—The treatment of these injuries should include the relief of pain; the performance of artificial respiration, along with the inhalation of oxygen; the customary treatment for shock, with the use of adrenalin, when needed, for raising blood pressure; absolute rest, and especially the enforcement of local physiological rest by bandaging or the application of broad strips of adhesive plaster about the thorax. In addition to these general measures special indications should be met when they arise. The occurrence of phenomena indicating the development of pneumonia or collection of fluid should be noted, as the latter may call for removal, with perhaps ligation of a vessel, if it be bloody, or later evacuation, should it be serum or pus. External extravasation will usually disappear under soothing, warm, and moist applications. No hesitation need be felt in opening a hematoma which does not show a disposition to prompt resolution. Other non-perforating injuries include, for example, severe burns or scalds, which may need the same treatment as when occurring in other parts of the body. Fluid may accumulate within the chest when there has been any such serious external disturbance.
PENETRATING WOUNDS OF THE CHEST.
Penetrating wounds of the chest are generally inflicted by stab or gunshot injury. Two serious elements of danger accompany these injuries: the first immediate, that of hemorrhage from division of some vessel of importance concealed from sight; the other that of infection, for either by the penetrating object itself or by air or clothing which may follow it, infection may ensue, which may result in septic pneumonia, pyothorax, or some deep phlegmonous process, with always dangerous and sometimes fatal results. Gunshot wounds vary, and according to the character of the missiles and the weapons from which they are discharged. Those occurring during warfare and made by bullets of the Krag or Mauser type are usually driven with such velocity that they produce a minimum of laceration, even though they pass through the chest. Such injuries have in the late wars in different parts of the world been frequently observed, and have shown a surprisingly low mortality rate, providing only that the heart itself, the pericardium, the large vessels, and the spine be not injured. Stories of the battle-field afford abundant illustration of men shot through the chest being scarcely affected by the injury, but continuing in action, at least for some time, and finally recovering. On the other hand, the ordinary revolver or pistol, with which most affrays in civil life are terminated, does not drive its bullet with nearly the same velocity, and is more likely to inflict a serious or even fatal wound. (See [Plate XLVIII].)
A bullet or a stab wound almost invariably so opens the thorax as to permit the immediate entrance of air. In theory this should be followed by prompt collapse of the lung; in fact, however, this is only partial, and often surprisingly so. If such a bullet wound be occluded the air thus admitted is more or less absorbed, disappearing into the bloodvessels, and the lung once more expands to its natural dimensions. Much will depend, therefore, on the size and character of the wound as to whether occlusion may occur spontaneously, or may be practised through the first-aid dressing or its equivalent.
The entrance of air may be recognized by a certain degree of embarrassment of respiration, by alteration in the percussion note, and often by its passage to and fro through the opening.
The principal indications of possible injuries, in addition to those just noted, will be the occurrence of paroxysmal coughing, with inspiration of blood, and the added physical signs of the presence of blood in the pleural cavity. Thus dulness on percussion, with the line of dulness altering with position, will indicate the presence of fluid, and should this occur soon after the injury it can only be regarded as an evidence of hemorrhage into the pleural cavity. A combination of abnormal tympanitic condition, as above, with the physical signs of fluid beneath, will indicate a condition of pneumohemothorax. These signs will change from hour to hour or from day to day in accordance with altering internal conditions. If they become rapidly more pronounced they indicate a condition which will probably call at least for free incision, evacuation of blood, and very likely determination of the source of its escape and proper attention thereto.
PLATE XLVIII
Radiograph of Chest, showing Mauser Bullet.
(From Plate X, “Use of Röntgen Ray by the Medical Department of U. S. Army in the War with Spain, 1898.”)