Rib vault

“ In like manner, when the ribs are fractured, whether one or more, provided there be no splinters, there is rarely fever, spitting of blood, and sphacelus, and ordinary treatment without evacuation will suffice, provided there be no fever;-bandaging, according to rule; and the callus forms in twenty days, the bone being of a porous nature. But in cases of contusion, tubercles form, along with cough, suppurating sores, and sphacelus of the ribs, for nerves from all the parts run along each rib. ”

“ In tracks crossing the chest transversely the injury to the ribs might consist in notching, perforation, or complete solution of continuity, sometimes with fine comminution. In the incomplete injuries some importance attached to the localisation of the lesion to the upper or lower border of the rib, in so far as the intercostal artery was concerned. Comminution at the wound of entry was, as a rule, not so extensive as at the aperture of exit, and in any case was less apparent, since the fragments were driven inward. ”

“ If only one person is available and the patient can stand up, let him place one arm round the neck of the bearer, bringing his hand on and in front of the opposite shoulder of the bearer.
To get at a broken limb, or rib, the clothing must be removed, and it is essential that this be done without injury to the patient; the simplest plan is to rip up the seams of such garments as are in the way. Boots must be cut off. It is not imperatively necessary to do anything to a broken limb before the arrival of a doctor except to keep it perfectly at rest. ”

“ If there be reason to believe that a rib or ribs have been injured—that any extraneous body is inclosed in the wound—or, from its appearance, that it will certainly reopen, an incision should be made in the part injured, for the purpose of giving the necessary assistance. The cure, however, will not only be assisted, but mainly effected, by procuring a depending opening by means of the small trocar and canula introduced as low down as auscultation will authorize ”

“ Cannot ride or take any exercise because it brings on the pain. The cicatrix shows a large, deep hole, and the deficiency of the rib is well marked. The side of the chest is altogether contracted and flatter; the heart has been moved behind the sternum; the beat of the apex being on the other side of the xiphoid cartilage, and that of the heart, as a whole, is more indistinct than usual. In other ways in good health. It is possible that the ball may be lodged in or be retained by layers of coagulable lymph in the angle formed between the diaphragm, the ribs, and the spine. ”

“ It must be kept stretched, just as Nature arranged that it should, like a drum-head. It is attached all around to the chest, though it crosses five or six ribs on its descent from the seventh rib to the sternum at the lower point and down to fourth lumbar vertebra. It is a continuous slanting floor, above bowels and abdominal organs, and below heart and lungs. It must, by all reason, be kept normal in tightness at all places, without a fold or wrinkle, that could press the aorta, nerves, œsophagus, or anything that contributes to the supply or circulation of any vital substance. ”

“ The track of the bullet between the point at which it had fractured the eleventh rib and that at which it entered the first lumbar vertebra was considerably dilated, and the pus had burrowed downward through the adipose tissue behind the right kidney, and thence had found its way between the peritoneum and the right iliac fossa, making a descending channel, which extended almost to the groin. The adipose tissue behind the kidney, in [Pg 513] the vicinity of the descending channel, was much thickened and condensed by inflammation. ”

“ If the effusion increases until it reaches as high as the second rib, the respiratory movements are scarcely perceptible to the eye. When it reaches its maximum, the clavicle, they appear to be arrested, but the vertical diameter is slightly altered by the action of the intercostal muscles as they endeavor to elevate the ribs, and of the diaphragm as it feebly contracts and relaxes. The pleural cavity, which in health is lubricated by about two drachms of moist serous secretion, is frequently filled to the extent of seventy, eighty, or more—even to one hundred and twenty—ounces. ”

“ The abdominal viscera being thus exposed, the lungs, heart and other parts of the thoracic viscera must also be uncovered. For this purpose, and with the cartilage knife separate the ribs from the sternum about two inches on either side of the latter; commencing from the second rib down to the last one, and extending to the transverse opening made in the abdomen, it will be found that the ribs at that distance from the sternum are attached to it by a cartilage, which it is very easy to cut in children, harder in adults, and it may sometimes be indispensable to use a saw on old persons. ”

“ If the ball have broken a rib, the orifice of entrance especially should be enlarged as early and as carefully as possible, so as to give an opportunity for the removal of the splinters and of all angular points of bone which may be turned inward. A little addition to the original opening can do no harm, and if the lung should not collapse, or should it be adherent, it will enable the surgeon to see whether any splinters are impacted in it, and to remove them. ”

“ In the thorax, for example, if a rib is struck, the charge and possibly fragments of bone, will penetrate the pleura, and be dispersed throughout the lung; in the head, the skull may be shattered and the brain torn up; and in the abdomen, the hollow viscera may be perforated in many places and the solid organs lacerated.
On covered parts the clothing, by deflecting the shot, influences the size and shape of the wound; the entrance wound is increased in size and more ragged, and portions of the clothes may be driven into the tissues. ”

“ It is more dangerous when due to a direct blow or injury, as then the splintering occurs internally and may wound the lungs, heart, or large vessels, while with fracture from indirect violence, from compression of the chest, the splintering of the ribs occurs externally. Fracture of the upper ribs requires more force than that required to fracture the lower ones, and consequently the former is the more dangerous. The diagnosis of fracture of the ribs is generally quite easy by means of crepitus felt or heard, false motion, local tenderness, etc. ”

“ An incision eight inches long was made over the 4th rib, six inches of the rib were resected, the bleeding intercostal artery was ligated, the blood was turned out of the pericardial cavity, this cavity being irrigated with hot water. The wound in the pericardium, which was two inches long, was sutured and the external wound was closed. Recovery followed. Harris gives an instance of a man who was injured by a bar of iron falling on his shoulder, producing a compound fracture of the ribs as low as the 7th, and laying the heart and lungs bare without seriously injuring the pericardium. ”

