If the patient survives a few hours, subcutaneous emphysema begins to ap pear at the base of the neck, or, if the parietal pleura is torn by a broken rib, at the site of injury (see below, EMPHY SEMA).
Associated injuries may prevent a given case from conforming closely to the type; but the elements of the pict ure — luemoptysis, pneumoluemothorax, and secondary emphysema—cannot be obscured.
Probing is not always. satisfactory, and it is more advisable to enlarge the and determine its depth with the rye. lu case a rih or cartilage is in the way resection should be resorted to only when there is haemorrhage from an in tercostal artery and when the source is otherwise inaccessible. When satisfied that the wound penetrates the pleura, an antiseptic tampon should be intro- ' duce(' into the chest-cavity. If there are no contra-indications it should be left • in situ for four or five days. In the cases in which the wound was sutured the pro eedure proved unmistakably harmful in 50 per cent. Complications should he treated on general principles. In cage of hoemothorax the chest should be opened with a troear or by resection of a rib. In progressive emphysema an outlet should be made for the air in the pleura. B. K. Finkelstein (hot kin's ia z.. St. Petersburg. Nos. 10 and 2S, 1902).
The course of the case, after the first shock has been passed, is that of a pneu mothorax, with a marked tendency to secondary inflammations of the lung and pleura (see CommcATIoNs).
-Accurately speaking, rupt ure of the lung is the bursting of that organ by a compressing force, but clin ically this true rupture is indistinguish able from laceration of the lung by a fractured rib (see above). In the ma jority of cases the ribs are broken. Less often they remain intact. The accepted explanation of rupture of the lung under these circumstances is that of Gosselin: the patient, forseeing his danger, in stinctively catches his breath, thus pre senting a tense lung, which breaks read ily under a crushing force. Yet this theory does not apply to all cases, nota bly those who are unconscious when in jured, nor need it be invoked in any case. Doubtless a distended lung is more easily torn than an empty one; but the fundamental fact is that when any part of the lung is suddenly compressed, not only is it contused as any other soft part would be, but the circumference of the lung, closely adherent to the chest-wall by virtue of the pleural vacuum, is torn directly at the point of impact or indirectly at some other point, quite as a paper bag distended with air (though the lung is distended by suc tion from without rather than by press ure from within) is torn by a blow of the fist.
In point of fact, rupture of the lung is usually caused by a severe crushing force, such as a fall from a height, the fall of a rider under his horse, a fall under the wheels of a wagon, or the kick of a horse.
—By extensive rupture of the lung-tissue an artificial cavity is formed, connecting the pleural cavity, the bronchi, and the torn blood-vessels, thus establishing pneumohwmothorax. Lesser ruptures form small hxmatomas or ecchymoses, like contusions of any soft part. If the healing is not inter fered with by infection or a large hhema toma, it is complete within a few days. Autopsy has shown complete healing of small lacerations within a week.
— The prognosis depends on the reaction of the vital forces of the individual to the injury received, and, hence, given individuals of the same age, habits, and constitution, the less the injury, the brighter the prog nosis. Yet in any case of injury to the lung, however slight, the prognosis must be guarded until the lapse of time has proved that the secondary complications are not to be feared (see Section V of this article).
— The treatment at the time of accident is the same as that of severe superficial contusions of the chest (which see): stimulants, morphine, phys ical rest, and external heat.
The subsequent treatment is that of the primary and secondary complica tions, and is reviewed in Sections III, IV, and V.
Wounds of the Lung. SYMPTOMS.—Wounds of the lung pre sent the combined features, already de tailed, of rupture of the lung and wound of the pleura. The smaller the wound, the more its clinical picture resembles that of simple rupture of the lung. The larger the external wound, the more it resembles a simple wound of the pleura.