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.