nerve. the superior and inferior thyroid arteries and the recurrent laryngeal If the foreign body is situated a little below the upper opening of the thorax, an attempt may be made to remove it h forceps passed into the œsophagus through the wound. The incisi in the œsophagus should be united by sutures, avoiding the mucos » membrane. The external wound should then be filled with iodofor. gauze, and dressed antiseptically. The patient should be fe entirely by the rectum for some days after the operation, or t a tube passed down the œsophagus and retained in situ. Opening the œsophagus in the posterior mediastinum has be proposed for the extraction of a foreign body in the thoracic port. of the tube, by cutting vertically through the third, fourth, a fifth ribs between the scapula and spine, so reaching the posteri mediastinum. INJURIES OF THE CHEST. Injuries of the Chest-walls. Contusions may be produced by any sort of violence applied the chest, and may be attended with laceration or rupture of th muscles, or with extravasation of blood into the tissues, whi again, may be followed by suppuration and abscess. They their chief importance, however, to the fact that they may be con plicated by serious injury to the contained viscera, such as contus: or laceration of the pleura, lung, pericardium, or heart, or rupture of large vessel in the mediastina. In some cases of severe contusio in which death has cccurred immediately or soon after the inj without any lesion being found, the fatal result may be due to dire pressure on the heart, vagus, or sympathetic, or to anæmia of ti brain due to a sudden fall of blood-pressure. Fracture of the ribs is a very common accident. Cau Generally external violence, rarely muscular action. 1. Extere violence may be—(a) Direct, such as the kick of a horse, a fall un the edge of a table, etc. The fracture then occurs at the set injury, the fragments being driven inwards, occasionally injure the thoracic, or more rarely, the abdominal viscera, especially * liver or the diaphragm; or (b) Indirect, as the severe compress of the chest in a crowd. The fracture then generally occurs s the angle of the ribs, their most complex part, and several are usually broken. 2. Muscular action.-The ribs are someTM mi broken in this way during violent coughing, or from stra during parturition. Complications. Fractures of the ribs may be complicated be external wound; a wound of the pleura and lung, or pericard an heart; laceration of a blood-vessel, as an intercostal arte" penetration of the diaphragm; and more rarely by perforation State of the parts.—Fracture of the Palm od than in the young, on accost of the ans advances, and is frequent dera parapsis 10 like fractures of other bones they may be ste capoti cơ comminuted. The middle rits tith to eggth art the as aly fected; the first and second rit being protected by the clavicle, and the eleventh and twelfth being moveatle, are not often broken. Fracture of the upper ribs is more serious than fracture of the lower, as the lung is more liable to be wounded. Signs.-Severe stabbing pain is felt over the seat of fracture, and increased on taking a deep breath or on coughing. On drawg the finger along the rib, some irregularity may be detected. repitus is usually felt on placing the hand flat over the fracture hile the patient breathes deeply, or it may be heard on listening with the stethoscope. When several ribs are broken there may e a distinct depression in the chest-walls. Emphysema, i.e., a rackling sensation, something like rubbing the hair between the ngers, may at times be felt on touching the part. It is nearly daays due to a wound of the lung, the air being drawn into the leura through the visceral layer during inspiration, and forcel rough the wound in the parietal layer into the subcutane ssue during expiration. Treatment. In an ordinary case the injured side shoud se rapped with strips of adhesive plaster, so as to control the revive on that side, and thus place the fractured rib a ble at rest. A broad bandage in addition applied mess het often gives relief. When several rites are keen. ritta-percha may be moulded to the chest-walls and ennåpner n occurs by ensheathing callus in toret de Fracture of the costal cartilages and epicon rtilages from the ribs or nam occurs by bone in each case the same as in fractured ros Fracture of the sternum se Tatt fracture of the ribs or m their cartilages, a5: -Direct violence 518 The chief S times the gladiolus is separated from the manubrium, a condition sometimes spoken of as dislocation of the sternum. are pain, increased on deep inspiration and coughing, irregulari": and crepitus at the seat of fracture, emphysema if the lung » wounded, and severe dyspnea if the upper fragment compressThe fracture may be complicated by injury of any e the trachea. the thoracic viscera, or by hæmorrhage or suppuration in th anterior mediastinum, and later by aneurysm of the aortic arc Treatment--Retraction of the head and shoulders will remedy u displacement; then rest on the back, and the application of bandage, if it can be borne, round the chest, or simple strapping in fracture of the ribs. Wounds of the chest-walls may be divided into the pr The non-penetrating are of no sere trating and non-penetrating. consequence, and may be treated like wounds in other situati The penetrating are those that pass through the parietes into pleura, pericardium, or mediastinum, and may be complicated wound of the lung, the heart, a large blood-vessel, an intere artery, or the internal mammary artery. They are producci bullets and by stabs. When the wound is small, and there are signs of injury to the thoracic viscera, it is not always possi determine whether it has penetrated the chest-wall; althongh Under t direction and situation of the wound, and an account of the w which it was inflicted, may point to its having done so. circumstances, the skin around the wound should be rendered as " and the hands having been purified, a finger should be caus passed into the wound, which may be enlarged if necessary, a loose fragments of a fractured rib, portions of clothing or If the chest is found to be perfor foreign body if felt removed. the case should be treated according to the nature of the (see Injuries of the Contents of the Chest). If perforation occurred, the treatment will be that of other wounds. Injuries of the Contents of the Chest. These may be divided into injuries of the-1, pleura 1. Injuries of the pleura and lung.