if the case had been literally as suspected. The bloody sputa, bowever, were only secondary, and neither so active nor alarming as those which pour at once from the lungs when wounded. There is also another source of deception as to the actual penetration of balls into the cavities or the limbs; this is where they strike against a handkerchief, linen cloth, &c., and are drawn out unperceived in their folds." (p. 368.)
In the museum of the Royal College of Surgeons, London, there is a preparation of a most remarkable penetrating wound of the chest which recovered, and which was under the care of MAIDEN of Stratford, Essex (a), and the late Sir WILLIAM BLIZARD In this case the lungs were probably not wounded.
CASE 1.-T. T., aged thirty-five years, on the evening of 13th June, 1812, having incautiously taken off the bridle, before disengaging his horse from the harness and chaise, the animal became unruly, and T. T., catching hold of the foretop, attempted to replace the bridle; "whilst thus occupied the horse made a violent plunge, and thrust him by the end of the off-shaft against the projecting part of the chaise-house; at which instant he felt the shaft perforate his side, under the left arm; whereupon he made a violent effort to draw himself back, while the horse kept plunging forward, and he soon felt the end of the shaft pass from under his right arm, occasioning acute pain. *' The horse continuing to press forward occasioned on the left side a second wound, by the front tug-hook under the shaft.” A person alarmed by his cries came to him, and drawing back the shaft discovered that its “end, which had confined T. T., had also entered the weather-boarding of the chaise-house, and passed through it, * * * and that he was pierced through the body by the shaft of the chaise, and apparently standing on tiptoe with both arms extended;" and that “the end projected several inches beyond the trunk of the body.” The shaft was then gently withdrawn, and when released he respired two or three times, and found no alteration in his breathing; after which he walked up two flights of stairs to bed. Whilst being undressed for the first time felt faint, and soon had extreme difficulty of breathing, feeling as he said, " as if he should be suffocated by the blood trickling on his lungs.” He was very speedily bled by a large orifice to the amount of four pounds, when fainting came on, but no stimulants were used, and only a little cold water given. Upon the left side of the chest there were two wounds, the lower by the iron under the shaft, and the upper where the shaft itself entered, immediately under the arm. On the right side was also a wound in nearly the same direction, through which the shaft came out; the latter two wounds, each four inches in extent. The left shoulder and side of the chest were slightly emphysematous. He had not thrown up any blood. On the morning of the 15th, as the difficulty of breathing had much increased, with considerable pain, weight, and soreness, he was bled to thirty ounces with much relief: and in the evening, as there was fulness of the belly and nausea, a castor oil injection and five grains of calomel were given. On the following day vomiting had come on, and also pain about the region of the diaphragm, in addition to the previous symptoms; he was therefore bled to eighteen ounces. The vomiting increased, and was accompanied with hiccough, but towards evening these were relieved by effervescing mixture. On the 17th the difficulty of breathing being worse. seventeen ounces of blood were taken away, which alleviated the symptoms; and the bowels had been cleared by the calomel, which has been taken nightly. He had no pain in his back, nor any on either side except smarting at the wounds; but he thought from the great pain and tenderness about the breast-bone that it was broken. Next day the breathing being very laborious, he was bled to twentytwo ounces; but, thongh his respiration was relieved, he had still general tenderness in the chest and epigastric region, and therefore a large blister was applied over the front of the chest, which benefited him. On the evening of the 20th the breathing had
(a) An Amount of a case of Recovery after the shaft of a chaise had been forced through the thorus, London, 1824. 4to.
