The incisions (the “taillades” of the French) into the cavity of the chest formerly recommended, should only be resorted to when the means indicated have failed, which they will rarely do when combined in the first instance with an antiphlogistic treatment, aided by sedatives, and if necessary by cordials.
The advantages to be derived from auscultation in these cases are evident. Its value has been sufficiently shown, and the ear or the stethoscope should be resorted to at least three times in every twenty-four hours, in every case, however trifling it may appear to be, until the absence of danger has been ascertained.
LECTURE XXII.
SIMPLE INJURIES OF THE CHEST, ETC.
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.