MALFORMATIONS OF THE THORAX.

Congenital malformations of the thorax are not uncommon, yet but few of them permit of surgical remedy. One or more of the ribs may be absent or defective in formation and produce lateral distortion of the spine. The clavicle also may be defective on one or both sides, or absent. This is a defect which causes but little inconvenience, in spite of its prominence. The chest as a whole may develop defectively or irregularly, some of these conditions being expressions of intra-uterine rickets and others being due to unknown or uncertain causes. Thus we have the absolutely flat chest seen most often in connection with an unduly rounded back, the flattening appearing rather in front, while perhaps the anteroposterior diameter is actually increased. As Hutchinson has shown, this may be a persistence of the fetal type of chest. Pigeon-chest or keel-shaped chest may be regarded as a reversion to a more primitive type, the anteroposterior diameter being increased at the expense of the lateral. The reverse of this deformity is the so-called funnel-shaped chest, where the sternum is depressed and the lateral dimensions increased. In addition to the defects thus noted in the ribs and sternum, absence of a vertebra has been known, the condition not producing deformity, but rather an appreciable shortness of the spine. Malformations are seen frequently in the sternum, which may be fissured in either direction, or may present perforations. With these similar defects of the ribs may also be seen, even to a degree permitting congenital hernia of the thoracic contents.

Supernumerary developments find their expression usually in an added rib, either in the cervical or in the lumbar regions. This condition is practically never noted at birth and may pass unnoticed. Nevertheless a cervical rib may, in adult life, produce discomfort or actual interference with function, partly by pressure upon the subclavian artery or the brachial plexus. When found it is in relation with the seventh cervical vertebra, and the space between it and the first dorsal rib is occupied by muscle developed for the purpose. The scalenus anticus may be inserted into its anterior edge. When sufficiently prominent to produce troublesome symptoms it may be recognized by palpation, and cases of doubt may be made clear by a radiograph. Should it prove troublesome it may be removed, an operation requiring considerable caution, because of its close relation to the pleura, which might easily be opened. It may be exposed by such an incision as would be used for ligation of the subclavian artery.

The thoracic muscles occasionally show anomalies, either in arrangement or by their absence, the pectoralis major being occasionally wanting in whole or in part, and furnishing the most frequent illustration of these defects, which are usually unilateral. (See Fig. 502.)

Congenital luxations of either extremity of the clavicle are also occasionally seen, particularly of the inner end. A peculiar displacement and relaxation are thereby permitted, with some degree of functional loss.

The acquired malformations of the chest may be produced from a variety of causes. Thus in connection with non-closure of the foramen ovale and the consequent disturbance of heart action, with its overdevelopment of the right auricle, the left side of the chest may be pushed forward and the apex beat found far below its normal position. Asymmetry in the young may also be produced by several different intrathoracic conditions, the most common being pleurisy and empyema, with their consequent distention of the pleural cavity, and later a tendency to cicatricial contraction. In this way marked forms of lateral curvature are produced. In a previous chapter it was stated that overgrowth of lymphoid tissue in the nasopharynx, ordinarily spoken of as adenoids, with consequent embarrassment of respiration, leads in time to stoop shoulders and poor development of the thorax. Deformity may also be produced by such defective vision as shall compel a peculiar or abnormal position of the head.

In chronic emphysema there is noted a peculiar barrel-shape of the chest, which is also to be regarded as an acquired deformity. Paralyses of the internal thoracic muscles will also permit of asymmetrical growth, and projection of the lower angle of the scapula, giving it a wing-like aspect.

The most common cause of thoracic asymmetry or deformity is rickets, which may be an early or a late manifestation. By the ordinary changes permitted in the epiphyses and along the costochondral junctions is produced the peculiar appearance known as “rickety rosary.” In these cases the effect of the weight of the upper part of the body upon the soft and changeable structures of the osseous and cartilaginous ribs, as well as the vertebræ and the sternum, are to be noted. Pronounced types of deformity result from such changes, producing extreme cases of pigeon-breast, or of hollowing in front known as birds’ nest deformity, while alterations occur in the vertebræ, producing various expressions of kyphosis and scoliosis. (See Fig. 504.)

