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lungs had not the slightest adhesion to to the pleura, but was in its natural detached state. The course of the ball through the substance of the lungs was readily traced by dissection, for an induration of the substance of the lungs was formed wherever it had passed; this was best seen by making transverse sections of this thickened part. The appearance of the lungs in the right side was of the same kind, but in a less degree. The course of the ball was nearly through the upper lobe of both lungs, at nearly the distance of two inches and a half from the highest part of them where it entered the left lungs. The portion of lungs above the ball did not contain air, but the cells were filled with serum, so that it was more dense than natural, and sunk in water; but this part was not in any degree shrunk or contracted. It had no communication with the branches of the bronchia, the adhesive inflammation consequent to the wound having consolidated all the parts above the line through which it passed.” (pp. 171, 72.) Upon this subject see also BREMOND; in the Mémoires de l'Académie des Sciences, an 1739. NORRIS; in the Memoirs of the Royal Society of London, vol. iv. RICHTERS, Chirurgische Bibliothek, vol. iv. p. 695. ABERNETHY's Surgical Works, vol. ii. p. 178. WILLIAMS, On the Effect of Air penetrating the Cavities of the Chest in Wounds of the Thorax; in London Medical and Physical Journal, June 1823.
REYBARD, above cited.
[480* In regard to the prognosis of wounds of the chest, HENNEN observes :-“I should be unwilling to lull either a patient or a Surgeon into a false security, or to underrate the real danger of any case; but I have seen so many wounds of the thorax, both from pike and sabre thrusts, and from gun-shot, do well ultimately, that I cannot but hold out great hopes, where the third day has been safely got over, for though occasional hæmoptysis may come on, at almost any period during a case, and its approach can neither be entirely prevented nor anticipated, the more deadly hæmorrhages are usually within the first forty-eight hours; and yet to this alarming symptom, when within moderate bounds, the safety of the sufferer is often due. Dr. GREGORY of Edinburgh was in the habit of stating in his lectures, that of twenty-six wounds of the thorax received at the battle near Quebec two only were fatal.” (pp. 386, 87.)]
481. Penetrating wounds of the chest are most conveniently treated under the following conditions :- 1. Simple penetrating wounds; 2. Wounds complicated with the presence of foreign bodies ; 3. Penetrating wounds with bleeding ; 4. Penetrating wounds with protrusion of part of the lungs.
482. Simple penetrating Wounds of the Chest, or those in which the cavity of the pleura merely is opened, are rare. Their treatment consists in the speedy closing of the wound, and in the prevention of inflammation. The patient, after a deep inspiration, should expire, and then the wound is to be carefully closed with sticking plaster, covered with a compress, and fastened with a broad chest-bandage and a shoulder-bandage. The patient is to be treated on a strictly antiphlogistic plan. If the inflammation be prevented the wound heals quickly. If inflammation come on and be long continued, consecutive extravasation from exudation of the pleura is frequently produced after a lapse of fourteen days, and renders the opening of the cavity of the chest necessary.
483. Foreign Bodies, which complicate penetrating wounds of the chest, are either broken pieces of the injuring instrument, balls, pieces of clothes, driven into the wound, or splinters of the ribs. If the state of the injury do not itself point out the presence of foreign bodies, the symptoms by which it can be inferred are very equivocal. They excite constant irritation, difficult respiration, pain at the wounded part, even though the most severe antiphlogistic treatment has been long continued; or although the symptoms had diminished, a fresh accession, copious suppuration, and so on, may occur. The circumstances of the accident must be carefully reviewed, in order to determine on the presence and position of the foreign body, which is often most decidedly possible by the introduction of an elastic or metallic sound, for the purpose, either by suitable enlargement, or by a fresh opening in the interspace of the ribs corresponding to its position, when it can be done, to extract it. The longer suppuration is kept up by a foreign body in the cavity of the chest so much more difficult is its extraction, because the interspace is much diminished by the falling together of the ribs. LARREY (a) has in one such case cut out the upper edge of the lower rib with the lenticular, as deeply as needful, for the purpose of extracting the ball, and did not wound the intercostal artery.
Bullets may penetrate the chest, run round the lungs, and pass out nearly opposite their point of entrance (1). Instances have occurred in which bullets have lain in the cavity of the chest for a long while, without producing inconvenience; in such cases they have been enclosed in a covering of coagulable lymph, as in a capsule (2).
