'WOUNDS OF THE PLEURA.—Per fora tions of the pleura containing fluid have been recorded as curiosities of surgery. Such an accidental paracentesis has a romantic rather than a scientific interest.
Puncture or incision of one layer of the pleura without injury to the other is, as may well be imagined, an unusual occurrence, and perhaps it might be more correct to speak of wounds of the pleura with a corresponding lesion in the lung too slight to produce symp toms. Be that as it may, cases do occur which give evidence of injury to the parietal pleura alone.
When the wound is so small as not to admit the entrance of any air the condi tion is practically a rupture of the pleura, and the consequent luemothorax is the sole evidence that the pleura has been damaged.
In the majority of cases, however, the wound is large enough to allow the nor mal suction, the "vacuum" of the pleural cavity, to draw in the outside air, and thus to produce a pneumothorax or a pneumohmmothorax. Such a case differs from a wound of the lung only in the absence of luemoptysis. If the wound is larger still, the uninjured lung may be seen fluttering wildly about, or a hernia of the lung may occur.
It is probable that the secondary pleurisy with effusion, which so often complicates a contusion or wound of the thorax, however slight, is due to some puncture, rupture, or contusion of the pleura, but what the exact nature of the lesion may be it is impossible to say.
The diagnosis between an injury to the pleura alone and one to the lung is generally unnecessary, often impossible.
The prognosis and treatment are along the same lines as those of pul monary injuries.
Rupture of the Lung.
—The evidence of pulmo nary rupture may be more or less marked.
I. When the lung is only slightly torn or contused, a small hmmoptysis may be the only sign added to the evidences of superficial contusion. There may be a few fine lilies at the point of injury, or a circumscribed area of dullness, with little alteration of voice and breathing.
In other cases these initial signs pass un noticed, and the first evidence that the lung has been injured is a pleurisy with effusion, a bronchitis, or a broncho-pneu monia (see Section V of this article).
H. When the pulmonary laceration is extensive there is immediate hemorrhage into the bronchi, and limmoptysis is in stant and copious. The shock is severe and the patient in collapse, with thready pulse, labored and irregular breathing, and subnormal temperature. Physical examination of the injured lung reveals evidences of pneumolumothorax (see below).
Study of 94 eases of thoracic injuries, caused by penetrating and incised wounds. In 1;0 patients the left. and in 32 the right. pleura was penetrated, while in 2 both pleura.. In 2 the arteries of the chest-wall were injured, neeessitating ligation. In one patient the thoracic duet was injured. Pnemnothorax com plicated all but 4 eases, and there was no indication that it, in itself, is a serious compliention. Subcutaneous emphysema was observed in 47 patients. Memo thorax occurred in 27 patients, develop ing into pyothorax in 14. In the diag nosis of obscure eases of thoracic wounds, enlarging the wound is the only means of ascertaining the degree and ex tent of penetration. Finkelstein (Bolnit. Gaz. Botkina, July 10, 1902; Phila.:Med. Jour., Jan. 3, 1903).
During the first twenty-four hours the patient may die of shock, loss of blood, or by drowning in his own blood, which fills the trachea and may even run into the bronchi of the uninjured lung. That shock is always severe is explained by the number of agencies at work to cause it: there is the "molecular disturb ance" of the trauma, the profuse inter nal limmorrhage, and—most of all—the shock of sudden pneumothorax, which arrests the functions of one lung almost instantaneously, and, at the same time, disturbing the normal thoracic tension, seriously hampers the action of the other lung and the heart.