These deformities of the back thus produced require to be differentiated from those produced by Pott’s disease, the former being unaccompanied by symptoms and occurring slowly, while the latter are usually accompanied by pain and are progressive in character, as well as more or less disabling. With a softened skeleton in a rapidly growing child such trifling influences as the position assumed in the nurse’s or mother’s arm, or that habitually taken in sleep, may affect and modify symmetrical growth. Rickety deformities of the spine and thorax, if not too far advanced, permit of being checked and much improved by braces, along with the measures indicated in rachitis. Without the latter, however, the former would be almost ineffectual.

Malformations may also be produced by injuries or certain occupations. Extensive burns may cause cicatricial contraction; contusions may produce paralyses, and more serious lacerations may leave extensive scars, which will gradually warp the chest out of shape. Burns, for instance, which may involve the axilla and the upper arm, may be followed by such dense scars as to limit the motion of the arm. Skin grafting should be resorted to early in the treatment of lesions thus produced.

Tight lacing is the source of a mild form of thoracic deformity, by which the chest capacity is reduced, the respirations made peculiar in character, the liver displaced downward, and the general welfare of the individual materially affected. Influence of the right-hand habit is frequently quite apparent in that the right side of the chest becomes overdeveloped as compared with the left. This may be seen in a large number of workmen who use heavy tools especially with the right hand. Certain occupations, as well as sports, lead to constant assumption of the stooping position, with the inevitable round shoulders and drooping head so apparent in bicycle riders.

Tattooing.—As a local expression of a bad habit, or in some instances almost of a criminal instinct, tattooing may be mentioned. This is seen usually upon the chest and arms. It is a prevalent custom among sailors, and is regarded by alienists and anthropologists as a habit indulged in by criminals and the insane. La Cassagne has spoken of tattooing as “an uninterrupted and successive transformation of an instinct.” Among the inhabitants of the Pacific Islands it is almost a mutual practice, and among them the tattoo marks are often found upon the back and upon the sexual organs. The materials usually employed are lamp-black, indigo, and India ink for the black or blue tints, and cinnabar or carmine for the red. Practised as it is by the unschooled and the ignorant it may be followed by all forms of local infection, while syphilis has been thus transmitted.

For the removal of tattoo marks many methods have been suggested, but few have been found satisfactory. The minute particles of pigment have become so deeply lodged that, like powder marks, it requires infinite patience in their detection with the lens and individual removal, or those portions of the skin must be destroyed which contain them. Mechanical methods should be limited to localized stains, unless a plastic operation is preferred, and, after removal of the affected area, healthy skin may be transplanted by one of the plastic methods or we may resort to skin grafting. Actual cauterization with strong caustics or with the actual cautery will be followed by superficial sloughing, which may remove the disfigurement. It is questionable, however, if the resulting scar will be considered much of an improvement upon the previous condition.

INJURIES TO THE THORAX AND ITS CONTENTS; CONCUSSION OF THE CHEST.

As a result of a severe blow made by a blunt object there may result a form of concussion or commotion, similar in its results to the conditions which were formerly described in the cranial cavity as concussion of the brain, but which are now known to be due to reflex vasomotor disturbances, by which blood pressure is seriously affected and extreme degrees, perhaps fatal, of shock or collapse produced. It is possible for fatal injuries thus produced to leave little or no evidence that may be discovered at the autopsy. Hence the term concussion of the chest may be retained as descriptive of what has taken place, and implying serious symptoms produced through the agency of the nervous system, especially through its sympathetic plexus. In such instances the heart is seriously affected and may continue to beat feebly for some time, as in shock from other injuries.

Severe blows upon the chest also disturb the function of respiration, and it is possible that asphyxia, even to a fatal degree, may result from a momentary paralysis of the entire respiratory apparatus thus produced. In such cases artificial respiration will be required. In many instances patients will complain of not merely distress, but severe pain, which may require local anodyne measures as well as the administration of an opiate.

Contusion of the chest leaves more visible and lasting effects upon the tissues of the chest wall. Thus extensive hemorrhages may result and hematomas form, or ribs may be broken, with or without injury to the pleura, or internal hemorrhages may occur, as from a ruptured intercostal or internal mammary artery, the consequences of such injuries not necessarily appearing at the time, but developing later. Along with these injuries to the chest there may occur other injuries to the abdominal viscera or to other portions of the body. Something will depend upon the distention or relative emptiness of the lungs at the time of injury, and whether there may have been at the same time a sudden closure of the glottis, in which case, by an external blow, something resembling an explosive effect may be produced within the air passages. The degree of stomach distention may also have its own effect. Laceration of lung tissue will usually be shown by appearance of bloody froth at the mouth, as well as by more or less dyspnea. Rapidly developing symptoms of pressure upon the lung would indicate the accumulation of blood within one pleural cavity and cause the ordinary physical evidences of the presence of fluid. The diaphragm may be ruptured, and the proper viscera of one cavity be displaced into the other. When emphysema of the tissues of the chest occurs it is usually safe to assume that a rib has been fractured, even though the injury cannot be located or even otherwise recognized.