(1) See HENNEN's Observations on this point (par. 480, note 2.) (2) In one case the ball remained in the substance of the lung for twenty years, the patient continuing in good health, and no symptoms occurring to indicate its position. In another, the ball rolled about in the cavity on every motion of the body (6).]
484. In penetrating wounds of the chest bleeding may occur from the arteria intercostalis, the arteria mammaria interna, from the lungs, or from the great vessels of the chest. In large and direct wounds the blood flows out freely; if the wound be narrow, if it form a long and, perhaps, curved canal, the blood empties itself into some one space internally, and the quantity poured out is relative to the size of the wounded vessel, and the space in which the effusion has taken place.
485. Under such collection of blood in the cavity of the chest the face is pale, the pulse small and quick, the countenance shrinks, there is singing in the ears, cold sweats over the whole body, exceedingly difficult breathing, danger of suffocation ; that side of the chest in which is the extravasation is more full and moves less during respiration ; the patient breathes best on his back, with the upper part of his body raised; suffocation threatens if he lie on the sound side. As the extravasation increases, the symptoms become more severe, and the patient dies suffocated.
486. The symptoms of extravasation of blood in the chest are very different, and often very equivocal. If the extravasation be slight, or if it have been slow in its production; if the lung be adherent with the pleura to a great extent; if the individual be less sensible on account of the loss of blood ; if previous disease of the chest exist; if spasmodic symptoms accompany the injury, then the diagnosis is extremely difficult.
487. The most certain and determinate signs of extravasation of blood in the chest are, the continued symptoms of an internal bleeding, difficult, quick and short breathing, with spitting of blood in wounds of the lungs, in which inspiration becomes easier and expiration more difficult, and in sleep threatens suffocation ; constant anxiety in a greater or less degree ; difficulty or utter incapability of lying on the sound side ; a dull (a) Mémoires de Chirurgie Militaire, vol. iv. (6) MANGETUS, Bibliotheca Chirurgica. Geneva,
sound on percussion of the chest, increasing with the increase of extravasation ; the respiratory murmur accompanied with a gurgling murmur, and in a severe case of extravasation subsiding entirely, or perceptible only at the upper part of the chest; a tolerable condition when lying on the back with the chest much raised ; irregular action of the heart and pulse; loss of sleep; pale, sparing, and even suppressed urine.
The less certain and constant symptoms are, increased expansion of the wounded side of the chest, by which the ribs are separated from each other, and their mobility interfered with; ædematous swelling of the chest (in some parts at least the muscles appear more full); in the greater extent over which the pulsation of the heart can be felt, and its displacement to the opposite side by the pressure of the fluid; a sensation of weight on the chest, or an audible squash on the patient's motions; a swelling beneath the short ribs and in the region of the belly, from depression of the diaphragm ; ecchymosis on the short ribs of the injured side, first occurring some days after the accident; edema of the hand and foot, and redness of the cheek upon the injured side.
488. The existence of extravasation may be distinguished with certainty when the symptoms described, (par. 487,) or if not all, yet the most part of them appear together, continue, and increase ; if they be unaccompanied with any other organic affection, and do not yield to general treatment in the first twenty-four hours.
489. The blood extravasated into the cavity of the chest operates not only as a mechanical hindrance to respiration by compression of the lungs, so that they gradually lose their cellular character, and unite with the pleura; whence it happens that, after long continued extravasation, its discharge is of no use, the lung being no more capable of expanding itself; inflammation of the surface, with which it is in contact, also soon takes place, as the blood operates fatally by its decomposition, though it often continues long in its naturally fluid state. The bleeding must therefore be stanched, the further extravasation be prevented, and the effusion into the chest removed.
[“ In incised or punctured wounds, hæmorrhage takes place," observes HENNEN, “ instantaneously, and profusely ; in gun-shot wounds, if the intercostal artery or lungs are only brushed, or some of the more minute vessels opened, it is not so violent; and we have rather to prepare for what may occur on the separation of the eschars, than to combat any existing symptoms, the general tendency to pneumonic inflammation excepted. In the event of secondary bleeding from the lungs themselves, we are in possession of no external means for remedying it; but whenever the tenaculum can be used to an injured intercostal artery, it should at once be applied, and the vessel secured by ligature. Unfortunately, however, we but too often are disappointed in finding the source of the hæmorrhage; and here judicious pressure is our only resource. In some slight injuries I have used the graduated compress with success; but if the sloughing is extensive, nothing but the finger of an assistant, relieved as often as occassion may require, and pressing direct upon a compress placed along the course of the vessel, or 60 disposed as to operate upon its bleeding orifice, will be of any avail.” (p. 375.)]