-Contusion of i a few days, but pneumonia, pleurisy, or even abscess or gangrene of the lung occasionally ensues. Wounds of the pleura and lung may be produced by the fragents of a broken rib, or by a stab or gunshot. When attended with a penetrating wound of the chest they are very serious. The deira alone may be wounded, but more often the lung is injured the same time. Signs. No single symptom is sufficient to Lake it certain that the lung has been wounded; but where several f the following are present, the diagnosis becomes fairly certain. hus, there may be marked shock, severe pain, abdominal breathing, d cough with expectoration of frothy blood-stained mucus, or en of pure blood. If there is an external wound, there will be ape of air intimately mixed with blood, and accompanied by a qalar hissing noise (hematopnora); or if there is no external and, emphysema in the region of the fractured rib. When the tura alone is injured, a very rare accident, the signs are similar; no blood is coughed up, and though air may escape from the ernal wound if there be one, it is not churned into a fine froth the blood, as it does not come from the lung, but is simply wn in and out of the pleura through the wound in the parietes ing inspiration and expiration. Complications.-Hæmothorax, anothorax, emphysema, hæmorrhage, and later pleurisy and amonia see Complications of Injuries of Chest). Treatment.— blute rest, ice to suck, opium to subdue pain, closure of the ad if small, or insertion of drain tube if large, and antiseptic kings, with such treatment as is appropriate for the complicathat may be present (see below). If the pleura alone is ed, the external wound should be closed, unless any complicaexists, and dressed antiseptically. If the wound is large and leeding from the lung continues, the lung may be exposed and morrhage stopped by ligature or plugging. Injuries of the heart and pericardium.-Contusions, is, and rupture of the pericardium may at times be produced severe crush of the chest-walls; but are more often due to enetration of a fragment of a broken rib, or to a stab or gunIn the last two instances the heart is generally also involved. -Severe shock, hæmorrhage, the position and direction of Found, and subsequently symptoms of pericarditis. The is is always very serious, death usually occurring either the effused blood impeding the heart's action, or from periis. The treatment consists in absolute rest, the local applicaf cold, and if inflammation threatens, of leeches. Should the I action become seriously impeded by effused blood, serum, aspiration or free incision and drainage may be required. there is an external wound it should be dressed antiseptically, ricardium being sutured if practicable. nds of the heart, especially when they penetrate one of its 樓 cavities and particularly an auricle, are generally instantaneously fatal from shock or hæmorrhage. Remarkable exceptions, however occur, and patients have been known to linger for a few hours or a few days, or even to recover. Signs. When not al once fatal, a wound of the heart is attended with great collapse syncope, a fluttering pulse, and dyspnea, and later with symptoms of pericarditis. The treatment is the same as that for a wound of the pericardium. Recently wounds of the heart have been sutured with some success after enlarging the wound of the pericardium. Rupture of the heart, though rare, occasionally occurs as the result of great external violence to the chest-walls, or of some sudden exertion on the part of a patient suffering from disease of the hearts substance. Death is as a rule almost instantaneous. 3. Wounds of the large blood-vessels, as the aorta or vena cava, are almost invariably and immediately fatal, and require no further comment here. Complications of Injuries of the Chest. The chief complications attending injuries of the chest are:1, external hæmorrhage; 2, hæmoptysis; 3, hæmothorax; 4, pue mothorax; 5, emphysema; 6, prolapse and hernia of the lung. 7, injuries to the diaphragm and abdominal viscera. 1. External hæmorrhage in penetrating wounds of the chest walls may come from :-(1), an intercostal artery or the internal mammary artery; (2), a wound of the lung; or (3), a wound of the liver or spleen through the diaphragm. Hæmorrhage from ab intercostal or the internal mammary artery, though it may generally be known by the arterial blood escaping in jets, is sometimes dithcult to distinguish from hæmorrhage from the lung. Treatment.An intercostal artery should, if possible, be tied; otherwise pressun forceps may be left on, or the artery with the periosteum may le separated from the lower half of the rib and then ticd, and to give room for this, a portion of the rib may be excised. Where assist ance is not at hand, the centre of a sheet of lint (wrung out of at antiseptic solution) may be pushed into the pleural cavity and the hollow stuffed firmly with antiseptic wool. On drawing on the link the artery will be compressed against the interior of the chest-wall, as shown in the accompanying diagram (Fig. 204). The interna mammary in the four upper spaces can be easily tied; in the lower spaces a portion of the costal cartilage must be first cut away. 2. Hæmoptysis may be due to a bullet causing a minute external wound or to a stab, through which wound there may le some external hæmorrhage. Frothy blood pours out from the mouth in an alarming fashion, but if not quickly fatal, there is good prospect of spontaneous cessation and recovery. When the |