A series of later lesions may result from such contusions, which may be of serious character. Thus there has been described a so-called contusion pneumonia, whose symptoms are similar to but milder than those of the genuine disease. It is a result of inflammatory and hemorrhagic infiltration. It may lead to a pleuropneumonia, with subsequent hydrothorax or pyothorax, or these may take place more directly and without its occurrence. The products of this disease afford foci in which, later, tuberculous expressions are commonly met. It has been shown experimentally that the blood serum of animals subjected to severe injuries of the chest and abdomen has well-marked toxic properties. Thus the appearance of sugar or albumin in the urine or of other toxemic indications may be perhaps explained.

Treatment.

—The treatment of these injuries should include the relief of pain; the performance of artificial respiration, along with the inhalation of oxygen; the customary treatment for shock, with the use of adrenalin, when needed, for raising blood pressure; absolute rest, and especially the enforcement of local physiological rest by bandaging or the application of broad strips of adhesive plaster about the thorax. In addition to these general measures special indications should be met when they arise. The occurrence of phenomena indicating the development of pneumonia or collection of fluid should be noted, as the latter may call for removal, with perhaps ligation of a vessel, if it be bloody, or later evacuation, should it be serum or pus. External extravasation will usually disappear under soothing, warm, and moist applications. No hesitation need be felt in opening a hematoma which does not show a disposition to prompt resolution. Other non-perforating injuries include, for example, severe burns or scalds, which may need the same treatment as when occurring in other parts of the body. Fluid may accumulate within the chest when there has been any such serious external disturbance.

PENETRATING WOUNDS OF THE CHEST.

Penetrating wounds of the chest are generally inflicted by stab or gunshot injury. Two serious elements of danger accompany these injuries: the first immediate, that of hemorrhage from division of some vessel of importance concealed from sight; the other that of infection, for either by the penetrating object itself or by air or clothing which may follow it, infection may ensue, which may result in septic pneumonia, pyothorax, or some deep phlegmonous process, with always dangerous and sometimes fatal results. Gunshot wounds vary, and according to the character of the missiles and the weapons from which they are discharged. Those occurring during warfare and made by bullets of the Krag or Mauser type are usually driven with such velocity that they produce a minimum of laceration, even though they pass through the chest. Such injuries have in the late wars in different parts of the world been frequently observed, and have shown a surprisingly low mortality rate, providing only that the heart itself, the pericardium, the large vessels, and the spine be not injured. Stories of the battle-field afford abundant illustration of men shot through the chest being scarcely affected by the injury, but continuing in action, at least for some time, and finally recovering. On the other hand, the ordinary revolver or pistol, with which most affrays in civil life are terminated, does not drive its bullet with nearly the same velocity, and is more likely to inflict a serious or even fatal wound. (See Plate XLVIII.)

A bullet or a stab wound almost invariably so opens the thorax as to permit the immediate entrance of air. In theory this should be followed by prompt collapse of the lung; in fact, however, this is only partial, and often surprisingly so. If such a bullet wound be occluded the air thus admitted is more or less absorbed, disappearing into the bloodvessels, and the lung once more expands to its natural dimensions. Much will depend, therefore, on the size and character of the wound as to whether occlusion may occur spontaneously, or may be practised through the first-aid dressing or its equivalent.

The entrance of air may be recognized by a certain degree of embarrassment of respiration, by alteration in the percussion note, and often by its passage to and fro through the opening.

The principal indications of possible injuries, in addition to those just noted, will be the occurrence of paroxysmal coughing, with inspiration of blood, and the added physical signs of the presence of blood in the pleural cavity. Thus dulness on percussion, with the line of dulness altering with position, will indicate the presence of fluid, and should this occur soon after the injury it can only be regarded as an evidence of hemorrhage into the pleural cavity. A combination of abnormal tympanitic condition, as above, with the physical signs of fluid beneath, will indicate a condition of pneumohemothorax. These signs will change from hour to hour or from day to day in accordance with altering internal conditions. If they become rapidly more pronounced they indicate a condition which will probably call at least for free incision, evacuation of blood, and very likely determination of the source of its escape and proper attention thereto.

