WOUNDS OF THE CHEST
In the ambulances lesions of the chest represent an average proportion of one in ten or thirteen
wounded, but a third of these wounded have already succumbed on the battlefield, and count among the killed; at
the rear the proportion is from 6 to 8 per cent. (Laurent). Sometimes the entire lesion is in the thorax; sometimes
one of the adjoining segments of the upper extremity is also implicated.
Injuries of the chest are divided into-
(1) Non-penetrating wounds, and
(2) Penetrating wounds.
They include wounds of the soft parts, and wounds of the bones and cartilages.
Among the wounds of the soft tissues which resemble those of all other parts, we will only mention
the arterial lesions of the very vascular scapulo- pectoral region.
The bony injuries present the same type as the lesions of long bones (clavicle, ribs), of spongy
bones (sternum), of flat bones (scapula).
Clavicle.-On the body of the clavicle, which is frequently
injured, we see contusions, simple or with extensive fissures ; fractures by contact, either transverse or oblique grooves and perforations, either
of the simple or the comminuted type. Comminuted perforations, the most frequent, have splinters, generally short,
like those seen in very compact bones. They are nearly always adherent.
The extremities of this bone present lesions of the epiphysis. The relations of the larger vessels
and nerves in the base of the neck with the inner end of the clavicle, and those of the subclavian and axillary
vessels and nerves with the centre of the bone, render wounds of this bone very dangerous. The wounded who present
these complications nearly always succumb on the battlefield.
Immobilization is absolutely necessary. It is obtained by an arm-sling,
more securely by bandages applied in the manner advocated by Velpeau or Desault. No exploration whatever. Instances
are reported of simultaneous fractures of both clavicles or of the clavicles and sternum.
Scapula.-The scapula is frequently injured. Its lesions belong to the class of injuries of the flat bones without diploë
(the body), or with diploë (the spines, the borders). They consist of perforations,
generally clean, on the body of the bone, or notches on its borders.
It is important to consider the direction taken by the projectile. When this is antero -posterior, the free splinters are superficial, of easy access, and
extrathoracic. When postero-anterior, the free splinters are
deeply situated under the body of the bone, and of difficult access. When transverse,
which is the most usual, the lesion is less regular and more complex. The bullet, even
when it simply grazes the bone, produces a fracture with numerous fragments, which are either maintained in place
or depressed, with radiating fissures or a slantingperforation (Delorme).
These fractures are of the greatest gravity.
Lesions of the acromion and the spine show some analogy to those of the skull ; they are notches,
extensive grooves, clean perforations, with or without fissures, and free splinters near the bony aperture of exit.
As for the coracoid process, it may be notched, perforated, or separated.
Lesions of the scapula may give rise to considerable haemorrhagic, oedematous, or inflammatory
swelling of the surrounding parts.
TREATMENT.-No exploration, no immediate interference for the removal of free splinters. Immobilization
of the limb by means of an arm-sling or bandages.
COMPLICATIONs.- Haemorrhage, often severe, from one of the three scapular arteries, renders compression,
or better still, ligature, necessary. The effusion of blood caused by a wound of the vessels that surround the
scapula is sometimes very abundant, and may find its way even down to the sacrum.
Suppuration, in infected wounds, is to be feared by reason of its depth, its diffusion under
the scapula, and because of possible thoracic infection. Formerly it contributed towards raising the death ratio
to 12.3 per cent. of these cases. Free escape should be given to the pus through large periscapular incisions.
Let us also mention the presence of subscapular foreign bodies, the removal of which requires
similar incisions. Foreign bodies are revealed by radiography, sometimes by subscapular friction sounds.
Sternum.-Wounds of the sternum are rare; they are perforations
with linear divisions of the periosteum, sometimes erosions and furrows.
Ribs and Cartilages - Unlike the other bones of the thoracic wall, the ribs are seldom affected singly, unless it be through tangential firing (contusions, grooves); whereas with bullets that penetrate we find notches with or without transverse or oblique fracture, perforations with radiating fissures and splinters, either free or pushed onwards, and corresponding to the last part of the thoracic wall through which the projectile has passed.
They are frequent. They are seen in one-tenth of the wounded under treatment in hospitals. The most common are those with an antero-posterior track. The surgeon, by calling on his anatomical knowledge, can tell by the position of the wounds what are the parts that have been injured. In the lower part of the chest, from the fifth rib downwards, the wound becomes thoraco-abdominal.
