HEMOTHORAX.
In medical cases the treatment is mainly symptomatic, since the primary cause of the bleeding is usually beyond the reach of surgery. The patient should be placed in bed, and have ice freely applied to the affected side; lie should lie upon this side unless where this interferes with the repeated applications of the ice. Food should only be given in quantities just. capable of maintaining life, and the utmost quiet and freedom from excitement must be maintained. A moderate dose of Opium or a small hypodermic of Morphia may be administered with advantage, as in cases of hwmoptysis.
Internal or Lactate of Calcium should be given by the mouth or rectum, and the reduction of the general blood-pressure effected by inhalations of Nitrite of Amyl or by Nitroglycerin, followed up by a brisk saline purge. The practitioners of a former generation under such circumstances did not hesitate to open a vein freely in order to relieve the tension in the internal bleeding vessel—a practice which is seldom or never ventured upon at the present time, but when the heart is embarrassed in traumatic cases life can only be saved by opening a large vein.
Where a large amount of blood has already been poured out, and a condition of acute anaemia has supervened, this must he met by saline injections hypodermically by the rectum or by the veins. At the same time the sudden compression of the lung and displacement of the heart will require prompt relief. A puncture by the exploring needle will reveal whether the effused blood remains still liquid, in which case the aspirator may be cautiously employed or a trochar and canula used, but should clots exist there may be no other course open but to make a free incision as in empyema, and provide for suitable drainage.
Haemothorax due to injuries is usually the result of a fractured rib perforating the lung or wounding an intercostal artery. When the internal haemorrhage is caused by a penetrating chest-wound the bleeding comes from the internal mammary or an intercostal artery, and the vessel must be ligatured. The ligature of an intercostal artery is often a difficult procedure requiring free enlargement of the wound and even resection of a portion of a rib. Where such an operation is inadmissible
owing to the state of collapse often following such injuries, three alter natives are available: A curved needle hearing a stout ligature may be passed round the rib, so as to include the bone and intercostal artery in its embrace; after tightly tying the silk or catgut the haemorrhage may be controlled, pressure forceps may be employed as a temporary clamp and left in Aitu, or Desault's expedient may be resorted to. This is carried out after sterilisation of the wound by laying a piece of stout gauze or lint over it and pushing the centre of the lint inwards till a cul de-sac is formed, which is next packed firmly with gauze; when the lint is pulled outwards the plug exerts its pressure upon the wounded artery, which is compressed against the bone or interior of the chest wall. The lint is finally fixed by a pad, and kept stretched by fastening it to the thoracic wall with strips of plaster.
Should the haemorrhage proceed trom the internal mammary, this vessel may be tied without much difficulty in the second or third inter costal space.
Where the haemorrhage is coming from a ruptured lung, one or more ribs will require resection to expose the bleeding viscus, which should be sutured with its visceral layer of pleura.
Blood effusions are to be distinguished from true haemothorax, and should be treated by the methods described under Pleuritis. Where laxmothorax is the result of tuberculous ulceration near the surface of the lung, air and pleuritic fluid will usually accompany the effusion of blood, and the treatment should be that of Pneumothorax or Empyema.
The vast experience in chest surgery supplied by the war has established certain broad principles:— I. That differential pressure boxes are unnecessary for operations on the chest.
1. That " sucking wounds " of the chest, with or without hmmothorax, must be closed at all costs.
3. That the chest is no more to be excluded from the surgeon than the abdomen, but that large crushing wounds with extensive fracture of ribs and hxmothorax give good results when the injuries to the chest wall and lungs have been dealt with radically.