An intercostal artery is of itself a small vessel, but when cut across by the edge of a knife or torn by the passage of a bullet it may pour sufficient blood into a pleural cavity to cause serious dyspnea and perhaps fatal result. To discover at the coroner’s inquest that a patient has been allowed to die because no one had the judgment to enlarge the wound and assure himself whether such a hemorrhage was not occurring is not at all creditable to those in charge of the case. The combined dangers of infection and of collapse of the lung are not so great as those of possibly fatal hemorrhage, or intrinsic disaster through septic infection from neglect of this kind.

Aside from the injuries thus produced to the respiratory apparatus there are those especially involving the heart. It has been supposed that gunshot wound of the heart was necessarily fatal. There is now reason to think that this is not invariably true, even in individuals not promptly operated upon, while the resources of modern surgery have enabled the surgeon to save a number of cases of absolute gunshot injury to the pericardial sac and even to the heart itself. (This subject has already been considered in the chapter on Surgery of the Heart and Great Vessels.) Every case which is not promptly fatal is worth attempting to save, if suitable help be at hand, by a resection of the chest wall, exposure of the pericardium, and of the heart itself, with the introduction of sutures or the use of the ligature wherever these may appear to be needed.

The occurrence of more special forms of traumatic lesion may be indicated by particular features. Thus if the esophagus has been wounded the patient may expectorate or vomit blood, whose presence in the stomach could not be explained by other features of the case. On the other hand blood which comes into the mouth from the lungs may be swallowed and its appearance in the ejected materials thus accounted for. A violent disturbance of cardiac regularity or evident paralysis of the diaphragm may be accounted for by injury to the pneumogastric or phrenic nerves.

Treatment.

—In regard to the general treatment of these injuries the use of the probe should not be encouraged, at least in the way in which it was formerly used. It is a serious matter to stir up clot or to open up a wound with a probe, thus inviting free entrance of air. Nearly all the information desired may be more accurately obtained by careful physical examination and study of symptoms. It should never be used except with aseptic precautions. It affords little information as to the course, and practically none as to the location of a bullet which has penetrated the chest wall. It may possibly be of service in searching for a bullet in the muscles of the back, but the only information it is capable of furnishing is afforded by a skiagram. Miscellaneous probing should be condemned, and in these injuries is rarely justifiable.

The first measure to adopt in cases of gunshot wound of the chest is to determine that the heart has not been disturbed; the next to estimate what injury may have occurred to large vessels, then a general determination of the other surgical features of the case. The patient who shows no depressing symptoms nor develops them during the ensuing few hours may be left with only a temporary occlusive dressing placed over the wound; but increasing embarrassment of respiration, or weakening and increasing rapidity of pulse, should be carefully watched to guard against internal hemorrhage. If it be learned that there is such internal bleeding prompt action should be taken for its control. This means anesthesia and perhaps thoracotomy, with resection of one or two ribs, in order to afford space through which to practise deep suture or ligation. So long as one side of the chest alone is involved—i. e., one lung thus exposed—the surgeon may widely open the chest and meet every surgical indication without the necessity for artificial respiration or the use of the Fell apparatus. It is, however, advisable to have this at hand for such work, while cases demanding such extreme measures can scarcely be made worse by the performance of a tracheotomy and resort to some means for forced and artificial respiration.

To simply enlarge a small bullet opening or punctured wound, in order to be sure that an intercostal artery has not been injured adds but little to the danger and much to the security of such a case. In case of doubt give the patient the benefit of that doubt and operate to any necessary extent. When hemorrhage is slight and not alarming it may be sufficient to make the occlusive dressing include a tamponing of the opening between the ribs, gauze being packed in the opening in such a way as to prevent hemorrhage.

A study of the escaping blood will permit of differentiation between arterial and venous hemorrhage, that which escapes from the lung being ordinarily of the latter type. Richter has suggested an ingenious method of deciding whether hemorrhage comes from an intercostal artery or lung tissue, by introducing a sterilized piece of pasteboard, similar to a visiting card, rolled up in the form of a circular tube and flattened with a crease; should blood flow out along the groove it shows that it is an intercostal artery which is bleeding; but if it flows out of the wound through the tube the source of the bleeding is the pulmonary tissue itself. (Dennis.)

