325. The most _simple injury_, perforating the wall of the chest, is
a stab by a triangular sword, a small knife, or other weapon, which
may or may not abrade the surface of the lung, and which is usually
attended by little pain, although it often gives rise to considerable
alarm. It might be supposed that a very slight wound of the lung would
be followed by some expectoration of blood, but this does not always
take place; and although its presence may be considered demonstrative
of the injury, its absence is no proof of the contrary; for a
considerable injury from a stab or from a musket-ball may be inflicted,
with scarcely any sign of blood in the matter expectorated. If the
pleuræ are in their natural state, a small quantity of air may enter
the chest, but the opening will require to be direct and tolerably
large before the lung will separate or shrink from the wall on that
account; if adhesions should have been previously formed between the
pleuræ preventing it, they will be for the advantage of the sufferer.
In a simple incised wound, injuring the lung perhaps extensively, as
supposed from the bleeding from the mouth, no examination by probes or
other instruments need or ought to be made as a general rule; but the
wound should be immediately closed by sutures after the external parts
have been sufficiently examined to satisfy the surgeon that no portion
of the offending instrument has been broken off, or other extraneous
matters are sticking in the part.
The advantages derived from the closure of punctured wounds of the
chest in former times led to the practice of sucking them by the mouths
of irregular practitioners, generally the drum-major of the regiment,
when the patient was a soldier; and the consequences, although in some
instances apparently miraculous, were in others quite as unfortunate.
That bleeding may take place from the lung into the cavity of the
chest is indisputable, but little or no blood will escape through a
small wound; and its continuing to flow from such a wound will be a
presumptive if not a conclusive proof that some artery external to
the pleura has been wounded. Sucking, under ordinary circumstances,
of a small wound, unattended by bleeding, does good by attracting the
natural fluids to the parts, and thus causing them to swell so as to be
placed in apposition in the most advantageous manner for their reunion.
Punctured wounds of small size, therefore, may be sucked chirurgically
if any one be willing to do it, after which a bit of gold-beater’s
skin, or dry lint, should be placed upon the wound, supported by a
compress covered by adhesive plaster; these dressings should not be
removed for several days.
326. The patient should lie on the wounded part, as a general rule,
if he can conveniently bear it, not for the purpose of allowing any
effused blood or fluid to flow out, unless some particular reason
require the precaution of keeping the wound open, but to allow the
pleura covering the lung to be as closely applied as may be to the
pleura lining the wall of the chest, with the hope that the adhesive
process may take place between these parts, and by this means cut off
the wound from the general cavity of the pleura, a proceeding due to
the practice of the Peninsular war, yet so little attended to at the
present time by some teachers of surgery, who seem to confound the
practice thus recommended in incised wounds penetrating the cavity of
the chest with that which should be adopted in gunshot wounds, that few
students obtain even a reasonable degree of knowledge on this subject.
Teachers are entitled to prefer any mode of treatment they please, but
they should be careful not to neglect the opinions of others, whose
authority, derived from experience, they are bound at least to notice,
even if it should be to disapprove.
327. _Incised_ wounds of even greater extent ought not to be examined
by the probe or finger; no disturbance of any kind should be permitted
unless the cartilage or bone be injured. The external parts should be
brought together as closely as possible, so as to facilitate in every
way their union, and the processes which it is desirable should go on
within. The external parts or skin and cellular membrane cannot be kept
in perfect and continued apposition without sutures, and the proper
method of proceeding is to sew up the wound in the skin with a needle
and fine silken thread in a continuous manner, including absolutely
nothing but so much of the cut edges as will retain the thread; a
small piece of gold-beater’s skin or lint should then be laid over the
stitches and retained by a compress and adhesive plaster.
In a _simple_ case of this kind little or nothing is effused into
the cavity or secreted from the membranes of the chest, which will
interfere with the processes which may have happily begun, and which
it is desirable should be aided by the absolute quiescence of the
patient, to whom no medicine should be given which may render any
movement of the body necessary. It was formerly supposed that the
greatest object to be attained was the prevention of inflammation, and
a man was no sooner stabbed by his opponent than he was blooded and
purged by his surgeon, regardless of the necessity which existed for
perfect rest and the presence of a certain amount of inflammation, in
order to enable nature to carry on those processes which are essential
for the restoration of the injured parts. This inflammation should be
allowed to commence without interference and to continue in a moderate
degree until the object shall have been effected. It should only be
interrupted or subdued when it is supposed to be about to exceed that
degree which experience has pointed out as likely to be useful.
