CHAPTER I URGENT THORACOTOMY. REPAIR OF INJURY TO THE (Part 1)

CHAPTER I URGENT THORACOTOMY. REPAIR OF INJURY TO THE LUNGS. REPAIR OF INJURY TO THE PERICARDIUM; OF INJURY TO THE HEART. PUNCTURE OF THE PERICARDIUM. As has been indicated elsewhere (see Injuries of the Thorax), urgent intervention for injuries of the thorax is a form of operative procedure at this present time with but a limited field. Whatever may be the apparent gravity of the case, it is far fram being the rule to operate, for such operations require trained assistants, a special equipment, and a superior surgical skill. Of necessity, then, in general practice, the treatment must, generally speaking, be conservative: that is to say, cleansing of the external wound with enlargement and trimming up If necessary, reunion and aseptic occlusion, firm bandaging of the thorax, and an absolute quiet in bed. These measures along with stimulation with caffein and camphorated oi! and normal salt solution, represent the clements of treatment which are within the scope of all. But there are cages so manifestly fatal without operation that, a8 ‘Lejars says, one cannot evade the question, “operate or let die?” Graze rupture of the lung indicated by an immediate flooding of the pleural cavity, followed by urgent symptoms of asphyxia and syncope, is the signal for immediate operation. Again, repeated attacks of secondary hemorrhage call for operation. URGENT THORACOTOMY, ‘The technic of this operation can be exactly defined only in a gen- eral way and will need to be modified to suit the individual case. Lejars insists that the opening must be large, that anything less will be a disappointment and the operation might as well not be — 423 aa URGENT THORACOTOMY, ‘The operation may proceed in one of two ways: (1) by a permanent resection of the ribs necessary to be removed, or (2) by temporary resection with the formation of a thoracic flap. (1) Make a U-shaped incision forming a flap with its base posterior, and of which the two arms run parallel with the ribs and are wile enough apart to include at least three ribs. ‘The incision reaches to the ribs. Rapidly dissect up this mesculo- cutaneous Hap, exposing the ribs and intercostal muscles. With the flap held out of the way, begin the resection of the ribs by incising the periosteum of the lowest rib along its middle line, the full length of the exposed part. Denade the rib with the rugine. ‘Take special care in the denudation along the lower barder that the artery and nerve re moved with the periosteum are not wounded. Divide the inner and the outer end of the denuded segment. (See Operation for Empyema.) Resect the other ribs exposed in the same manner. Raise the musculo-pleural flap. Begin by dividing the upper border; then the lower border; and finally the anterior border, catching eack intercostal artery as cut. When this fap is lifted the lung is exposed. ‘This procedure has the advantage that it can be rapidly carried out; — the disadvantage, that it permanently sacrifices a part of the bony wall of the chest, but that is a small matter in the face of such emer gencies. (2) A thoracic flap may be formed. Make the same “U"* y incision and expose the ribs as in the preceding operation, Each costal segment is then denuded of periosteum at either end sufficiently for the passage of the bone-cutting forceps, In this manner each rib is divided at exch end. Next carefully divide the intercostal muscle parallel with, and abowr, the first segment, and lift the anterior end of this rib, and begin the separation of the pleura. Work along the front at first, dividing the intercostal muscles arteries and ligating as necessary. ‘The liberation of the Bap the lower border next follows and, as the musculo-osseous flap i elevated, the separation of the pleura ix more and more Finally the flap is freed and tured back and the pleura is lef The pleura is next divided and the wounded \wng is vane freely = TREATMENT OF INJURIES TO Tit MEART, 425 Wipe out the clots and search for the bleeding surface. If necessary a hand may be lipped under the base of the lung pulling it forward for Inspection. Repair the lung. ‘The ideal method is by suture, employing a No. 2 or 2 silk thread and passing it through the parenchyma with a round curved needle, If this is not possible samponade is the next resort. Ifa border is lacerated and projecting it may be ligated en masse and resected. Whether or not drainage is employed depends upon the amount ‘of oozing and the probabilities of infeetion. If infection subsequently develops, the infected area is to be opened and drained as any other empyema. REPAIR OF INJURIES TO PERICARDIUM AND HEART. ‘The general practitioner does not see many injuries to the heart. Gunshot wounds are, of course, usually immediately fatal; so that the form of cardiac injury most likely to present itself for treatment is a stab wound. Occasionally the heart is lacerated by a broken rib. ‘The sudden death from cardiac wounds may occur in several ways. It may occur from syncope arising from the pressure of the blood within the pericardium; or the heart may be unable to contract be- cause of its divided fibers and cerebral anemia follows; or shock or pulmonary edema may be the immediate cause of death. Even if death does not immediately occur, hemorrhage and infection muy later provoke a fatal issue (See Injuries to the Thorax, page 99). The treatment of traumatisms of the heart and pericardium has three ends in view; to combat shock, to control hemorrhage, and to prevent infection. Keep the patient absolutely quiet, lower the head, apply artificial heat, give morphine in small doses (1/8 gr.) hypodermically; and, if there is an open wound in the chest, disinfect and dress asepti- cally, but do not operate merely to disinfect. If the heart is injured sufficiently to bleed, operate, ‘The