The question of the presence of a foreign body, bullet or otherwise, is important. This is less so when it is a question of the bullet itself than of driving in some fragment of rib or of foreign body introduced from without. A bullet, a broken knife-blade, or anything of such character will be revealed by an x-ray picture. The probe will rarely give this information. Clothing, objects carried in the pocket, or various other foreign material may escape detection.

The first measure of importance is the determination of the occurrence of serious internal hemorrhage, the second is the emergency treatment of the injury itself, which should include primary aseptic occlusion, to be followed later by other measures. A withdrawal of fluid is also indicated. Escaped blood may be contaminated and produce later a pyothorax. As the result of a traumatic pleurisy serum may collect within the ensuing few days, and it too should be removed. It should be first found with the exploring needle. If seen to be free from pus it may be withdrawn by the aspirator; but if it be destined to become pus, then the sooner it is evacuated by incision the better.

Increasing embarrassment of the heart’s action, which is not caused by the collection of blood, may be due to pyopericardium. So soon as the physical signs indicate gradual enlargement of the cardiac area the exploring needle should be used. A traumatic pericarditis may simply require aspiration of the pericardium, whereas the presence of pus in the pericardial cavity will not only necessitate aspiration, but occasionally open incision, with or without drainage. The appropriate manner of affecting these procedures will be found more fully discussed in the section on the Heart.

INJURIES TO THE THORACIC VISCERA.

In general, and without regard to the nature of the accident, injuries to the thoracic viscera include wounds of the pleura, the lung, the diaphragm, the various large and small vessels, the pericardium, the heart, the thoracic duct, and the nerves.

Wounds of the Pleura.

—Injuries to the pleura, including rupture, are produced by severe blows which do not inflict fractures, although these are rare in the absence of such injuries. They are usually not accompanied by external markings, but are indicated rather by dyspnea and cough, with involuntary limitation of respiratory motions and by the physical signs of escape of blood (hemothorax) or air (pneumothorax), or by some crepitation at the site of fracture, which may be recognized with the stethoscope. In many instances lacerations of the pleura are accompanied by more or less injury to the lung, perhaps with perforation of air cells or small bronchi and the inevitable pneumohemothorax. With a wound situated near the twelfth rib the lung, which extends normally only to the tenth, may escape injury. A small wound of the pleura is of little consequence. By itself it is of serious import only as it is accompanied by more serious disturbances of the lung which it envelops, or the heart which it contains.

When air passes freely to and fro through the opening in the chest wall, without expectoration of froth or bloody mucus, it may be assumed that the lung itself has not been injured. To this condition the name traumapnea has been given.

Uncomplicated cases of pneumothorax usually take care of themselves, the air being gradually absorbed by the bloodvessels. In certain cases this air may be withdrawn by the aspirator. A small amount of blood within the pleural cavity is usually absorbed. An amount sufficient to embarrass respiration should be withdrawn either with the aspirator or by incision. For the latter purpose the wound may be utilized when properly situated.

Wounds of the Lung.

—Wounds of the lung are made immediately dangerous by injury to its bloodvessels or are given a serious aspect by the possibilities of various forms of infection, including septic pneumonia. In serious cases this may proceed to abscess formation or gangrene. Should either of these be sufficiently localized no surgical procedure directed to evacuation or to excision or removal of the gangrenous tissue can be more dangerous than the condition left to itself. The surgeon may, therefore, be impelled to perform a pneumotomy or a pneumectomy.

When the lung tends to protrude or prolapse through an external injury the condition is referred to as pneumocele, or sometimes as hernia or prolapse of the lung. This is rare, and occurs usually in connection with punctures or stab wounds placed anteriorly and generally low. The lung may be entangled, after having been forced out by violent coughing, and the external portion has been known to be strangulated in such a way as to slough off. Should this occur the mass may be permitted to slough, or it may be removed by cautery or by ligature, the wound being left to heal by granulation. In rare instances the pneumocele has been covered by the parietal pleura, as is abdominal hernia by parietal peritoneum.

Another form of pneumocele is the later consequence of injury, the soft, crackling, or crepitating tumor presenting beneath the skin and returning the usual breathing sounds when auscultated. It may increase and diminish in size with the respiratory movement. Such a hernia may occur beneath a scar or through ruptured intercostal muscles. It is of small surgical consequence, and, if troublesome, may be retained by a suitable pad.

