An intercostal artery is of itself a small vessel, but when cut across by the edge of a knife or torn by the passage of a bullet it may pour sufficient blood into a pleural cavity to cause serious dyspnea and perhaps fatal result. To discover at the coroner’s inquest that a patient has been allowed to die because no one had the judgment to enlarge the wound and assure himself whether such a hemorrhage was not occurring is not at all creditable to those in charge of the case. The combined dangers of infection and of collapse of the lung are not so great as those of possibly fatal hemorrhage, or intrinsic disaster through septic infection from neglect of this kind.
Aside from the injuries thus produced to the respiratory apparatus there are those especially involving the heart. It has been supposed that gunshot wound of the heart was necessarily fatal. There is now reason to think that this is not invariably true, even in individuals not promptly operated upon, while the resources of modern surgery have enabled the surgeon to save a number of cases of absolute gunshot injury to the pericardial sac and even to the heart itself. (This subject has already been considered in the chapter on Surgery of the Heart and Great Vessels.) Every case which is not promptly fatal is worth attempting to save, if suitable help be at hand, by a resection of the chest wall, exposure of the pericardium, and of the heart itself, with the introduction of sutures or the use of the ligature wherever these may appear to be needed.
The occurrence of more special forms of traumatic lesion may be indicated by particular features. Thus if the esophagus has been wounded the patient may expectorate or vomit blood, whose presence in the stomach could not be explained by other features of the case. On the other hand blood which comes into the mouth from the lungs may be swallowed and its appearance in the ejected materials thus accounted for. A violent disturbance of cardiac regularity or evident paralysis of the diaphragm may be accounted for by injury to the pneumogastric or phrenic nerves.
Treatment.
—In regard to the general treatment of these injuries the use of the probe should not be encouraged, at least in the way in which it was formerly used. It is a serious matter to stir up clot or to open up a wound with a probe, thus inviting free entrance of air. Nearly all the information desired may be more accurately obtained by careful physical examination and study of symptoms. It should never be used except with aseptic precautions. It affords little information as to the course, and practically none as to the location of a bullet which has penetrated the chest wall. It may possibly be of service in searching for a bullet in the muscles of the back, but the only information it is capable of furnishing is afforded by a skiagram. Miscellaneous probing should be condemned, and in these injuries is rarely justifiable.
The first measure to adopt in cases of gunshot wound of the chest is to determine that the heart has not been disturbed; the next to estimate what injury may have occurred to large vessels, then a general determination of the other surgical features of the case. The patient who shows no depressing symptoms nor develops them during the ensuing few hours may be left with only a temporary occlusive dressing placed over the wound; but increasing embarrassment of respiration, or weakening and increasing rapidity of pulse, should be carefully watched to guard against internal hemorrhage. If it be learned that there is such internal bleeding prompt action should be taken for its control. This means anesthesia and perhaps thoracotomy, with resection of one or two ribs, in order to afford space through which to practise deep suture or ligation. So long as one side of the chest alone is involved—i. e., one lung thus exposed—the surgeon may widely open the chest and meet every surgical indication without the necessity for artificial respiration or the use of the Fell apparatus. It is, however, advisable to have this at hand for such work, while cases demanding such extreme measures can scarcely be made worse by the performance of a tracheotomy and resort to some means for forced and artificial respiration.
To simply enlarge a small bullet opening or punctured wound, in order to be sure that an intercostal artery has not been injured adds but little to the danger and much to the security of such a case. In case of doubt give the patient the benefit of that doubt and operate to any necessary extent. When hemorrhage is slight and not alarming it may be sufficient to make the occlusive dressing include a tamponing of the opening between the ribs, gauze being packed in the opening in such a way as to prevent hemorrhage.
A study of the escaping blood will permit of differentiation between arterial and venous hemorrhage, that which escapes from the lung being ordinarily of the latter type. Richter has suggested an ingenious method of deciding whether hemorrhage comes from an intercostal artery or lung tissue, by introducing a sterilized piece of pasteboard, similar to a visiting card, rolled up in the form of a circular tube and flattened with a crease; should blood flow out along the groove it shows that it is an intercostal artery which is bleeding; but if it flows out of the wound through the tube the source of the bleeding is the pulmonary tissue itself. (Dennis.)
The question of the presence of a foreign body, bullet or otherwise, is important. This is less so when it is a question of the bullet itself than of driving in some fragment of rib or of foreign body introduced from without. A bullet, a broken knife-blade, or anything of such character will be revealed by an x-ray picture. The probe will rarely give this information. Clothing, objects carried in the pocket, or various other foreign material may escape detection.
The first measure of importance is the determination of the occurrence of serious internal hemorrhage, the second is the emergency treatment of the injury itself, which should include primary aseptic occlusion, to be followed later by other measures. A withdrawal of fluid is also indicated. Escaped blood may be contaminated and produce later a pyothorax. As the result of a traumatic pleurisy serum may collect within the ensuing few days, and it too should be removed. It should be first found with the exploring needle. If seen to be free from pus it may be withdrawn by the aspirator; but if it be destined to become pus, then the sooner it is evacuated by incision the better.