sole in- dication, then, for operative treatment is hemorrhage. ‘The patient will probably die even if operated upon, but he will 426 URGENT THORACOTOMY, most certainly die without the operation; so that it is our duty to give him the additional chance which intervention offers. If the wound seems likely to have reached the heart; if there is bleeding; if there is pain and precordial oppression; if there are fre- quent attacks of syncope; if there are signs of increase of fluids aboot by el he ae Si Ba the heart; then one is justified in believing that the heart bas betx wounded sufficiently to produce hemorrhage and must prepare ie modiately for the operation. There must be no delay. Tt will depesd upon the degree of urgency whether the time shall be taken for formal Preparation of the field, However iniinyeoshte wsegsis may be = OPERATION FOR REPAIR OF THE HEART. 7. yet hemostasis in such cases is the more urgent indication. Even in the most desperate cases one must at Jeast scrub his hands and wash the field, for there is little use to check the hemorrhage if the patient is to die later from sepsis. While the anesthesia is under way, the skin may be washed with soap and water followed by alcohol and bichloride ‘solution; or Tr. iodine may be used on the dry skin. Pins are Semel iT Treen an boot wen eapeoed., eal ow General Anesthesia. —Ether should be employed if the patient’s con. dition will permit. ‘The operation proposes to make a thoracic flap, to open the peri- cardium and expose the heart, and to repair the injury. ‘There is no operation that requires more decision, courage, and sel{-consxch. Incision. —Bexin in the third intercostal space jurk in ironk oh Ye 428 URGENT THORACOTOMY. anterior axillary border and cut inward to the border of the sternum, abruptly curving there and following the sternal border downward to the sixth space; again abruptly curving and following that space outward (Fig. 310). These incisions expose the ribs and intercostal muscles. ported @ pate ol bamt preparatory to auturing, (Afr Ertan) Formation of the Flap.—Divide the foarth, filth, and sixth cartilages near the sternum and also the intercostal muscles, along the fine of the original incision. AL the lower outer angle of the inchion, expose the sixth 1b MF ma ill SUTURE OF WOUND OF THE HEART. 49 pulling the tissues upward. Incise the periosteum over its external surface and with the rugine free the rib of periosteum and divide it At the upper outer angle expose the fourth rib, free it of periosteum, and with the costotome or a bone-cutting forceps, divide it in the same way. The flap is now attached only by the fifth rib which is to be fractured. Raise the sternal end of the flap with the left hand and press on the fifth rib with the right hand and with a little force the rib is broken in the line of section of the other two ribs. ‘The flap is now gradually raised as its adhesions to the subjacent structures are freed, and the pleura is exposed, Pi 33s —Butere of wound heart. Flo, 314 Suture of heart completed. Tf there is a wound in the pleura, it may be enlarged and the pericar- dium may be reached through it; otherwise proceed to the liberation and refraction of the pleura, With a grooved director, liberate the fibrous attachments of the triangularis sterni to the posterior surface of the sternum, which at the sume time liberates the pleura. With the fingers, draw outward the free border of the pleura with its covering the triangularis sterni (Fig. 311). In thié manner is the pericardium exposed, The assistant holds the pleura with a retractor, Incision of the Pericardium.—Enlarge the wound in the pericardium and in that manner expose the heart. Retract the edges of the peri- cardial wounds with forceps. Locate the wound in the heat. Sip 430 URGENT THORACOTOMY, the left hand under the apex and pass the first suture, and the heart may be thereafter steadied by traction on the threads of the first suture (Fig. 312). Suture the wound in the keart. Use cither interrupted or continuows suture of catgut. There is no particular advantage in passing the suture in diastole, Pass them deeply, but not to the endocardium (Figs. 313, 314). Now wipe out the pericardium with sterile coxajcenen aad eipele the pericardium by continuous catgut suture. Next, wipe out the adjacent portion of the pleural cavity, repair any part of the lung that may be injured and repair the Plewra without drainage. Finally, replace the thoracic flaps, and suture. It is generally wise to excise the tissues along the mark of the wound. Ne drainage is to be employed except under these circumstances; _ if the case was operated on late and there is great probability of infection, it is better to leave drainage in the pleural wound, pro- jecting from the thorax at the lower angle of the skin wound; if there is much oozing, it is better to leave a wick of gauze in the pleural wound, A case of successful suture by Gibbon, of Jefferson Medical College, illustrates the subject (Jour. American Medical Assn., Fels 10, 1906), Patient, aged 38, healthy colored man. Stab wound of chest, a few moments after which he fell unconscious. An hour later at the bor pital his condition was very grave: unconscious, puphs dilated, skin cold and moist, respiration rapid and shallow. No pals in the peripheral vessels and the heart sounds were dent eae irregular. Vigorous stimulation was employed with morphia and steal and his condition slightly improved. Operation about oot and half hours after the injury. Only a small quantity of ether The fourth costal cartilage was found and divided and the en cartilage and a part of the rib was removed, The was explored and-a wound located which would only admit index finger, This pericardial wound was enlarged and the emptied of clots and liquid blood. It began rapidly to fill Two Gngers passed