become more difficult, and nineteen ounces of blood were withdrawn. Some threads of flannel were observed deep in the wound under the right arm, but were not disturbed. On the 22nd he had less pain and difficulty in breathing than since the accident, but complained of distressing sensations about the chest, which he could not describe. Today his body linen was for the first time changed, and careful examination being made, not the smallest trace of injury could be found on the back. This done, it was thought advisable to take away fourteen ounces of blood, which relieved him more than before, not feeling any pain. only a smarting sensation, similar to that he had experienced in the wounds under the arms, on each side of the breast-bone internally, in the direction in which he was convinced that the shaft had passed. A blister was then re-applied, and kept open for some days. From this time he slowly recovered, and at the end of nine weeks the wounds were nearly closed. He lived for five years without inconvenience, except being put out of breath, on making any exertion, sooner than usual, and having the motions of his arms backwards, or raising them upwards, restricted by a feeling of tightness across the chest. After this time he occasionally suffered from considerable difficulty of breathing, irregular pulse, and struggling rather than pulsating action of the heart. He did not take much care of himself, and, after a time, became more seriously ill, and died March 2, 1823, nearly ten years subsequent to the accident.
Eramination.—The thorax was somewhat distorted, from an angular projection at the union of the upper and middle portions of the sternum, on each side of which was an irregular depression ; on the left, and four inches and a half from the middle of the bone, the depression extended forwards three inches, along the intercostal space between the second and third ribs; on the right, at three inches distance, the depression extended backwards two inches between the same ribs. The upper cicatrix, on the left side, was behiud the margin of the great pectoral muscle, and the under one an inch below it. The right cicatrix was opposite the intercostal space of the third and fourth ribs. The m. pectoralis minor adhered to a membranous substance occupying the place of the destroyed intercostal muscles, thin, sinooth, strong, and transparent, through which the lung could be seen on the left side, but not on the right. The cartilage of the left second rib had been broken, and was only united by ligamentous substance, and the rib itself also fractured, two inches behind, had united with its inner edge turned a little into the chest ; the third and fourth cartilages had been fractured, but united by bone. The right third rib had been broken. On opening the chest, the lungs were found strongly adherent, at their back part, to the pleure. In front, on the left side, the lung adhered to the displaced second rib, and to the membrane between the second and third ribs, the adhesions extending to the mediastinum as low as the fifth rib. Another portion of lung also adhered between the third and fourth ribs, where probably the tugiron had entered. On the right side, the lung adhered to the membrane between the ribs, to the extent of an inch and a half around its margin. The pericardium was almost entirely adherent to the heart, but not very firmly. The heart itself was larger than usual, and the cavity and fibres on the right side proportionally greater than on the left. - MAIDEN observes, in regard to this case, and which the examination seems to bear out fully :" I have no hesitation in declaring my firm belief that the shaft, being small at the top and of a wedge-like form, was forced between the ribs, on the left side, into and through the cavity of the thorax, under (behind) the sternum, and out between the ribs on the right side; not suddenly, but by several distinct movements, whence the lungs, large blood-vessels, &c., escaped injury.” (p. 32.)
For the following case I am indebted to my friend ANDREWS, of the London Hospital, under whose care the man was. In this there can be no doubt that the left lung was penetrated.
CASE 2.-J. T., aged nineteen years, a Prussian sailor, whilst engaged in lowering, the trysail-mast (a), the rope supporting it gave way, and he was transfixed by its bolt, to the deck. At the time of the accident the mast bad been lowered to within about six feet of the deck; the man raised his arms to lay hold of and guide the bolt into its proper place, when at the moment the suspending rope slipped or broke, and the mast dropping perpendicularly, fell on his chest, knocked him down on his back, and the bolt passing through his chest, pinned him to the deck, which it penetrated to the depth of an inch, so that his chest must have been compressed, from before backwards, to a space not exceeding four inches. Some time elapsed before the bolt could be drawn out, and he was then carried to the hospital,
The trysail-mast, about thirty-five feet long, and two feet in circumference at the bottom, has at this part an iron bolt five and a half inches long, and two and a-half wide, by which it fits into the boom, with a collar above to prevent it entering further.