328. When the most courageous persons are wounded in parts essential
to life, there is more or less alarm or shock created by the injury;
although it has been gravely argued that a man does not always know
when he is actually shot or run through the body. A continued state of
anxiety and depression after an accident of this kind is a disagreeable
accompaniment of the injury, during which little should be done
beyond the giving a little cordial, and quieting the apprehensions of
the patient, leaving him to rest, if possible, after the necessary
applications have been made. If a gradual improvement take place, if
the pulse rise, if the patient resume more of his natural appearance,
and that state of commencing excitement which is denominated reaction
follow, hope may then be entertained. The general symptoms, as long as
they continue within ordinary bounds, are of little importance; the
local ones, significative of action commencing in the injured part,
are, however, to be carefully watched. They are those of inflammation
of the pleura, and it may be of the lung. This inflammation begins
slowly, and a day may elapse before it is well marked; for, when
persons have died within the first few hours after such injuries,
the pleura has often shown but little sign of inflammatory action.
Auscultation should always be resorted to from the moment of injury,
and constantly used throughout the treatment. Whenever it is concluded
that adhesion between the two pleuræ has failed to take place, the
direction to lie on the wounded side ceases to be of importance. Until
this period no food whatever should be allowed, and thirst should be
allayed by small quantities of water.
329. A punctured, incised, or gunshot wound, going fairly through
both cavities of the chest, is usually believed to be quickly if not
immediately mortal--an opinion generally correct with respect to wounds
made by musket-balls, although it is certainly not the case with regard
to punctured wounds, and does not always occur in those made by pistol
or musket-balls.
Sergeant-Major Richards, of the 29th Regiment, received thirteen sword
or bayonet wounds, and other injuries, on the heights of Roliça, on the
17th August, 1808--one particularly through each side of the chest,
between the ribs, as if the small-sword had made a wound of larger
size than usual. He had distinguished himself greatly in covering the
body of his commanding officer, and was beaten down before the British
column, which had been repulsed, could rally and recover its ground.
He was an object of particular attention to me, for the few minutes
he lived after I saw him; he had coughed up a little blood, and died
gasping, as if suffocated, the chest laboring on each side to do its
work in vain. His commanding officer, Colonel the Hon. George Lake, lay
dead by his side, killed instantaneously by a musket-ball, which passed
from the upper part of the left through the right side of the chest.
A French gentleman, fencing with his pupil in July, 1834, received a
blow under the right axilla in a very violent lunge, whereby the button
of the foil was broken off, and the foil itself passed into and through
the back part of the thorax, the point coming out between the sixth and
seventh ribs on the left side near the angles. There was but little
bleeding. The chief symptoms were those of great inflammation of the
contents of the cavity, which gave way to full and repeated bleeding
from the arm, with perfect rest and almost starvation. He recovered
very favorably, and was quite well in about eight weeks. He remains
well, and is following his profession as a teacher of fencing.
330. When an incised wound into the chest is large and direct, injuring
the lung, two very important points usually demand immediate attention.
The first is to relieve the oppressed state of the breathing; the
second, to suppress the bleeding.
In large penetrating wounds of the chest, with injury of the lung, it
has been observed that the patient has breathed most easily when the
external wound has been covered; and has been hardly able to breathe
when it was opened, which is attributed to the air getting into that
side of the thorax in inspiration, instead of entering the lung by the
trachea. If the wound admit of being well closed, the difficulty of
breathing diminishes; adhesion may take place, and the inflammatory
action within the chest may terminate; but if the inflammatory symptoms
continue, adhesion does not take place, and the secretion and effusion
of a quantity of serous fluid are the consequence. This secretion of
fluid is the natural consequence of inflammation which has passed the
stage of adhesion, whether the injury of the chest have occurred from
a stab or from a gunshot. It is the leading fact in the treatment of
these injuries, hitherto disregarded by writers on this subject, but
on the proper management of which, in both instances, a successful
result principally depends. If the closure of the wound lead, in the
course of a few days, to the re-establishment of the breathing, and
the antiphlogistic means employed to the cessation of all urgent
inflammatory symptoms, adhesion has most likely taken place, or is
about to take place, in the neighborhood of the wound, and the patient
will in all probability recover without much further suffering. If
this should not occur, and effusion take place, the wound should be
reopened, or the fluid otherwise evacuated.