Transverse tracks are often accompanied by lesions of the arm. These tracks should be designated as postero-anterior, vertical (cervico-thoracic).
Contour wounds no longer exist. The track followed by a non-deflected bullet is rectilinear. A deflected or pivoting bullet, a round shrapnel bullet, may make a sinuous. and irregular track, but never the contour wound formerly considered classical.
Simple Penetrating wounds, or wounds that implicate the pleura,
are exceptional. The majority are penetrating with a lesion of the lungs or heart.
WOUNDS OF THE LUNG.
Penetrating Wounds with Injury of the Lungs: - Being elastic and not very dense, the lungs usually present pretty simple lesions when injured by bullets fired at point-blank range, such as the following: fissures, furrows, cul-de sac wounds, or total perforations. The aperture of entry is circular, oval, like a slit, or narrow; that of exit is less regular. The canal is not lacerated, but is slightly suffused with blood; its walls adhere.
The dimensions of the apertures and of the track are the same as the diameter of the projectile (short range) or inferior to it; the apertures then each look like a small red spot (3 millimetres). Remote fissures are seldom met with.
A healthy lung may present a large gap at the aperture of exit of the bullet, but it does not burst. There is no explosive effect.
Shrapnel bullets form somewhat larger tracks. The aperture of entry is rounded, that of exit more extensive and irregular (Laurent). The sanguineous trail that indicates the bullet track is undiscoverable at the end of a week (Laurent).
Diagnosis - Shock varies, sometimes slight, "so much so that the wounded man can continue to fight or go on foot to the ambulance, even if it is at a considerable distance" (Laurent); sometimes marked: "The grave lesion brings down the wounded man and leaves him almost bloodless for several hours" (Laurent).
Most of the wounded men say they feel a pain resembling the stroke of a whip. This pain may be very violent.
Dyspnoea is aggravated by fractures of the ribs. Escape of blood through the external wound, which is rather rare, has no particular signification, unless it is concomitant with haemoptysis.
Haemoptysis is a surer sign. Slight, average, or excessive, it varies between the spitting out of a few sputa, either immediately or during two or three days, and the expectoration of a litre of blood or more. In both cases it is characteristic. Laurent has found it in 75 per cent. of the wounded, others have noticed it in one-third of the cases. Issue of air from the wound, traumatopnoea, emphysema, are not frequent. The same may be said of pneumothorax. Haemothorax is an excellent sign. Contraction of the abdominal walls has been noticed. Spontaneous immobilization of the chest occurs habitually. Lastly, let us recall one of the most favourable signs - the connection of the track with the lung.
The wounded zone should be specified so far as possible:
(i) The peripheral zone, the small vessels and the bronchioles being the only parts affected.
(2) The middle zone with vessels and bronchi of medium size.
(3) The central zone, region of the hilum and of the larger bronchi.
Wounds of the middle zone present the plainest symptoms, and the ones most usually observed; those of the hilum are the worst.
Complications. - Haemothorax is the most serious primary complication in wounds of the chest. It is often concomitant with partial pneumothorax. Variable as to the rapidity of its course and the abundance of its contents, it may entail the death of the wounded man, or else throw him into the gravest state of acute anaemia, or finally it may be found compatible with life.
It is reabsorbed in the majority of cases treated by the surgeon. The wound would be exposed to infection if interfered with under precarious conditions. Pneumonia is exceptional.
Pleurisy is a frequent consecutive complication. It is adhesive, serous, or purulent. A large thoracic wound, infection through fragments of clothing, large haemothorax, favour its appearance. It accounts for the fever of the wounded man. Its treatment, which here offers nothing special, is one of the most active amongst those for wounds of the chest by projectiles.
Hernia of the lung is very rare; extensive emphysema is exceptional; foreign bodies (splinters, bullets, fragments of clothing) are pretty frequently noticed. Metallic foreign bodies have a tendency to find their way into the pleural cul-de-sac.
Treatment. - It is simple, and carries out the following indications:
(1) Rest for the wounded man.
(2) Application of dressings, with occlusion of the wounds.
(3) Immobilization of the thorax.