Feb. 25, 1831, On his admission, 10, A.M., the countenance was livid, the breathing excessively distressed; small quantities of frothy blood were occasionally spat up, the palse intermitting; and for some time after his admission, these symptoms increased threatening almost immediate suffocation. The bolt had entered the chest, between the fourth and fifth ribs of the left side, about an inch and a half from the middle of the breast-bone, passed obliquely downwards and outwards, and came out between the eleventh and twelfth ribs, four inches from the left side of the spine, but was presented passing further by the collar, which chipped out a piece of cartilage, leaving the point of the heart with very insecure protection. The fourth rib was broken at its junction with its cartilage, as was also the twelfth, and that side of the chest was flattened. In addition to his hurt, the scalp on the right side was considerably lacerated, extending from the frontal to the lower part of the occipital bone, and exposing a great part of the temporal muscle. The lower jaw was also badly fractured.
A pledget of lint was applied over the wound, and fastened with adhesive straps, bet nothing more was done, and two hours after his admission the more urgent symptoms of suffocation had subsided, and he rallied a little.
7 P.M. The pulse had become full and rapid, varying between 100 and 110; the respiration on the left side was inaudible, except at the upper part of the chest; and a the right side it was puerile; twelve ounces of blood were taken from the arm, which slightly relieved him, and a dose of calomel and rhubarb given, which freely porged him
Feb. 26. Has passed a restless night; pulse 110; tongue brown and dry in the middle In the afternoon thirty leeches were applied to the chest : two grains of calomel ordered every four hours; milk at his pleasure. In the evening the same number of leeches were again applied; and, the pulse continuing accelerated, towards midnight ten ounces of blood were taken from the arm, which produced syncope, and on his revival the patient thought himself better.
Feb. 27. Had passed a quiet but sleepless night; pulse 110. Leeches were applied morning and evening.
Feb. 28. He passed a tolerable night, occasionally getting half an hour's sleep. The pulse continued rapid but weak. On applying the ear to the chest the pulsations of the heart were found violent, much more than indicated by the pulse. Thirty leeches were therefore ordered to the region of the heart. In the afternoon his bowels were copiously relieved. As towards evening he became restless, and dreaded a long night, fifty minits of laudanum were given at bed-time, which threw him into a profound sleep that lasted four hours.
March 1. Was not so well this morning; and the pulse being quick and fuller, the leeches were repeated on the chest, and fifteen ounces of blood, which was highly buffed and cupped, were taken from the arm; these rendered him faint, but somewhat relieved him. At midnight, the pulse continuing rapid, twelve ounces of blood were taken away, and a draught containing forty minims of laudanum and thirty of tincture of digitalis were given.
March 2. Has passed a good night, and had some refreshing sleep; pulse less free quent; tongue white, but the mouth not affected by the calomel. The leeches were repeated, the calomel ordered every six hours, with half a grain of opium at each dose. ÎThe notes do not state, but probably the calomel had run off by the bowels, and therefore had not affected the mouth; to check the purging, I presume, the opium was added.J. F. 8.] The leeches were repeated in the evening, and the anodyne draught at bed-time
March 3. Has had a good night and five hours' sleep; pulse continued quick; the wound was dressed, and the leeches applied to the chest, and repeated in the evening; forty drops of laudanum were given at bed-time.
March 4. Has passed a good night; thinks himself better, and that he shall get better if undisturbed. The leeches repeated; the calomel only to be taken twice a day. In the evening his pulse 132; tongue dry and brown. Leeches repeated, and also the night draught.
March 5. Has had a better night than he expected; pulse 120; he complains of soranes of his gums and mouth ; wounds in the chest rapidly granulating. Leeches repeated.
March 6. Mouth very sore, specially near the fracture; pulse 134, very weak; tonga moist and less coated. The scalp wound was first dressed, and found to be united throughout; the wound in the chest going on well. The calomel and the anodyne draught continued.
March 7. Has slept well; pulse 120, and fuller; the respiration continues inaudible at the lower part of the left lung, with dulness on percussiou ; the mouth being less sore the calomel was ordered four times a day; the leeches repeated, and anodyne draught continued. On the following evening he was ordered arrow-root and biscuit powder.
March 9. Better; calomel thrice a day; on the following day only three grains were given, and only twenty-five minims of laudanum given at night.