A soldier of the 9th Regiment was wounded at Roliça, in 1808, by the
point of a sword in the left side; it penetrated the chest, making
a wound somewhat more than an inch long, through which air passed
readily, accompanied by a very little frothy blood, which was also spit
up on any effort being made to cough, leaving no doubt of the lung
having been injured, that viscus appearing to be retained against the
wall of the chest. As the edges of the wound could not be accurately
kept in apposition by adhesive plaster, two sutures were applied
through the skin, and the man was desired to lie on the injured side,
with the hope that adhesion might take place, as there appeared to be
no effusion of blood into the cavity. He was freely bled on each of the
two days following the receipt of the wound, and gradually recovered.
A French soldier was brought into the village after the battle of
Vimiera, wounded by a sword in the right side of the chest. He said he
had lost a good deal of blood; was very pale; pulse small; extremities
cold; breathing hurried and oppressed; had spit up some blood. On
removing the handkerchief, a gaping wound presented itself, an inch
and a half long, through which the cavity of the chest could be
seen, the lung having receded. The wound did not bleed. As adhesive
plasters would not keep the edges of the skin in perfect contact if he
attempted to move, they were sewn together, and after the application
of a compress he was much relieved. The next day all the symptoms were
alleviated, and after the supervention of some serious inflammatory
symptoms, he was forwarded to Lisbon, for embarkation for France, in a
fair state of recovery.
It was the successful results of these cases which led to the closure
of all such wounds in the first instance, with the hope of preventing
thereby the extension of the inflammation to the whole sac of the
pleura, which in many instances it succeeds in doing; and thus that
which was done in the first instance from apparent necessity, rather
than scientifically adopted, became a rule of practice, which may be
laid down as a principle to be followed in similar cases. When persons
thus wounded are neglected, the wound remains open, and the cavity of
the pleura passes into a state of suppuration, after all the symptoms
of acute pleuritis or of pleuro-pneumonia have taken place.
331. If the union of a large incised or other wound by the adhesive
process does not take place, a bloody, serous fluid oozes out from
under the dressings, if the oppression of breathing should not have
led to their removal; the patient is relieved by the discharge, which,
after a time, as the case proceeds toward recovery, will become less in
quantity and more purulent in quality.
If the union of the divided parts should take place externally, and
the general as well as local symptoms become more urgent, there can
be little doubt of a collection of some kind having taken place, and
then auscultation and percussion, if the latter can be borne, become of
the greatest importance. From the moment the wound is closed the ear
becomes the most important guide; the only one in fact to be depended
upon as to what is going on within the chest. The case is one of
pleuritis, perhaps of pleuro-pneumonia, and hence the reason that the
symptoms and treatment of these complaints have been more fully noticed
than might be considered to appertain to the province of surgery.
The effusion of a bloody, serous fluid comes on, after a penetrating
injury, from the third until the seventh or ninth day, by which time
the cavity of the pleura may be filled; puncturing the chest between
the sixth and seventh ribs at the point of election, or reopening the
wound, should be early resorted to for its evacuation.
A picket of Portuguese infantry being surprised by a sudden rush of
French cavalry from the town, during the first unsuccessful siege of
Badajos, were nearly all sabred. The survivors were brought to me. Two
had been run through one side of the chest, and one through both sides;
the last died a few minutes after I saw him. The other two seemed to
be nearly in a similar situation from loss of blood by the mouth and
from the wounds. These were immediately closed by stitches, compresses,
and adhesive plasters. A little hot brandy and water was given to
each, and they were laid aside without hope of recovery. They did not
die, however; the breathing became more easy, the distress less, and
the pulse more distinct; reaction after a time took place. The next
morning, the siege being abandoned, they were removed to Elvas, where I
afterward heard they were doing well.
A soldier of the Third Division of Infantry, under the command of Sir
James Kempt, was wounded at Waterloo, by a straight sword or sabre,
which penetrated the left side of the chest. He fell, and lost a
considerable quantity of blood from the mouth as well as from the
wound, and was supposed to be dying. On showing some signs of life, the
wound was covered by a part of his shirt; and on his arrival at the
Elizabeth Hospital in Brussels, four days afterward, it was closed.
On the ninth day, when my attention was drawn to him, he was sitting
up in great distress, from difficulty of breathing, his hand pressed
upon the wounded part, the cicatrix of which was red, swollen, and
projecting. I recommended the assistant-surgeon in charge to open this
with an abscess lancet, which he did, giving vent to a very large
quantity of bloody and purulent matter, to the great relief of the
patient for several days, although he did not ultimately recover.
The advantage derived from the closure of the wounds in these cases
was manifest. It relieved the breathing, and caused the hemorrhage
to cease, aided, in all probability, by the exhausted state of the
patients. The relief to the breathing was at the moment the most
essential point, the wounds of entrance being nearly two inches long,
and the free admission of air quite unopposed; the lung had receded
from the opening.
