CHAPTER X. WOUNDS OF SPECIAL REGIONS. (Part 3)

folowing an injury to the thorax, whatever its nature, is significant of one thing—that the lung has been involved. ‘Thede- gree of injury may be in a manner estimated by the amount of blood expectorated, In the dangerous cases, the blood pours from the wounded lung tissue into the bronchus and gushes from the mouth, In other cases, there is only a slight spitting of blood, leading to the belief that the lung has not been seriously tors. It might be mistaken for a hematemesis, but’ the presence of riiles in the bronchus of the affected side (or of both) and the light color of the blood and its admix- ture with air, point to the character of the hemorrhage. Hemothorax, a0 aecumulation of blood in the pleura, is nearly always the result of injury to the lung; although, of course, the internal mammary artery or the intercastals may occasionally be the source of the extravasation. Gravity determines where the blood will accumur late and therefore the patient's position will modify the physical signs, ‘The symptoms and signs are both modified by the quantity of blood and the rapidity with which it is poured Into the plearal cavity. In the slighter forms, there is scarcely any disturbance of breathing and only slight dullness over the base of the lung. In the graver forms, the lung is collapsed and crowded toward the hilum, so that there are symptoms of asphyxia added to those of in- ternal hemorrhage. The face is pale, the skin moist and cold, the patient is impelled to sit up and gasps for breath, the palse ix rapid and thready, and the patient may thus go on to death, Inspectios bulging chest percussion, a complete dullness, an absence of fremitus and of the vesicular murmur Often there is an immediate rise of temperature, due to absorption, and which & to be distinguished from the temperature of hia its earlier appearance No attempt to evacuate the extravasated blood is to be made in the INJURIES TO THE THORAX. ror moderately severe cases; In others, of more urgency, an aspiration ‘may give some temporary relief, tiding the patient over a critical point, Finally, in rare cases, the magnitude of the hemothorax will be such as to demand an immediate intervention, with the purpose in view of exposing the lung and repairing the wound in its substance. Subse- quently, even if the case is mild, infection may occur and is to be treated as any other empyema. Prenmothorax,—Air may enter the pleural cavity from without through an opening in the chest wall, or from within through a rupture in the lung tissue. In the first case it enters during inspiration, and in the second, during expiration, ‘The physical signs and symptoms grow out of the pressure within the pleural cavity and the consequent collapse of the lung. The chest wall on the injured side is distended, the intercostal spaces bulged out, the viscera are displaced, the ribs motionless, the vesic- ular murmurabeent. If a coin laid on the front of the chest is tapped with another coin, the sound will be heard at the back. The symp- toms are principally those of dyspnea. If there are no complications, the air is gradually absorbed and the function of the lung restored. Tn extreme cases, puncture will relieve the intrapleural pressure; and in the case of a valvular wound in the chest wall, which permitted entrance of the air but not its exit, enlargement of the wound is UW air and blood accumulate simultaneously—if a hemo-pnewmo- thorax exists—the physical signs will be altered, but not the symptoms. Emplsysema.—The subcutaneous cellular tissue may become charged with air and practically the whole body be involved. It is nearly always due in the marked cases to puncture of the lung by a broken rib. The air escaping from the lung is prevented, by the close contact ‘of the pleural surfaces, from entering the pleural cavity, and is forced into the loose tissues of the ruptured chest wall, In other rarer cases the inner aspect of the lung is wounded, and the air escapes into the tissues of the mediastinum, and follows them up Into the neck. Tn ordinary cases no treatment is indicated and the air is soon ab- sorbed. However, in the severer forms, the symptoms of asphyxia and cyanosis may supervene and then free incision over the infiltrated zone may be required. Hernia of the lung is a rare complication, and may be immediate or secondary. In the first case, the pulmonary tissue is forced through: the breach in the chest wall by violent expiratory effort. In some cases where the skin is not broken, the hernia may be felt as a crepitant tumor beneath the skin. Tn the secondary cases, it forms more slowly, and is often due to the weakening of the thoracic wall by inflammatory processes. Hemo-pericardium.—Blood in the pericardial sac follows injury to the pericardium. It develops more rapidly and, of course, the out- Took is much more grave if the heart is also wounded. The symptoms are those of syncope induced by the compression. of the heart by the accumulated fluid; the signs are those of increased cardiac dullness, The apex beat is lost, the heart sounds muffled, the precordium bulged. It is upon the signs that one must depend for the diagnosis, for the symptoms are often complicated by those of shock and by those which originate in other injuries in the thoracic region. To repeat, then, when you reach the patient suffering from some | form of chest injury, you will observe the character of his respiration — and his pulse; whether his condition is immediately serious or not is to be determined at once by that means. If the circumstances permil, you will proceed to a systematic examination. Learn from the suf- ferer the location of his pain and the character of his chief distress. Note the appearance of the sputum, if there is cough. Inspect the chest wall for change in outline and mobility and location of apex beat. Determine by percussion the limits of the lung resonance and heart dullness; and by auscultation, the presence or absence of the vesicular murmur or of riiles. ‘The case may be so grave that exact diagnosis Is unnecessary) OF again, it may require the most minute examination and judicious weighing of the symptoms and signs to make a correct forecast of the — eventualities, and to formulate a treatment which will leave to regret. CONTUSIONS OF THE CHEST. 