"KIir3)6 Columbia Mitiu^rBxtg ttt tl|? (Ettg flf Nfui fork QlnUpgp nf piigatrtana attli ^ttrgpona Digitized by tine Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgeryofchestOOpage THE SURGERY OF THE CHEST. THE SURGERY OF THE CHEST. BY STEPHEN PAGET, M.A. Oxon., F.R.C.S., SURGEON TO THE WEST LONDON HOSPITAL, AND TO THE METROPOLITAN HOSPITAL. ILLUSTRATED. NEW YORK: E. B. TREAT, 5 COOPER UNION. JOHN WRIGHT & CO., BRISTOL, ENGLAND. J. HOOD COMPANY, MONTREAL. 1897. MAGISTRIS MEIS OMNIBUS PRIMO PR^SERTIM OMNIUM ET SUM MO PATRI DILECTISSIMO IMO DE PECTORE REFERO GRATIAS LIBELLUM DEDICO. PREFACE. From time to time I have published notes on cases illustrating the Surgery of the Chest, and in this way I was led to study the accumulated records of it. During the last five and twenty years, thanks to Lister, it has advanced with won- derful rapidity : and there has been an equally rapid increase of the literature relating to it, both in this country and abroad. Concerning one most important part of my subject, the Diseases of the Lungs and Pleura;, we shall before long have a work written in part by Mr. Godlee, the pioneer of English surgeons in this great field of practice. But hitherto no attempt has been made in England to put together a book on the whole subject of the Surgery of the Chest, both in injury and in disease. Now is the time when such a book can hardly fail to be useful : first, because there is a vast store of good material to be worked into it ; next, because there are signs that we have reached a stage, in this portion of our art, beyond which, on our present lines, we cannot advance much further. However this may be, I have tried to state the viii PREFACE. case for Surgery, as it now stands, clearly and fairly : and to present, from a wealth of scattered writings, those rules which are most likely to help the surgeon in the difficulties of practice. Reading the literature of this great field of Surgery, I have often found myself wandering off the main road down pleasant unfrequented paths : for I have tried to make a collection of such facts and experiences as lie outside the usual course of our work. The original drawings in the book w&vq done by my wife. Dr. Hunter has been so good as to review what I have written, and to keep it free from mistakes in those parts of it that are medical rather than surgical. M. Reclus has let me add to it a translation of his address at the French Sur- gical Congress last year. Prof. Polaillon's very valuable work ("Affections Chirurgicales du Tronc," Paris, 1896), contains many cases which I would have noted : but it was not published till this book had passed out of my hands. 57, WiMPOLE Street, W., June, iSg6. CONTENTS. PART /.—INJURIES OF THE CHEST. PAGl!. — Surgical Landmarks. Congenital Malformations i — Concussion and Contusion of the Chest - 8 — Fractures and Dislocations of Ribs, Costal Cartilages, and Sternu.m - - - - 14 4. — Simple Fractures with Internal Injuries - 35 _«). — Surgical Emphysema - - - - - 55 6. — Pneumothorax ----- 64 7. — Hernia of the Lung - - - - - 78 —Wounds of Intercostal and Internal MA.^LMARY Arteries. H.emothorax - - - 87 —Wounds of the Lung ----- 106 —Wounds of the Heart - - . . 121 — Wounds of the Diaphragm. Diaphragmatic Hernia ----.. 1^0 PART //.—DISEASES OF THE CHEST. 12. — Caries and Necrosis of Ribs and Sternum. In- flammation of Anterior Mediastinum - 154 13. — Tumours of the Ribs and Sternum- - - 167 14. — Pleural Effusions, other than Empyema - 184 15. — Empyema ------- 204 16. — Operation for "Empyema . - - - 230 17. — Difficulties that may arise after Operation - 246 18. — Chronic Empyema with Fistula. Estlander's and Schede's Operations - - . . 270 19. — Abscess of Lung. Bronchiectasis - - - 2S6 H X CONTENTS. PACK. 20. — Gangrene of Lung - - . . 302 21.— Tubercular Phthisis ----- 314 22. — Inflammation of the Bronchial Glands and the Posterior Mediastinum - . - - 335 23. — Foreign Bodies in the Air-Passages - - 356 24. — The "Surgery of the Heart" - - - 371 25. — Pericardial Effusions . _ - - 384 26. — Intra-Thoractc Tumours. Hydatid Disease. Actinomycosis ----- 3g8 27. — Subphrenic Abscess. Hydatid of the Liver in- vading THE Chest - - - - - 422 Appendix A. — M. Reclus' Address at the French Surgical Congress of 1S95. Appendix B. — On Bulau's Treatment of Empyema by Con- tinuous Syphon-Drainage. LIST OF PLATES. I. — Usual Form of Displacement of Sternum - - 26 II. — Wound of Intercostal Artery in the Operation for Empyema - ... - 89 III.