332. _The important question of hemorrhage_, in cases of incised wounds
admitting of being accurately closed, remains for consideration. In
many instances, the quantity of blood effused is trifling, and in
others, although greater, it is absorbed without being productive of
evil. In a third class, the quantity extravasated is larger than can
be absorbed, although it does not flow in an inconvenient or dangerous
manner through the wound, and may ultimately become coagulated and
adherent to the diaphragm and spine in the angle between them, when the
patient lies long on his back. In the worst or most alarming cases, the
loss of blood is and has been so great that its suppression offers the
only chance for the continuance of life. It is between these two last
cases only that a difference of opinion exists as to the treatment to
be pursued: one party desiring that the effused blood, if moderate in
quantity, should be allowed to discharge itself, the wound being kept
open; the other, that under all circumstances, whether the quantity
of blood poured out be small or great, the wound should be closed,
and the result awaited. The right course is, I apprehend, to remove
all the blood which can be evacuated by position, provided it can be
done without danger to the patient, rather than to allow it to fill
the chest; but as the bleeding vessel in the lung cannot readily be
got at, if seen, nor be secured by ligature with advantage, it is
advisable, if the bleeding continue, to close the wound, and allow the
cavity of the pleura to be filled, until the lung shall be sufficiently
compressed to cause the hemorrhage to cease, if the person survive
so long. The first object is to save life; after that, if time be
given, the next will be to relieve the loaded cavity. After the wound
has been closed, and the patient has so far recovered that reaction
has begun to take place, it may be concluded that the bleeding has
ceased. The chest should then be most carefully auscultated from day
to day, so that its respiratory state may be known, particularly with
regard to the increase of effusion, which will then be serous. This
will not take place until after the third, and not perhaps before the
fifth or sixth day, in any considerable quantity; when, if it should
have occurred, the wound should be reopened, or another opening made
at the most convenient place for the evacuation of the effused blood
and serum. It is probable that the wound of the vessel in the lung
which furnished the blood will be closed in five or six days: while
it is of great importance that the lung should be early relieved from
pressure, that it should be allowed to expand, and not be bound down
by false membranes; which will be the case if the compressing fluid be
not removed, and the inflammatory symptoms subdued. There is no object
to be gained but the suppression of the hemorrhage by retaining the
blood and serum within the chest; while the probability of a return of
the bleeding is not great after an opening has been made, and the blood
and serum have been evacuated, although much mischief will inevitably
follow the effused fluids remaining too long.
Repeated observation has shown that in sabre-wounds penetrating the
chest and lung, which have not united, and from which no excessive
hemorrhage has occurred, a great discharge of serous fluid usually
takes place from the cavity, which, gradually diminishing, becomes
purulent, and at last ceases, without the function of the lung being
destroyed; while, if the wound had been early closed, and the fluid
collected too long retained, the functions of the lung would be
impaired, and a counter-opening, for the relief of the resulting
empyema, may be unavailing. Whenever, therefore, the adhesive process
between the pleuræ has failed, and great effusion has taken place, the
sooner it is discharged the better.
In addition to the closure of the wound, it is desirable to arrest
the hemorrhage by other means, if possible, such as the abstraction
of blood from the arm to such an extent as it may be considered the
patient can bear, the administration of the acetate of lead with opium,
turpentine, matico, or the mineral acids; and the external and internal
use of cold or iced water, if it can be borne. If there be reason to
believe that a rib or ribs have been injured--that any extraneous
body is inclosed in the wound--or, from its appearance, that it will
certainly reopen, an incision should be made in the part injured, for
the purpose of giving the necessary assistance. The cure, however, will
not only be assisted, but mainly effected, by procuring a depending
opening by means of the small trocar and canula introduced as low down
as auscultation will authorize; the introduction of this instrument
will give the desired information on the one hand, and do little or no
harm on the other.
A soldier of the 3d Regiment of Infantry was wounded by a lance at the
battle of Albuhera, in the left side, between the fifth and sixth ribs;
and was thrown down, bleeding from the mouth and from the wound, which
was afterward closed by his comrades, by confining upon it a piece of
his shirt folded up for the purpose. Brought to the hospital, at the
village of Valverde, he appeared ten days afterward to be dying from
difficulty of breathing. On enlarging the opening in the integuments,
a quantity of blood, partly fluid, partly coagulated, issued from the
cavity of the chest. The wound was kept open to allow the discharge of
this, and of a reddish, watery fluid, which, after a few days, became
purulent. At the end of three weeks I sent him to Elvas, doing well,
and with but little discharge from the wound.