103 CONTUSIONS OF THE CHEST. Simple contusions of the thorax, without fracture of a rib or the ster> cum (which are considered elsewhere) and without symptoms point- ing to internal injury, need but brief consideration, A hematoma is likely to form. The pain and soreness disappear rapidly in the young, but are extremely persistent in the aged and the rheumatic. Strapping and massage with liniment are usually sufficient. ‘On the other hand, following simple contusion, there may be a de- gree of shock out of all proportion to the trauma. A man of thirty, apparently in good health, received a slight blow over the chest in a friendly scuffle. The blow was slight, und yet it seemed to touch « vital spot and made him gasp for breath. It was with difficulty that he reached home and for two weeks he seemed apon the verge of a pneumonia. A month Jater he was still unable to work and an examination at this time revealed grave organic lesions of the heart. It was greatly dilated and not a single valve seemed to be performing fts function fully. In spite of rest and treatment, his condition gradually grew worse, and in six months he died with a general anasarca. We must consider that the heart, as well as other organs, is Hable to contusion and that from such injuries acute endo carditis may result In graver coniusions, such as crushing injuries, it is rupture of the lung which is always to be feared and which is usually evidenced by # large hemothorax. It must always be remembered that such an injury may occur without fracture of the ribs or sternum, Lejars cites the case of a boy leven years of age, whose chest was run over by a wagon. He arose immediately after the accident, but fell again unconscious, with blood pouring from mouth and nostrils. This hemorrhage did not long persist, but on the fourth day the temper- ature rose and he was taken to the hospital. His condition was alarming, the pulse weak with a rate of 104, hia face cyanosed and the dyspnea intense; his heart was displaced to the right, and on the left side were the signs of marked hemo-pneumothorax. A puncture removing t80 G. of the exudate gave but temporary relief. The pulse continued to grow weaker and the dyspnea more intense, and 105 WOUNDS OF SPECIAL REGIONS. ao urgent intervention was indicated. The pleura was opened and the lung found retracted toward the hilum. In the upper lobe a tear was found, 7 cm. long, and running upward, and backward from the cardiac incisure. The wound gaped freely. The lung was drawn into the opening in the chest wall, and the pulmonary wound with five sutures of silk which included considerable tixsee to prevent their pulling out, The coaptation was perfected by a few superficial sutures. The upper lobe was sutured to the parictes and a tamponade with gauze completed the operation. The outcome was unfortunate, for death occurred on the second day, but the autopsy found the lips of the lung wound well aggla: tinated. There was no costal fracture. The symptoms of ruplure of the lungs ate the same whether a rib be broken or not: hemo-pneumothorax, abundant and increasing; a spreading emphysema; symptoms of grave anemia; to all these may be added more or less quickly, the symptoms of pleural infection. ‘The treatment, except in the cases of extreme urgency, must be con» servative and expectant. Shock must be combated, the patient kept absclutely quiet, and the dyspnea relieved by the sitting posture, and, if possible, by inhalations of oxygen. ‘The anemia can be relieved by injections of small quantities of mor- mal salt solution frequently repeated. A puneture will partly empty the pleural cavity, affording great relief; and, eventually, the remaining exudate will be absorbed. Tt may happen that after two or three days the symptoms will improve. But in the worst cases, where the dyspnea is progressive and menac> ing, and the beart rapidly growing weaker, the responsibility cannot be shifted. It is indicated to operate at once, to open up the thorax and repair the tear in the lung, to do an urgent thoracotomy (see page 423) OPEN WOUNDS OF THE THORAX, Non-penctrating wounds of the chest wall are of slight significance and are to be treated on general principles. ri Penetrating wounds of the thoraa derive their significance from WOUNDS OF PLEURA AND LUNG. 105 particular viscera and vessels which may happen to be involved. On the clinical basis, then, these wounds may be divided into three classes: A. Wounds which involve the pleura or lung, B. Wounds which involve the diaphragm. ©, Wounds which involve the pericardium aod heart. A. WOUNDS OF THE TLEURA AND LUNG. In whatever manner the wound may be inflicted, there are three elements of danger; hemorrhage, asphyxia, and infection. These are the factors which will determine the line of treatment, and without some urgent indication from one of these sources the treatment must be conservative, There are many things which stand in the way of radical procedures such as are employed in the case of abdominal wounds [n the first place, the operative technic is difficult; there is a marked disturbance of respiration following free access of air to the pleural cavity; the exact location of the lung lesion cannot often be determined; and, finally, there is always, as Lejars remarks, so much