The lung is occasionally ruptured by a violent concussion of the chest, as is also the heart. Its consequences will be emphysema, pneumohemothorax, with vomiting of blood, and later infection.

The later consequences of hemothorax, simple or uncomplicated, may be troublesome pleuritic adhesions, by which freedom of respiration is impaired, and, it may be, chest motions interfered with and chest development limited. The pleural surfaces are usually gradually drawn toward each other by the development of granulation tissue and its subsequent contraction and condensation.

Wounds of the Diaphragm.

—The diaphragm may also be lacerated by the compressing effects of violent blows, either upon the chest or abdomen. In consequence there may be passage of viscera (hernia) from either cavity into the other. Accurate recognition of these cases will scarcely be possible, but the development of distinct abdominal symptoms or noticeable displacement of the heart or of the abdominal viscera may lead to exploratory section, which shall reveal the location of the rent and possibly permit of appropriate repair or suture.

Injuries to the Thoracic Duct.

—The thoracic duct is occasionally injured by penetrating wounds, while, at the base of the neck, it has been known to be divided in the course of the removal of deep and adherent tumors. In the latter case the escape for a short time of the milk-like chyle, which it carries, will give evidence of the injury. Several cases on record show the comparatively innocent nature of the injury and its tendency toward spontaneous recovery without the necessity for further intervention. The very low pressure of the fluid in the duct is a contributing cause to this exemption from serious harm. Should the duct become obliterated near its upper end doubtless collateral circulation will enable the right and smaller duct to take up its work and continue it.

Injuries to the Upper Nerve Trunks.

—In regard to injuries of the upper nerve trunks in the chest it is necessary to add but little to statements made regarding injuries to the same nerves in the neck. The writer has collected over fifty cases of destructive injury to the pneumogastric, in over one-half of which recovery followed. It has been shown that unilateral resection of the vagus is almost devoid of danger, though when it is required the nerve is rarely in a normal condition. Unless the nerve be attacked or involved below the branch which forms the recurrent laryngeal, laryngeal symptoms may be certainly expected. Irritation to the cervical sympathetic is usually followed by dilatation of the pupil, widening of the palpebral fissure, some degree of protrusion of the bulb, and paresis of that side of the face, while absolute sympathetic paralysis, such as follows division, will produce dilatation of the pupil, ptosis, and increased flushing of that side of the face. The sympathetic nerve may have to be extirpated in certain cases of excision of malignant tumors. Again, it has been deliberately resected, as recommended by Jonnesco and others, for the cure of epilepsy, of exophthalmic goitre, and of glaucoma. This will demonstrate the fact that injury to it is not necessarily of itself a severe accident.

In certain injuries to the chest branches of the brachial plexus will be divided or compromised, or displaced by fragments of bone or otherwise. When nerve pressure can be recognized the compressing cause should be removed. If a nerve be divided every attempt should be made to suture it.

Partial or complete division of the large vascular trunks is usually too promptly fatal to justify much consideration here. On the other hand, injuries to the intercostal and internal mammary vessels are not uncommon and should not be fatal if only they can be properly recognized and treated. It is stated that even an intercostal artery may pour four pounds of blood into the pleural cavity in case of gunshot or stab wound. The presumption would be that one of these vessels, if injured, is wounded at the site of the evident puncture. While this is usually true it is possible that a bullet penetrating may have divided an intercostal on the opposite side. If a ligature is to be applied it should be done on each side of the wound, whereas a tampon used to check hemorrhage may be packed in such a direction as to completely meet the indication. While many methods have been suggested for arresting bleeding, the surgeon will enlarge the puncture, seek out the source of the hemorrhage, and then resort to ligature or to tamponing, as the case may indicate. When the tampon is used it is well to push ahead of it a piece of gauze like a glove finger and fill this with the tampon, in order to ensure complete removal of the whole mass at the proper time.

