THORAX AND THORACIC VIS CERA. INJURIES OF.
I. Mural Injuries.
Contusion of the Chest.—The discrep ancy often observed between cause and effect in the matter of contusions of the chest is only one degree less notable than in the case of abdominal or bral contusions. Given an individual case, it is impossible to predict, with any degree of certainty, in what degree the symptoms resulting from the blow, fall, or crush will be, simply those of a local contusion, or those of shock or concus sion. Compare, for example, the im mediate death of a well-trained pugilist from a blow "over the heart" delivered in a friendly bout, with Pare's ease: a child whose chest was run over by a "carriage containing five men," without even producing a fracture. It is fore necessary to accept the clinical pict ure of each case as it occurs and to strive to differentiate the symptoms of shock —the effects of which may be severe, but are usually transient—from those of jury to the viscera; and more especially to recognize injuries to the viscera which may be overshadowed by severe shock, or disguised by the mildness of the symptoms.
Case of a young man, 28 years of age, of vigorous constitution, who received a severe fall from a bicycle. At the time he was going at good speed, and some portion of the tubing, probably the handle-bar, came violently in contact with the chest. The skin was not torn, but there was a slight depression as though the costal cartilage had been fractured. At the post-mortem exam ination there was found some laceration of the intercostal muscle; the pericar dium was intact, but was distended with dry, clotted blood. Examination showed a transverse rent at the apex of the right ventricle, extending through its wall.
Rupture of the heart, with contusion, without penetration of the chest-wall, is a rare accident. A collection made by Cecil Robinson, in 1S97, showed a total of twenty-two cases. R. C. Newton (Med. Rec., June 17, '99).
The LOCAL, SUPERFICIAL SYMPTOMS of contusion of the chest are tant. The comparatively slight toma and comparatively severe and pro longed soreness alone deserve mention. This soreness may combine with the pa tient's fright to produce an alarming, but temporary, dyspncea, and it may, in the middle aged, drag on for months as a pain of rheumatic or neuralgic type.
The SYMPTOMS OF SHOCK are present to a greater or less degree in almost all cases. The pallor, weakness, syncope, or temporary intellectual confusion, and so forth, are not peculiar to thoracic juries. Yet what might be termed "local shock" — shock to the heart, namely — may seriously interfere with the action of that organ, even proving fatal, as in the case cited, without caus ing any appreciable lesion.
From research into the cause of col lapse or death from blows upon the lower chest and the epigastrium upon animals, it is found that collapse or death may be caused wholly independently of the vagi, though the vagi probably slightly con tribute to the result.
Collapse or death from violence applied upon the lower chest or abdomen are due mainly to the loss of rhythmical contrac tions from the mechanical irritation of such violence on the heart-muscle itself. There is evidence tending to show that the vagal terminal mechanism in and near the heart may contribute to the re sult, but in a minor degree. G. W. Crile (Phila. Med. Jour., Mar. 31, 1900).
The SYMPTOMS OF "INTERNAL" IN JURY arc so bound up, clinically, with the symptoms of simple contusion that they deserve some notice here. When ever a patient receives an injury to his thorax sufficient to disable him for the time being, he should be kept in bed and his symptoms, as well as the ical signs of his lungs, carefully noted for several days until the physician feels assured that no pleurisy or bronchitis will develop as a result of the injury.
To discharge a patient as cured and to have him return, or worse still, apply elsewhere, with a chest full of scrum, is not delightful. Needless to say, the pa tient—whether conscious or not—should be immediately examined for signs of injury to the heart or lungs and fracture of the ribs or sternum.
— The prognosis of nn complicated superficial thoracic contu sion is entirely favorable. Recovery is rapid in the young, tedious in the old and rheumatic. Yet, clinically speaking, the prognosis must always be guarded until the passage of three or four days without evidence of internal injury con firms the diagnosis.
—Slight contusions may be treated by the adhesive-plaster splint, applied as for fracture, or massage with alcohol, witch-hazel, or chloroform lini ment, according to the fancy of the physician.
Severe contusions, if the symptoms of shock are marked, require active stimu lation by external heat, strychnine, whisky, enemata, etc., and absolute quiet. Morphine is a specific in such cases, by relieving pain, quieting the mind, stimulating the heart, and slow ing respiration. The patient should be moved and handled with the utmost gentleness, so as not to aggravate pos sible internal injuries, the existence of which cannot be ruled out with cer tainty during the first hours. If the pa tient responds to the stimulation recov ery is quite rapid, unless there are in ternal injuries. The usual rules of diet, catharsis, and diuresis carry the patient through his convalescence. The lungs and heart must be examined at least every other day until the patient is dis charged.
Fractures and Dislocations. — The fractures and dislocations of the various bones of the thorax have already been described (see FRACTURES AND DISLOCA