490. It is very difficult in most cases, in many quite impossible, to determine the origin of the bleeding in penetrating wounds of the chest.
491. Injury of the Intercostal Artery may be presumed when the wounded person does not spit blood, and when the symptoms of extravasation are urgent. If the wound be large, bright-red but not frothy blood spirts from the wound in an unbroken stream; if the finger be put on the point where the artery is wounded, its spirting may be felt. The wound is directed towards the lower edge of the rib.
The insertion of a gutter-shaped curved piece of card-board, recommended by RICHTER and others, is useless. The finger alone can distinguish the bleeding vessel, if the blood pour into the cavity of the chest, in which case, in expiration or in coughing, it always flows from the wound in a full stream. In the symptoms already given, it must not, however, be overlooked, that they refer to injury of the intercostal artery alone, but that ordinarily injury of the lung happens at the same time. This objection applies also to the canula proposed by REYBARD (a), provided at its front end with a lateral aperture to be held against the wounded vessel, and at its hind end connected with a bladder.
[An interesting example of a fatal gun-shot wound of the intercostal artery is given by GRAËFE (6), which was the cause of considerable dispute on account of the shot not having been found in the neighbourhood of the wound :
A young man, aged fifteen years, received a discharge of small shot in the chest and belly at the distance of about forty-eight paces. He instautly fell, but soon afterwards got up and ran for about six hundred paces when he again fell exhausted. About an hour afterwards he was discovered and taken home. On examining his person the following external injuries were observed :-), a small round wound of the form of a middle-sized shot on the right side of the chest near the sternum and the interspace between the first and second ribs; from this wound a quantity of florid blood continued to issue: 2, a wound of about the same size and shape, on the right side of the belly, between the navel and ribs. This wound appeared to be superficial: no blood issued from it: 3, a slight contusion of a circular form on the left side of the belly not far from the navel. He died thirty-eight hours after the receipt of the wound. On examining the body and tracing the wound in the chest, the substance of the m. pectoralis major, through which the shot had passed, was found filled with thick black blood; a quantity of the same kind of blood continued to escape from the chest through the orifice during the inspection. On laying open the cavity the quantity extravasated amounted to twenty-eight ounces, the greatest quantity being in the right side. The right lung was collapsed, Occupying only about one-fourth of its cavity. There was an opening on its anterior surface at the upper part, corresponding to the external wound. From this a canal was traceable for about an inch and a quarter into the substance of the right lung backwards ; it then passed towards the surface of the organ for about an inch and a-half, and terminated in a cul de sac. At the inferior margin of the sixth rib, and at about two inches from its head posteriorly and internally, a lacerated opening of about an inch in depth was discovered. On carefully dissecting this part, the sixth intercostal artery was found torn through, and the muscular structures around filled with blood. No foreign body was here discovered by which the wound might have been caused, nor was there any communication externally and posteriorly, by which such a body might have passed out. The abdominal wound was about the size of a pea ; it had penetrated the abdominal cavity, but the viscera were uninjured. No shot could be discovered to account for this wound.
The Medical College to which the dispute was referred, after giving a review of the case, decided that “the only wound penetrating the cavity of the chest being that already described as situated anteriorly between the first and second ribs, through this opening the shot must have entered, which produced the deep-seated laceration. From the examination of this wound during life and after death, it is clear that the canal which the shot had formed did not pass horizontally backwards, but in a direction from above downwards. Under these circumstances, the part at which the shot would strike posteriorly would be between the sixth and seventh ribs. The circumstance of no shot having been found in the neighbourhood of the wound, is no obstacle to the admission of this opinion of its origin; since it is well known that large musket-bullets are often deflected from their course by a slight resistance, and lie concealed in parts remote from the wound. If this be observed with regard to such large masses of lead, a fortiori it would take place with small shot.)
492. We are rich in remedies proposed for stanching bleeding from the intercostal artery, but equally poor as to the facts which determine their fitness and applicability. To these belong the tying round of the rib according to GERARD (c), GOULARD (d), and LEBER (e); the tying the artery (without the rib) by means of an armed needle, jointed at its fore(a) Above cited, plate iii. fig. ?.