This is true also of injuries to the internal mammary. Dennis mentions five cases, quoted to him by Langenbeck, of perforation of the chest with a sword-blade, as the result of duels among university students of Göttingen, of which number two died. The latter also stated that up to 1876 there never had been a successful ligation of this artery. The vessel, leaving the subclavian between the two heads of the sternomastoid muscle, lies in its course just to the inner side of the sternum, with the vein on its inner aspect. Near the clavicle it lies on the pleural sac, where if injured the pleura will not escape. Lower down the pleura is not necessarily opened, although it rarely escapes. As Dennis shows, the inference from this is that tamponing the wound in the two upper intercostal spaces is impracticable, while below these it might succeed, as the triangularis sterni lies between the pleura and the artery. The mortality of the injury has been stated to have been nearly 70 per cent. Diagnosis is not difficult so long as the blood escapes externally. With a wound properly situated and rapid accumulation of blood within the chest, and increasing collapse, assumption of the injury or provisional diagnosis will scarcely prove fallacious.

The internal mammary when injured should be secured. The operator need never hesitate to resect a portion of the sternum, or the rib ends or cartilage, in order to expose it, since no danger can be so great as that of not finding it. Incision may be made along or between the ribs, parallel to them, or over the known course of the artery. After retracting the tissues down to the bone a sufficient amount of the bone should be removed to afford space for the examination. The pleura should be first separated, care being taken not to inflict upon it more than a minimum of injury. A T-shaped incision will afford more room when the case is complicated. The ends of the vessel having been found and secured, it becomes then a question of emptying the chest of the blood already accumulated. This is preferably done by incision placed laterally and sufficiently low, with the introduction of a drainage tube. Should the blood be already coagulated the incision should be made sufficiently wide to permit of breaking up the clot and completely removing it.

Treatment.

—In general, with regard to the treatment of all these injuries, it should be said that, in addition to whatever local measures may be indicated, general rest of the parts should be secured by as complete immobilization of one or both sides as can be effected. This should be made a part of the treatment of all fractures, simple or compound, as well as of all perforating injuries. Anodynes, hypnotics, and the like need to be used both to restrain motion and to allay cough, either of direct or reflex origin, by which harm is always done.

THE THORACIC WALLS.

The complex structure of the thoracic walls is not exempt from the infections and other diseases which may involve skin, muscle, cartilage, and bone. Thus upon its surface all sorts of phlegmonous lesions may occur, assuming carbuncular or localized type, or occasionally ending in widespread gangrene, usually of that particular type which is due to the morbid activity of the gas-forming bacilli, whose first expression is a gangrenous emphysema. These infections occur not only in consequence of some external irritation, but are seen after the infectious fevers, as well as in connection with syphilis, tuberculosis, scurvy, actinomycosis, and other forms of infection. Tuberculous disease beginning on the exterior of the chest wall may spread to the interior and even deeper, and, vice versa, tuberculous lesions beginning within the chest spread to the adjoining bone, producing caries, and then to the exterior surface, the resulting sinuses being irregular and sometimes opening at a point at considerable distance from the origin of the trouble.

All the infectious processes, whether slow or rapid, need radical attack, including free incision, curetting, removal of diseased bone, cauterization of the affected area, and suitable dressing and packing. Carious ribs or portions of the sternum may be removed without fear, it being necessary in certain advanced cases to remove nearly the entire sternum. Any concealed focus of disease is sure to spread and do more harm than will a well-directed attempt to eradicate it. Infection originating within the bone may spread in either direction, and may give rise to pleurisy, with adhesions, and possibly even subsequent abscess of the lung. The same is true of the diaphragm, while products of infection travelling in the proper direction may cause the beginning of an extensive subphrenic or hepatic abscess.

The pressure of advancing tumors will sometimes cause surprising changes, not so much the result of ulceration as of mere absorption in the path of the advancing mass. Thus aneurysms will gradually erode the sternum or the ribs, and in time form bulging projections from within the chest, which may ultimately rupture and thus terminate the case. Even upon the vertebral column the effects of such pressure are pronounced. Figs. 505 and 506 illustrate what may happen under circumstances just detailed.

Remarkable expressions of subcutaneous emphysema may be seen in certain cases of fracture of ribs, with perforation of the lung, air escaping into the tissues and puffing up the whole upper part of the body and neck, giving it an appearance and shape very different from the original. For this condition there is no particular treatment, save immobilization, by which respiratory efforts shall be limited. Ordinarily the tissue distention quickly subsides. Should, however, putrefactive organisms enter with the air there may arise emphysema, terminating in gangrene, with fatal septicemia.