guesswork in the prognosis, that we are constrained togive the patient the benefit of the doubt and leave the casc to take its natural course. Tr is best to proceed in this wise: If the case is seen from the first, Supervise the transportation. Too much importance cannot be at- tached to the dangers of rough handling, As has been said elsewhere, the nearest shelter is the best. Cut away the clothing, scrub the skin ‘adjacent to the wound, and wash out the wound itself with alcohol or sterile salt solution. If, on opening the lips of the wound, a bleeding point is seen, catch it up and ligate. Tf there fs oozing from the depths, it is best to disregard it for the ‘This constitutes the primary intervention except for suture of the wound, which follows. Apply a dressing of sterile gauze, plain or soaked in collodion. Cover this with a layer of absorbent cotton and apply a frm bandage encircling the whole chest. Place the patient on his back with the head’ and shoulders slightly clevated. Absolutely prohibit conver- sation and movement of any kind; and, in the meantime, keep the patient under close surveillance. ae 105 WOUNDS OF SPECIAL RECIONS, In general terms, then, the treatment of any ordinary open wound of the chest involving the lung and ploura {s to be summed up in two words, dmmediate occlusion and immobilization. But there are conditions which demand immediate infervention. ‘These are acute anemia or asphyxia, which may follow hemorrhage, ‘external or internal; and hernia of the lung. External hemorrhage may follow any extensive wound of the chest wall, welling up from its depths or flowing by spurts daring expiration. Tf there is no hemoptysis, it may be inferred that the lung ix mot wounded; but, in any event, the first treatment must be directed to- ward the intercostals and internal mammary. It may be that a tempo- rary hemostasis will be necessary, and the tamponade described on page 49, will be indicated. ‘The definite hemostasis requires a free enlargement of the wound. If pressure made against the lower border of the rib by an aseptic finger introduced through the enlarged wound causes cessation of hemorrhage, it is certain that it is an intercostal artery that is at fault. Tt may be difficult to clamp; it may be necessary to resect a rib, or to detach the periosteum, which will carry the artery with it, A curved needle threaded with catgut is then carried around the artery. The ligature is tied and the hemorrhage thus controlled. The internal mammary may require ligation above and below the wound, Internal hemorrhage is in every way more serious, for to the anemia is added the asphyxia which follows the compression of the lung. The patient is pale, anxious, with cold extremities, weak pulse, and sighing respiration; the chest wall bulges; the normal resonance and vesicular murmur are altered; in short, there are all the indications for an increasing hemothorax or hemo-pneumothorax. But even in the presence of these grave symptoms, it is by no means always indicated to operate. One must be content to repair the wound, occlude and immobilize, and wait awhile. But when the wound fs followed by an immediate and complete hemothorax, or when the symptoms and signs point to a rapkily ape proaching fatality, one must stand by with folded hands and see re end come, or operate; tor there is nothing else of any uae. An thoracetomy must be done. WOUNDS OF PLEURA AND LUNG, 107 Hernia of the lung is rare. The tumor is of variable size and is at first crepitant, but rapidly darkens and becomes hepatized. ‘The indications for treatment depend upon the time which has elapsed and upon the condition of the tumor. If the wound és recent and the long intact, the hernia must be reduced. Begin by a careful disinfection of the wound, Cover the tumor with an aseptic com- press and tuck its edges under the whole circumference of the wound. A steady pressure over the central portion of the tumor will expel the air little by little; and, by reducing its volume, favor the reduction of the tumor, ‘The compress is to be left until the skin wound is partially sutured, since by that means one may prevent the sudden pneumothorax which sometimes follows reduction, Hf the lung has been wounded, it must be repaired by suture, or by ligation and resection before being reduced. __ Tf some time has elapsed, it is as unsafe to reduce it as to reduce w doubtful herniated gut. re Lejars insists upon resection with the thermocautery. Around the base of the tumor pass a ligature threaded on a blunt needle, By tying the ligature, a pedicle is formed which is to be amputated with the thermocautery. The stump is carefully disinfected and reduced, the chest wall repaired, and drainage instituted Finally, in the case where the tumor is already gangrenous and slough- ‘ing, it is necessary to limit the treatment to antisepsis, leaving the ough to detach itself, and happily a cure may follow such spontaneous amputation. Axtell reports a case of open wound of the chest which illustrates what the doctor's patience and nature's efforts may accomplish in conditions apparently most desperate, (American Jour. Surg., Feb. 1909.) A shingle sawyer of twenty-eight, robust and muscular, fell against @ great circular saw revolving many thousand times per minute. Sections of the second, third, fourth, fifth and sixth ribs were cut away, these segments varying in length from one inch at the second to three inches at the fourth and fifth ribs. The costal pleura was com- pletely destroyed over the seat of the greatest injury. The hung and 108 WOUNDS OP SPECIAL REGIONS. pericardium were exposed. There was one puncture of the hing from which the air bubbled and emphysema followed. All the Inter- ‘costal arteries, veins, and nerves in the injured area were severed. ‘The pectoralis major was