(c) Dionis, Cours d Opérations de Chirurgie, (6) In HENKE's Zeitschrift für die Staatsarznei par DE LA FAYE, Paris, 1771, p. 341. kunde, 1836, and British and Foreign Medical Re (d) Mémoires de l'Académie des Sciences, an 1740. view, vol.iii. p. 536. 1837.
le) PLENCK, Sammlung von Beobachtungen, vol. ii. p. 210.
part, after the manner of REYBARD and NEVERMANN (a); its immediate ligature proposed by Ben. BELL (6); the compression of LOTTERY (C), QUESNAY (d), Bellon (e), and HARDER (S); the compressors of DESAULT and SABATIER (9), by means of a square piece of linen, of which the middle is so deeply thrust into the wound and fitted with charpie, that if the ends be pulled the middle is pressed as a plug against the artery; or by a proper, thick plug, furnished with a strong thread, passed through the wound, and, by means of the thread brought to the rib. According to MEDIN the wounded vessel should be completely cut through with a myrtle leaf, pushed back, and a tent pressed upon it. ASSALINI proposes cutting the artery through, and allowing it to retract ; to close the wound carefully, and subsequently to discharge the existing extravasation.
GROSSHEIM (h) recommends von ARENDT's aneurismal needle. My observations b the contrary are in the Heidelberger klinischen Annalen (i).
NEVERMANN (k), after enlarging the wound to the intercostal muscles, divides the latte together with the pleura, a little from the lower edge of the upper rib for some lines, ani introduces a staphyloraphic needle armed with a thread flat into the chest upwards, that the point of the needle is some lines above the rib; the needle is then drawn round, so that the point readily turns forwards to the incision, and passed with it close to the bone, and specially on its under edge; he then pulls the thread out of the needle's ere, withdraws the needle, and ties together the intercostal artery, vein, and nerve.
493. To employ the greater number of the plans of treatment recommended and above described, for stanching bleeding of the intercostal artery, a large wound is always needed, and if the wound be not large, it must be increased. They are generally to be considered as exceedingly dangerous proceedings, the result of which is always uncertain. If the uncertainty be remembered, in which the Surgeon generally finds himself as to the source of the bleeding, and that in simultaneous injury of the lungs, the bleeding from those organs is increased by the employment of most of these remedies, the application of immediate ligature or of compression must not be unconditionally recommended. Injury of the intercostal artery, near the breast-bone or in the middle of the ribs, where most wounds of the chest occur, does not always produce severe bleeding, as foreign and home practice proves (1). The injury of the intercostal artery, near its origin, always indeed causes very dangerous bleeding; but in this case also on account of the depth of the artery, and also the knowledge of the source of the bleeding, is the application of the preceding means difficult and indeed impossible (m).
It is most suitable therefore, in bleeding from the intercostal artery, to employ only such treatment as is pursued when the bleeding is from a vessel of the lungs, and to hope that by closing of the wound, by strict antiphlo gistic treatment, by cold applications to the chest, by the pressure of the blood retained in the cavity of the chest, the wounded artery will become (a) Above cited, p. 141, plate iii. fig. 2.
der Art, intercostalis nach Verwundungen zu stilles (6) System of Surgery, 3rd Edit. Edinburgh, in Berliner Med. Centralzeitung, 6 Aug. 1836. 1787.
(1) RAVATON, Pratique Moderne de la Chirur (c) Mémoires de l'Académie de Chirurgie, vol. gie. Paris, 1785, vol.ii. p. 130. Spiess, above ii.
ited. (d) Dissertatio de Hæmorrhagia Arteriæ inter (m) CHELIUS, Ueber die Verletzung der Art, incostalis sistenda. Berol., 1823.
tercostalis in gerichtlich medicinischer Hinsicht; (e) Médecine Opératoire, vol. i. p. 179.
in Heidelberger klinisch Annalen, vol. i. part is. U Neue Bemerkungen und Erfahrungen. Ber also vol. iii. part ii., and in SPIES, above cited, lin, 1781, vol. i, p. 59.
See also Von GRAËFE, Bericht über das klinische (9) Manuale de Chirurgia. Milano, 1812.
chirurgisch-augenärztliche Institut der Universitat (b) In von GRAEFE and WALTHER's Journal. zn Berlin für das Jahr 1826. Berlin, 1827. And (0) Vol. iii. part ii.
in Journal für Chirurgie und Augenheilkunde, ) Ueber das beste Verfahren, eine Hæmorrhagie vol. x. p. 369.