March 12. Has passed a very good night; says he feels quite well, and is astonished so many inquiries are made about his health. "A grain of calomel twice a day; the anodyne at night. Milk, arrow-root, and biscuit powder, as he pleases. From this time he continued improving, till
March 23, When he had a slight rigor; the pulse became very rapid, varying from 140 to 150; tongue dry, and excessive thirst; is very restless, and apprehensive that all is not right; the bowels have not been relieved for two days. Sixteen ounces of blood were taken away, which was rather buffy; a cathartic injection immediately, and a cathartic draught ordered every three hours till the bowels are moved.
March 24. Has slept but little ; tongue dry; pulse very quick and weak. Thirty leeches applied to the chest; saline mixture and two grains of calomel every three hours ordered. He was rather better in the evening. Sixteen leeches to the chest.
March 25. His mouth being slightly affected, the calomel was ordered only every six hours, and twelve leeches to the chest. Feels himself better; pulse 118.
March 26. Says he feels quite well again; pulse above 100. This morning for the first time complains of a cough accompanied with tickling in the throat. Twelve leeches to the chest. Two grains of calomel thrice a day; and next day, he complaining of soreness of the mouth, it was ordered only night and morning.
March 28. Says he feels quite hearty again: cough is troublesome; respiration returning in the left lung; very feeble just below the wound on the front of the chest with slight rhoncus mucosus. Blanc-manger and a little coffee twice a day.
April 2. Since the last report has been going on as well, except that his bowels have been disposed to costiveness, and it has been therefore necessary to give sulphate of magnesia in peppermint water every three or four hours, and a purging clyster. Complains of his cough becoming more troublesome.
April 4. Has been going back for the last day or two. The cough harasses him very much, and prevents him sleeping : pulse rapid and very weak. The wound in his chest looking well, but a sinus about three inches long passes obliquely outwards between the ribs and skin, which, being laid open, exposed a small portion of the cartilage of the fourth rib.
April 8. Much the same : cougb as troublesome : gets but little sleep: pulse 120, feeble. He takes syrup of poppies and squill vinegar three or four times a day, when the cough is urgent. To continue the blanc-manger, milk and broth as he pleases, and have one egg every morning.
April 9. Has had a better night and less cough.
April 12. Going on satisfactorily; says he feels quite himself again; sleeps well ; appetite good; pulse about 90.
April 22. Continues improving daily: respiration more audible, except at the lower part of the left lung: pulse perfectly quiet; sleeps well. Allowed table-beer and half a chicken daily. After this time nothing of consequence happened; and on the 30th of May he was convalescent. . The quantity of blood spat up in this case, did not exceed that commonly coughed up in broken ribs. The discharge of pus from the wounds till they had healed was very trifling. The pulsation of the heart was very violent, and distinctly raising the bed-clothes.
He recovered his health perfectly; first went into service as a footman, but returned to the sea, and was twice shipwrecked, and saved his life by swimming a considerable distance. In 1841 he was well, and went a voyage to the West Indies.
ASTLEY COOPER mentions the case of “a man who had been wounded through the intercostal muscles with an iron spindle; the wound healed, but tetanus supervened, of which he died. Upon inspecting the chest after death, the lung was found to have assisted in closing the wound by adhering to the injured pleura.” (p. 230.)
Opportunities of examining the condition of wounded lungs after their cure are of rare occurrence. HENNEN says he has “ never had the opportunity of examining the lungs after recovery from a severe wound.” (p. 386.)
An account of such a case has, however, been given by EVERARD HOME (a), thirtytwo years after the injury had been received. “In searching for the course of the ball, the spot where it entered the lungs of the left side was very readily discovered by the remains of a small cicatrix, the membrane at that part being thinner than common, and having a puckered appearance which terminated in a central point. This part of the
(n) The case of a person who was shot through the lungs and survived for thirty-two years, with an account of the appearance of the contents of the thorax after death; in Trans. of a Society for the improvement of Medical and Chirurgical Knowledge, vol. ii. London, 1800.