Painful affections of the thoracic walls are associated with lesions, either of the intercostal nerves or the ganglia or special nerves with which they are connected, which produce intercostal neuralgia of various types, including that with its peculiar eruption known as herpes zoster, or as the laity call it, “shingles” (being a corruption of the Latin cingulum, meaning a girdle). Neuralgia may also be caused by inclusion of nerve branches in callus which is formed around a badly united fracture of the ribs. The diseases of the vertebræ which lead to softening and changes of shape will also permit of pressure upon nerve centres and trunks, which cause more or less pain, referred more often to the distribution of the nerves involved than to their origin. Thus the referred pains of spondylitis (Pott’s disease) are to be thus explained and are sometimes very pronounced. We give the term “neuralgia” to those painful affections for which there is no satisfactory explanation, and thus we are told that in intercostal neuralgia there are three points of tenderness, known as those of Valleix, whose determination confirms the diagnosis—the first being at the point of exit of the spinal nerve from the vertebral canal, the second in the axillary line, and the third close to the costosternal articulation. Abrams has shown that if a freezing spray be applied over the first spot the neuralgia will at once subside if it be of peripheral, but not if of central origin. Again, if one pole of the galvanic current be placed on the affected side and the other upon any one of the above spots the pain, if neuralgic, will disappear. If the current employed be the Faradic, and the pain subside, its cause is located in the muscles, as the induced current does not influence the pain of a genuine neuralgia. (Dennis.) So far as the treatment of these painful affections is concerned it is rarely surgical; although it was the relief afforded by the accidental stretching of an intercostal nerve which first suggested to Nussbaum the utility of nerve stretching as a more general procedure, and it was thus introduced to the profession. The treatment of herpes, i. e., of that form of neuralgic affection which is characterized by the appearance of papules which soon become vesicular, which collect in clusters and appear along the course of certain intercostal nerves, is rarely surgical. It is not difficult to distinguish this from ordinary eczema, which does not follow the nerve distribution and is not accompanied by the severe pain of herpes.

THE MEDIASTINUM.

MEDIASTINITIS.

The principal interest attaching to diseases in either mediastinum pertains to the consequences of spreading infection, which will be practically always of the phlegmonous type, and which will produce clinical expressions varying much with its location and the direction of its course. These are included under the general head of acute or chronic mediastinitis, which might be the result of an extension from above, as from cervical abscesses, spondylitis of the cervical vertebræ, deep cervical phlegmons, and the like; or the result of perforation, or of foreign bodies impacted in the esophagus or elsewhere; or may again come from the osseous structures of the chest proper, spine, ribs, and sternum. Doubtless certain cases of subphrenic abscess are the result of suppuration begun in the mediastinum. Instances are also occasionally seen after typhoid and the other infectious and contagious fevers.

The indications of mediastinitis consist of intrathoracic soreness and pain, increased upon coughing and deep inspiration, difficulty of deglutition, disturbances of respiration and of heart action. Any irregularity of the pupils is evidence of irritation along the sympathetic nerves. Displacement of the heart means accumulation in its neighborhood and pressure disturbance. The lesion which will produce this will probably give dulness on percussion, and alterations of the ordinary chest sounds. With trouble high in the thorax the recurrent laryngeal may be involved, with the inevitable change in the voice. If the pneumogastric be compressed there will be rapid and irregular heart action. If the esophagus thus suffer dysphagia will result. Should the presence of pus be suspected a differential blood count may do much to clear up the diagnosis. Should pus come near the surface it will probably give the ordinary surface indications which one should be quick to appreciate and to relieve. Collections of pus within the chest tend always to migrate and pus may burrow to a considerable distance.

Treatment.

—The treatment of phlegmonous mediastinitis mainly depends upon recognition of the lesion and its degree of accessibility. Certain deep forms are hopeless, since they tend to kill before even pus can be located and evacuated. So soon as there be found any surface indication surgical attention should be promptly given. Any of these cases may be complicated by septic conditions within the lung or accumulations within the pleural cavity. The latter at least may be recognized and relieved. The proper use of the exploring needle may afford much information, and, in the presence of suitable indications, the sternum should be trephined and exploration made behind it. The main thing in all these cases is to distinguish between pressure effects produced by phlegmon and those due to aneurysm or tumor. Only rarely, and then only by surgeons of wide experience, should radical measures be attempted for the latter. Chronic processes, of tuberculous character and leading to formation of cold abscesses, will usually produce symptoms much less urgent, while the nature of the relief to be afforded will scarcely be left in doubt.