(4) Treatment of complications. No extensive surgical intervention is to be undertaken.
1. At the shelters for the wounded; at the relief and first aid station; at the ambulance: Rest in a supine or sitting position.
The wounded must be raised with the greatest care, to avoid syncope, cough, pain, detachment of clots.
When they present lesions of the central zone, the wounded must not be sent back to the rear. Their transport should be effected as much as possible on stretchers, and should be strictly limited to the distance necessary to take them to the nearest ambulance.
Transporting to a distance makes the prognosis much more serious. Against pain and dyspnoea, injection of morphine.
2. Dressing. - It must be occlusive, without suture. Occlusive to prevent the access of the external air, but not enough to hinder the exit of the intrathoracic air. Thus emphysema is prevented. We must. be careful not to introduce drains into the wounds; their use gave rise to deplorable results during the Balkan War. We should abstain from suturing either direct or instrumental.
After touching the wound and its immediate vicinity with tincture of iodine (only once), the dressing is applied. It must be very large, covered with cotton-wool, and should include the whole thorax and even, according to the seat of the wound, the adjoining regions, the abdomen, the neck.
3. The dressing, firmly maintained by a body bandage, will secure immobilization of the thorax. Loosening of the dressing will be prevented by more bandages. This dressing is to be preferred to bands of sticking-plaster applied round the thorax over aseptic gauze.
4. It is chiefly in serious cases that the application of the above-mentioned methods of treatment should be very complete.
In cases presenting a grave general state, especially when it is connected with haemothorax, we must make a point, according to the case, of administering anodynes, of giving injections of morphine, making the patient keep, so far as possible, the semi-recumbent position, or at least a lateral one on the injured side. We must also have recourse to alcoholic stimulants, to cardiac tonics (ether, caffeine, camphorated oil), to injections of adrenalin, chloride of calcium, normal saline, to circular ligation of the limbs at their proximal end. in order to secure venous stasis.
If asphyxia is threatening, we should aspirate which must be repeated if necessary; but as a general rule it is best not to meddle with haemothorax. It insures a salutary compression. Aspiration should not be carried out till after the first twenty-four or forty-eight hours.
Although we advocate great extensive interventions in those cases of very severe intra- or extra-thoracic hxmorrhage we see in civil practice, we have always been opposed to them in ambulance work. They would be neither opportune nor wise, for reasons we cannot here develop. Even in extreme cases one must abstain from any big operation.
Pleurisy, which, we repeat, is frequent, calls for puncture at first, then for the operation for empyema, so soon as the pus is revealed by the Pravaz syringe. This operation is one of the triumphs of thoracic surgery in these cases. When done early, it insures rapid recovery. No washing out is necessary ; large dressings renewed at frequent intervals ; no portions of rib resected (Laurent), for the tendency towards rapid recovery is here strongly marked.
In very extensive wounds, the result of shell splinters, hernia of the lung may necessitate, according to cases, reduction or ligature. Against generalized emphysema we should employ a large incision of the tissues as far as the muscular wall, or overlapping circular incisions.
The extraction of the foreign bodies will be done subsequently through a sloping incision.
In thoraco-abdominal wounds the abdominal lesion dominates, and abstention is our line of conduct.
Prognosis-Thus treated, and without being transported, men wounded in the chest recover rapidly and completely when primarily the wound has not been of very great severity. A very large number of thoracic bullet wounds surprise us by their extreme benignity. This is because the pulmonary wound is narrow, not complicated by the presence of foreign bodies (make certain by inspection of the clothes that there is no loss of substance from them), and without notable haemorrhage, the lung wound being peripheral.
They are never, so to speak, met with in the ambulances (Laurent); the same may be said of wounds of the large vessels. The great interest with which the former are regarded in daily practice, by reason of the brilliant operations that they give rise to, ceases to exist in war surgery. In our sanitary formations abstention must be the rule, because of the risks in surgical interference, the dangers of infection, etc. In the very rarest contingencies only an exception to this rule may exist, therefore we will simply pause an instant to state that the heart, when wounded by bullets fired from a short range, has sustained explosive effects; when the bullets are from other distances, it is eroded or perforated.
Expectation is the line of conduct to follow: it includes absolutely perfect rest, absence of all excitement, the use of morphine, and immobilization of the chest.
Wounds of the Abdomen