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able ejaculation, “ I wish you had said so earlier, because you will find it in my waistcoat pocket.”
This caution would not appear to apply, however, to old cases ; for in the British and Foreign Review for January 1858, page 266, an American case is reported, wherein the pleural walls seem to have borne with impunity an extraordinary amount of rough usage. Verily, the sensibilities of our cousins seem to be roughened.
LOCAL TREATMENT OF PENETRATING WOUNDS OF
THE CHEST (CONTINUED).
IF the local treatment of penetrating wounds of the chest could be based upon mechanical laws such as Stromeyer has laid down, viz., “ To prevent ingress of air, and obviate inflammatory action”, the extent of the wound would be the first consideration, and our success in the treatment would be commensurate with the small or large implication of the vital organs; but unhappily such is not the case. When there is only one opening into the thoracic cavity, and no missile lodged and the lung not collapsed, the primary treatment will be, to remove from the wound all jagged sources of irritation, such as spiculæ of bone or foreign matters, and, if need be, to cut down upon and remove the broken ends of ribs. The ancients approved of this practice; and Albucasis gives a drawing of an instrument called “Meningophylax”, used to protect the subjacent membrane during the operation; then lay on the wound a pledget of lint
soaked in cold water, and enjoin absolute rest, and he guidert in the administration of food and stimalanta by the state of the patient.
If the lung, although inwounded, should have collapsed, the immediate indication will be, to restart it into action before it becomes permanently attached by pleuritic adhesions to the posterior walls of the thorax. This may be attempted by closing the wound as much as possible, and applying emplastrum plumbi, spread upon leather; but a happy consummation is not often granted. The plan appears very well in theory, but in praetice is unsuccessful. The air, if it be ever absent, will find admission into the thoracic cavity, and serum or blood will be poured out, inducing the very evil we desire to avoid, and compelling an immediate removal of the plaster to allow the exit of the fluid.
I cannot subscribe to the very easy matter made of this part of the treatment by S. Cooper. He says: “ After a few days, the wound in the collapsed lung is closed by the adhesive inflammation, so that the air no longer passes out of it into the cavity of the chest, and the outer wound may thereforo be healed.” Such statements tend to lead practitioners astray, by a supposition of the ease and success of the treatment. When we perceive that blood is being poured out from the wound, an examination should be instituted to ascertain if the blood proceeds from a wounded intercostal ar
tery. If such be the case, an attempt must be made to arrest the bleeding by pressure. In case No. 13, this proceeding was partially successful.
Several writers have indulged in lengthened descriptions of the modes by which this hæmorrhage may be arrested, a full list of which is to be found in Cooper's Dictionary. Gerard's plan appears the best. He introduced by the wound, as far as the upper edge of the rib corresponding to the wounded artery, a curved needle armed with a strong ligature, to which was attached a dossil of lint. The needle was then passed outwards, with its ligature, and the dossil of lint brought over the wounded vessel, and, by tightening, sufficient pressure was obtained. Hæmorrhage from this cause, however, is very rare, or, perhaps, this cause may not be detected; at all events, Mayer, Stromeyer, Larry, and others, wrote of its rarity; also, in the Director General's Report only one instance is noted, at page 66, Captain F. S., 9th regiment. Only one case came under my own observation, viz., No. 13. If there should be two openings, and one in the posterior or lateral surface of the chest, the accumulation of fluid is to be prevented by posture, for the fluid will gravitate and drain out continually. Under such circumstances, the anterior wound may be closed with safety. The advantage of closing the wound will be greatest in punctured wounds, where the edges are more or less in apposition; or when the bullet-hole is small,
and the entrance of air is restricted. But when the missile is large, and the soft parts torn and the ribs splintered, and an opening made sometimes large enough to admit an ordinary sized walnut, little if any benefit will attend this procedure.
Hæmorrhage, with the older and with many of the modern writers, is held to be a great source of danger in lung wound, and in its arrestment the chief element of success is held to be venesection; to what extent this theory is correct remains to be proved. In my experience, the surgeon is seldom called upon to control“ primary hæmorrhage”; for, if it be great, the wounded man expires before help can be accorded. In those cases where the hæmorrhage is into the thoracic cavity, Valentin, Larrey, and Bauden recommend that it should not, unless impending suffocation approaches, be evacuated, as its pressure on the open vessels will become the best and easiest styptic or ligature. To further this object, M. Duret has suggested that a large opening should be made into the chest, to cause collapse of the lung by the sudden irruption of air. This proposal, to allow the effused blood or serum to remain in order that it may act by pressure in arresting hæmorrhage, does not receive much encouragement from the following case ; and there are many other cases noted, showing that a very frequent cause of a fatal result has been the pressure of a large effusion, arresting the action of the lungs.