“ The patient must avoid wearing anything, such as a garter, which constricts the limb, and any obvious cause of direct pressure on the pelvic veins, such as a tumour, persistent constipation, or an ill-fitting truss, should be removed. Cardiac, renal, or pulmonary causes of venous congestion must also be treated, and the functions of the liver regulated. Severe forms of muscular exertion and prolonged standing or walking are to be avoided, and the patient may with benefit rest the limb in an elevated position for a few hours each day. ”

“ Any blow delivered at or near the basic level tends primarily to involve the weaker area, the base, passing secondarily upwards on to the vault. One may go even so far as to say that in most combined vault and basic fractures, the vault fracture is a secondary development, the basic fracture being the primary lesion. ”

“ A groined vault does not of absolute necessity demand the use of ribs any more than the plain waggon-head vault. Even the latter was from an early period frequently divided into compartments or bays by transverse ribs, which were useful as a means of giving it rigidity; but in groined vaulting these were of nearly constant use, both for the same reason, and because the vault, being reduced at its springing to so narrow a footing, required this additional strength. The arrises, however, or diagonal lines of intersection, were always left without ribs. ”

“ The three ribs at the stern cannot be put in whole, and will require a certain amount of scheming to make them bend and fit in their proper places. The ends of the ribs must be cut off level with the top laths. The screws which hold the rib ends to the top lath are only temporary, for, after the canvas has been stretched on, and the gunwales screwed into their places they must be removed, and longer and stronger ones driven through rib, lath, and canvas into the gunwales. ”

“ Thus man's ignorance has made a condition for the knife. Had he taken the hint and let the blood pass on when its work was done, he would not have to witness the guillotine of death to his patients, whose early pains told him a renal vein or some vessel below the diaphragm was ligated by an impacted colon, or a few ribs pulling and bringing diaphragm down across vena cava and thoracic duct and causing excitement or paralysis of solar plexus, or any other nerves that pass [Pg 156] through diaphragm with blood to and from heart and lungs. ”

“ This is easily adjusted by drawing the curve of the back of the rib, whose position is first determined, drawing against it the vertical line of its intersection with the next rib, and then, from the apex point of the adjoining rib, to draw its curve through the point of intersection, which will give on the springing line the distance backward or forward at which the{194} springing section of that rib should be placed (Fig. 361) .
The ribs of all vaulting of early date are square and flat at the back; the vaulting, which is often very thick, passing over and resting upon their backs. ”

“ In some cases the softened ribs not only compress the organs of the chest, but are also pressed down upon the abdominal viscera, or even into the pelvis. The symptoms arising from such displacement are at first urgent, as can readily be imagined, and are often treated as inflammatory, to the detriment of the patient. ”

“ It will frequently happen that the arm may be irrecoverably shattered, and the thorax partake in a less degree of the injury, there being apparent only some slight contusion or grazing of the skin; if low down, the elasticity of the false ribs may have prevented the integuments being much injured in appearance, although the blow has been violent; yet the force of the large shot may have ruptured the liver or spleen. ”

“ If the thorax be pierced from any point whatever, provided the instrument be directed towards a common centre, A, Plate 1, the lung will suffer lesion; for the heart is, almost completely, in the healthy living body, enveloped in the lungs. So true is it that all the costal region (the asternal as well as the sternal) is a pulmonary enclosure, that any instrument which pierces intercostal space must wound the lung.
As the sternal ribs degenerate into the “false” asternal or incomplete ribs from before, obliquely backward down to the last dorsal vertebra, so the thoracic space takes form. ”

“ Momburg recommends an elastic cord wound round the body between the iliac crest and the lower border of the ribs, but this procedure has caused serious damage to the intestine.
When digital compression is not available, the most convenient and certain means of preventing haemorrhage--say in an amputation--is by the use of some form of _tourniquet_, such as the elastic tube of Esmarch or of Foulis, or an elastic bandage, or the screw tourniquet of Petit. Before applying any of these it is advisable to empty the limb of blood. ”

“ The same system of muscles comprising those of the thorax, abdomen and perinaeum, performs consentaneously the acts of respiration, vomiting, defecation and micturition. When the spinal cord suffers injury above the origin of the phrenic nerve, immediate death supervenes, owing to a cessation of the respiratory act. Considering, however, the effect of such an injury upon the pelvic organs alone, these may be regarded as being absolutely excluded from the pale of voluntary influence in consequence of the paralysis of the diaphragm, the abdominal and perinæal muscles. ”

“ Where the victim is thrown to the ground and knelt upon, fracture of the ribs and ecchymosis of the chest wall may occur.
In a case examined by me of combined strangling and throttling, marks of the ligature and fingers were both present, and on the clavicles separate marks produced by the knuckles while tying the cord. These knuckle marks did not show up till some time after death. Effusions of blood were present in the tissues of the neck on each side of the larynx, and amongst the muscles on both sides, and in the sheath of the left carotid artery. ”

“ According to Vibert, [656] the order of frequency of rupture of the various organs is as follows: liver, spleen, kidneys, lungs, heart, stomach, intestines, bladder, brain. Rupture of the liver occurs especially on the anterior and inferior surfaces and the bleeding is rather abundant. The healthy spleen does not rupture readily, except from a severe traumatism, but if it is hypertrophied it may rupture spontaneously from muscular violence. The lung may be ruptured internally without showing the rupture on the surface and with the ribs intact. ”