1920 Journal of the American Medical Association (JAMA)  
History.\p=m-\C.G., aged 20, automobile salesman, admitted to the French Hospital, March 15, 1920, had shot himself in the chest two days before with a 32 caliber revolver and was removed to the Central Emergency Hospital in profound shock, blood flowing quite freely from the wound in the chest, necessitating frequent changing of the dressings. I examined him first at the Central Emergency Hospital. He was thin but well developed, 6 feet 2 inches tall, and weighed about 175 pounds. He was
more » ... d up in bed, pale to the point of exsanguination and in a state of collapse. He complained of pain and weakness and often called for water, which had been given him freely. The chart showed, since his entrance, temperature not over 97, pulse from 128 to 150, and respiration from 38 to 48. Morphin sulphate, one-sixth grain, had been given him every four to six hours. He vomited a dark brownish fluid and coughed some blood. The left pleural cavity had been aspirated and 2 pints of blood withdrawn. He had the appearance of one who had but a short time to live. The dressings were removed, and blood flowed from a small hole about the diameter of a lead pencil, situated 4.5 cm. to the left of the midsternal line and 1 cm. above a line drawn between the nipples, and from another hole in the back 10 cm. to the left of the median line and on a level with the hole of entrance of the bullet in front. On inspection it seemed that if the bullet had passed straight through, it must have passed through the heart. Operation.-He was removed to the French Hospital and an operation to stop the bleeding was decided on. At 8 p. m., under ether anesthesia, with the assistance of Drs. B. F. Alden and V. E. Putnam, I made an incision at the junction., of the third interspace with the sternal border, downward to the fifth interspace, and then laterally to the right from each end of this incision for a distance of 10 cm. The knife was made to pass through the costal cartilage close to the sternal border. The ribs were cracked at the outer end, and the flap containing skin, muscle, cartilage and rib was turned outward. There was an immediate gush of blood which masked the whole field of operation. Laparotomy pads were introduced into the pleural cavity and all the blood was removed, thus giving a good view of the field of operation. The lung had collapsed into the vertebral gutter. The opening into the pericardium was easily found and the course of the bullet readily followed. The wound in the pericardium was about 3 cm. long, and permitted the blood ready access to the pleural cavity. The pericardiac wound was enlarged and a wound of the outer side of the left ventricle about midway between the auricle and apex was seen. This penetrated through the outer edge of the muscle. A clot had formed, yet blood was seen to leave the heart at each pulsation. The pulsations were so rapid and feeble that it was impossible to distinguish whether the blood spurted during diastole or systole. The heart was sutured with two No. 2 chromic gut on a full curved intestinal needle. This stopped the bleeding immediately. The pericardium was closed with continuous chromic gut, the cartilage sutured with chromic gut and the skin with interrupted silkworm. No bleeding was seen to come from the lung or parietal pleura. A drain was placed in the puncture wound of the chest for drainage of the pleura. , Postoperative Course. -During and after the operation, 1,000 c.c. of hypertonic solution was given intravenously. The duration of the operation was thirty minutes. After operation the foot of the bed was raised, external heat applied, etc. The patient suffered shock for twelve hours. The following five days showed a gradual improvement, although the pulse remained from 100 to 130, respiration from 30 to 38, and temperature from 99 to 102. Culture from the drain revealed Staphylococcus aureus. The patient's appetite was good and he conversed freely. At midnight on the sixth day after operation he became irritable and restless and wanted to lea've the hospital to visit his wife, who he claimed was the cause of his mis-fortune. A temporary absence of the nurse gave him the desired opportunity, and when she returned to the room the patient had disappeared. A fifteen minute search disclosed him in the garden of the hospital. The next day he had a chill followed by a consolidation of the lower lobe of the right lung, and he died, March 26, just thirteen days after the injury. The body was delivered to the coroner. Necropsy.-The heart and pericardium had healed completely. There was very little blood-tinged fluid in the pericardium. Death was due to an empyema and pneumonia. The pulse was regular and of good volume a few days after operation and until shortly before death. This splint was developed for traction in fractures of the humerus. It is best adapted to those cases in which the fracture is of the shaft, 3 inches above or below the joint. Front and rear views of traction splint for fractures of the humérus. The splint is made of some light wood, 3 inches wide, 19 inches long and \m=3/4\ inch thick. It is made concave on the inner side for coaptation. A piece of drill steel 18 inches long and \m=1/4\inch in diameter should first be bent to have a hook in the upper end, and an arm 1\m=1/2\inches long extending from the hook to the shaft. The shaft is approximately 14 inches long. This shaft is threaded from the lower end up to within 2\ m=1/ 2\ inches of the arm going over to the hook; a wing nut is run up on the threaded shaft. On the back of the splint, in the upper 9 inches, is fastened a piece of \m=3/8\inch metal tubing. This holds the extension rod and gives a surface on which the rod may be extended by use of the wing nut. To the inner side and lower end of the splint is fastened a 2 inch right angle bar, % inch wide. A piece of adhesive plaster 2 inches wide and sufficiently long to form a loop in which can be fastened the metal bar of the lower portion of the splint is then applied to the inner and outer sides of the lower portion of the arm, care being taken that the adhesive does not extend more than 1 inch above the site of fracture. The arm is then bandaged very carefully with a thin layer of wadding, and the bar at the lower end of the splint is fastened in the loop of adhesive plaster. A piece of % inch felt pad about 6 inches square is then covered with wadding and placed in the axilla. A web strap % inch wide is then passed over the felt and brought up over the extension bar at the hook and fastened. Coaptation splints are then placed about the humérus on the outer and inner sides. Finally, the entire dressing is bandaged with gauze.
doi:10.1001/jama.1920.26220450003013e fatcat:vq4723g5rbe5xglexpajudubbq