under the beart lifted it up into the epening and with rapid sponging, toe wound was loraited ~~ REPAIR OF WOUND OF THE HEART, 430 situated in the right ventricle near the auriculo-ventricular groove, Tt bleed freely, controlled by pressure; was about three-fourths inch in length. The wound in the endocardium was about one-half as long. A traction suture of chromicized catgut was passed through both edges and by that means the heart was held in position, while four other sutures were passed and no effort was made to avoid the en- docardium. A small gauze drainage was applied to the line of Sutures and brought out through the pericardial wound which was not sutured. During the subsequent twelve hours there was enough oozing to require a change of dressing, His general condition was fairly good, The second day his condition was alarming; respirations 62. The gauze was found to be interfering with drainage and removed. The respirations fell to 38 in a short time. Large quantities of salt solution were given by rectum. Liquid food on second day. The dressings were changed every other day, ‘Six days after the operation the skin wound was sutured almost com- pletely, the wound in the pericardium being practically healed, In six weeks he returned ta work completely recovered, with heart's action regular and normal, Gibbon does not advise an ostco-plastic flap unless a pleural wound is demonstrated, believing it best to excise as much of the sternum or cartilage or rib as may be necessary to give free access. He em phasizes the value of the traction suture, and advises the repair of the pericardial wound without drainage, but would always drain the external wound. ‘Travers (Lancet, Sept., 1906) operated upon a case in which the patient was impaled upon a spike fence. The right ventricle was torn, the spike penetrating the sternum to reach it. The wound in the heart was closed hy twenty sutures. The patient did very well up to the eleventh day, when he died from heart failure, due to the pressure of a slowly forming clot. ‘Travers notes that the suturing scemed to stimulate the flagging heart. Stewart, among the first in the United States to suture he bear successfully, turned the musculo-cutaneous fap to the left and thoracic (lap to the right, fracturing the cartilages near the base of | ‘sternum. ‘The pericardial wound was enlarged in the axis of the heart. ‘The heart wound, produced by a stab with along, rusty pen-knife, involved the thickness of the left anterior ventricular wall, ran parallel with the axis of the heart, and was about three-fourths of an inch in bength, was larger than either the skin, pleural, or pericardial wound. The heart” bled freely and continuously, and resembled a mere quivering mast ‘of muscle, ‘The wound was closed with a continuous silk suture, the pericardial cavity cleansed and the sac sutured with silk, A gauze drain was left at the lower angle. The pleural cavity was cleansed and irri gated with salt solution. ‘The thoracle flaps were sutured with silk worm-gut and a gauze drain left also in the pleural cavity. During the operation, which lasted about forty-five minutes, twemty- four ounces of salt solution and adrenalin were injected, pete | anid atrophia given hypodermically. Some infection followed, and by the eighth day, the vemnpieratends_ was 103°, pulse 150, and respiration 50. From that time, the symptoms of sepsis gradually declined until at the end of three weeks, these 6 ditions were practically normal; at the end of the fifth week, the pati was out of bed. Stewart, discussing the operation (American Journal Med, Sei Sept., 1904), notes that the size of the heart wound cannot be p from the external wound; and concludes that the only safe p in doubtful cases is to enlarge the wound and ascertain if it the chest wall; and if there be symptoms of hemorrhage—of tamponade—operate, In all of these cases already mentioned, it was the ventride whi required repair. Peck, of New York, describes a case in which ft ¥ necestary to suture the auricle (Annals of Surgery, July, 1909). ‘The patient, a colored irl twenty-four years of age, was bn to the hospital suffering from a stab wound over the third costal lage at the leit border of the sternum. Her condition was: radial pulse; the heart sounds could vot be heard; respiration PUNCTURE OF THE PERICARDIUM. 433 shallow, and the extremities cold; operation begun about forty-six minutes after the receipt of the injury. A quadrangular flap of the soft parts with base external was dissected back, ‘The third, fourth, fifth and sixth cartilages were divided at the sternal junction, and the third, fourth, and fifth ribs near the costo-chondral junction, and the flap turned out and the internal mammary ligated above and below. The pericardial wound was near the border of the sternum, a part of which was resected with rongeur forceps to give a better view. ‘The tense pericardium was incised and ‘the clots emptied out, whereupon the radial pulse could be felt. The bleeding seemed to come from the upper part of the cavity but the rapidly beating heart, churning the free blood, made it impossible to locate the wound until a transverse cut in the sac gave a better exposure. Lifting the heart forward and slightly rotating it to the left, a wound of the right auricle was brought into view. With each systole a stream of dark blood spouted two or three inches. Four sutures of chromicized catgut passed on a curved intestinal needle controlled the bleeding, The pericardium was cleansed, closed without drainage with continuous chromic catgut suture ‘The cartilaginous flap was carefully sutured with No. 3 chromicized gut and the soft parts with catgut and silkworm-gut. No drainage was used. The operation lasted sixty-five minutes, during which time 1900 C. of normal salt solution was given intravenously. For the first