A heavy dragoon, of the German Legion, was wounded at the battle of
Salamanca by a sword, which penetrated the cavity of the right side
of the chest, between the sixth and seventh ribs. He fell from his
horse, and lost a considerable quantity of blood from the mouth and
from the wound. On examining the wound next day, a black coagulum
was seen filling up the orifice, the cellular membrane around being
considerably ecchymosed, and little doubt existed that the oppression
in breathing under which he labored was caused by blood effused into
the cavity. On separating the edges of the wound with a director,
several ounces of blood, half fluid, half coagulated, were evacuated
by making the external opening, which was enlarged, quite dependent.
The lung was then seen in contact with the external opening of the
wound, having expanded as the pressure of the blood was removed
from it. The wound was closed simply by lint, compress, and adhesive
plaster, without bandage; the man was largely bled, and placed upon his
wounded side on the ground, being the most comfortable position, in
some degree relieved from the oppression in breathing. Two days after,
the wound discharged freely a reddish-colored watery fluid, evidently
from the cavity of the chest, the exit of which was aided by keeping
the wound generally dependent. This continued for several days, the
fluid gradually becoming less in quantity, and purulent; under careful
management he was able to go to the rear, nearly well, by the end of
October.
333. On the subject of the ecchymosis, which Valentin considers to be
a pathognomonic sign of effusion of blood within the chest, he says:
“It is very dissimilar to that which occurs after a blow or wound,
and which takes place shortly after the accident, beginning around
the wound, if there be one, and extending from it. The patient also
complains of pain when the bruised part is pressed by the fingers.
These characters are not observed in the ecchymosis, the sign of
effusion, which always takes place near the angles of the lower or
false ribs descending toward the loins. Its color is identical with
that which appears on the abdomen of persons some time after death,
a bright violet, (_violet très éclairci_.) It appears about ten days
after the receipt of the injury, sometimes later.” The same sort of
thing, he thinks, takes place when the cavity of the chest is filled
with pus, but that edematous swelling is without discoloration.
334. In order to be explicit on points so important as those of which
I have treated, I have thought it right to lay down certain general
conclusions, subject to occasional deviations:--
_a._ All _incised_ or _punctured wounds_ of the chest should be closed
as quickly as possible by a continuous suture through the skin only and
a compress supported by adhesive plasters, the patient being afterward
placed on the wounded side--a precept which is absolute only with
respect to _incised_ wounds capable of being united by suture in the
manner directed.
_b._ As soon as the presence of even a serous fluid in the chest
is ascertained to be in sufficient quantity to compress the lung,
a counter-opening should be made in the place of election for its
evacuation by the trocar and canula, which may be afterward enlarged;
unless the reopening of the wound should be thought preferable, which
will not be the case unless it should be low in the chest.
_c._ If blood flow freely from a small opening, the wound should be
enlarged so as to show whether it does or does not flow from within the
cavity. If it evidently proceed from a vessel external to the cavity,
that vessel must be secured by torsion or by a ligature applied on it,
all the other methods recommended being simply surgical absurdities.
_d._ If blood flow from within the chest in a manner likely to endanger
life, the wound should be instantly closed; but as the loss of a
reasonable quantity of blood in such cases, say from two to three
pounds, will be beneficial rather than otherwise, this closure may be
delayed until syncope takes place or until a further loss of blood
appears unadvisable.
_e._ If the wound in the chest have ceased to bleed, although a
quantity of blood is manifestly effused into the cavity of the pleura,
the wound may be left open, although lightly covered, for a few hours,
if the effused or extravasated blood should seem likely to be evacuated
from it when aided by position; but as soon as this evacuation appears
to have been effected, or cannot be accomplished, the wound should be
closed. It must be borne in mind that the extravasation which does
take place is usually less than is generally supposed--a point which
auscultation will in all probability disclose.
_f._ If the cavity of the pleura be full of blood, and the oppression
of breathing and the distress so great as to place the life of the
patient in immediate danger from suffocation, the wound should be
reopened, if it have been closed, or freely enlarged, if small, to such
an extent as will allow a clear evacuation of the effused blood. It
has been supposed that in such a case the lung does not sufficiently
collapse, and the bleeding is therefore continued because the vessel
cannot contract; but the lung will usually collapse under pressure of
the air, unless prevented by previously-formed adhesions, when the
hemorrhage may possibly cease--instances of which are said to have
taken place, and the practice should therefore be borne in mind.