- Multiple Tuberculous Osteo Myelitis of the Ribs - 15S IV. — Caries and Necrosis of Sternum - - - 165 V. — {A .) Extreme Thickening of Pleura, with small cir- cumscribed cavity - - - - 222 (B.) Extreme Thickening of Pleura, with small cir- cumscribed empyema - - - 222 VI. — (A.) Ulceration of Pleura . - - - 251 {B.) Tuberculous Disease of Pleura - - 251 VII. — Transverse Section of Chest from Fatal Case of Chronic Empyema . _ . _ 280 VIII. — Advanced Bronchiectasis of Lower Part of Lung 294 IX. — Gangrene of Lung - - - - 310 X. — Bronchial and Mediastinal Glands - - - 337 XI. — Lungs and Air Passages, with a foreign body in right bronchus ----- 368 XII. — (A.) Diagram of Pyo-Pneumothorax - - 424 (5.) Diagram of Subphrenic Abscess - - 424 ADDENDA ET CORRIGENDA. 1. Fractures of First Rib and of Sternum (Chap. III). — I have omitted a reference to Mr. Arbuthnot Lane's valuable papers in the "Transactions of the Pathological Society," 1883, 84, and 85. See also Dr. Rolleston's paper, in the "Transactions" for 1S91. 2. Wounds of the Heart (Chap. X). — The reference to Cap- pelen's operation will be found at the end of the chapter on the " Surgery of the Heart." 3. Diaphragmatic Hernia (Chap. XI). — There is a valuable paper by Dr. Jaffe, on Congenital Diaphragmatic Hernia, with a collection of twelve cases, in all of which a sac was present, in the " Pathological Society's Transactions," for 1894. 4. CEdema of Lun^ after Aspiration of Pleural Effusion (Chap. XIV). — This subject was recently brought before the Clinical Society, by Dr. West (April icth, 1896) ; Dr. Hale White also reported a case at the same meeting. 5. Extensive Resection of Ribs for Empyema (Chap. XVIII). — Dr. F. W. Murray has lately recorded two cases of sudden cedema of the opposite lung after this operation, one on the fourth day, the other, a fatal attack, on the tenth day ("Annals of Surgery," May, 1806)'. SURGERY OF THE CHEST. Part I.— INJURIES OF THE CHEST. CHAPTER I. THE LANDMARKS OF THE CHEST. CONGENITAL MALFORMATIONS. npHE 'surgical landmarks' of the chest,i so far as we -*- are here concerned, are not numerous. In front, we may take a Hne one finger's breadth from the edge of the sternum, to mark the course of the internal mammary artery. The vein lies a little nearer the sternum than the artery. A wound half an inch from the edge of the sternum may divide the artery,- and its blood will pour either into the pleura, or the mediastinum, or both. Behind the manubrium sterni lie the left innominate vein, '"Landmarks Medical and Surgical," Holden, second edition, 1877: True, " Essai sur la Chirurgie du Poumon," 1885. The course of the internal mammary artery is illustrated in Sir Astley Cooper's " Anatomy of the Breast." See also Vosz, " Die Ver- letzungen der Arteria Mammaria Interna," Inaug. Diss. Dorpat, 1884. He gives a number of exact measurements: practically, any deep wound about half-an-inch from the sternum may divide the artery. - " Toute blessure situee le long du sternum a un centimetre au moins de cet os, de la premiere cote a la septieme, lorsqu'elle a une profondeur suffisante, peut faire soupfonner la lesion de I'artere " (Toxirdes). T 2 . SURGERY OF THE CHEST. and, beneath the vein, the great branches of the aortic arch. The top of the arch, and, behind it, the bifurca- tion of the trachea, he behind the junction of the manubrium with the body of the sternum. The pleurae slope toward each other behind the ster- num, and may even be in contact about the level of the middle of the sternum ; but the anterior mediastinum slants a little to the left, so that a puncture through the middle of the sternum would be more likely to wound the right pleura than the left. The exposed area of the heart (area of cardiac dulness) is about covered by a circle two inches across, having its centre midway between the nipple and the juncture between the ster- num and the ensiform cartilage ; and a stethoscope put over the third intercostal space, just at the edge of the sternum, may cover some part of all the valves of the heart. At the sides of the chest, the edge of the pleura follows a line, slightly curved downward, drawn from the juncture between the sternum and the ensiform cartilage, to the last rib. The lungs rise an inch or an inch and a half above the level of the first ribs ; and there is a very rare con- genital malformation, first noted by Cruveilhiori during dissection of a foetus, where one or both apices rise high into the neck, lying alongside the cervical spine. From a surgical point of view, True divides the lungs into three zones : upper, middle, and lower. The lower zone occupies the space between the ribs and the diaphragm, and is moulded to the surface of the diaphragm. The ' For references, see Riedinger. Of this nature was a case shown some years ago at one of the London Medical Societies — a little girl whose lungs rose so high into the neck as to form well-marked swellings, soft, crepitant, resonant, moving with the movements of respiration. SURGICAL LANDMARKS. 3 middle zone is most easily accessible, and even that part of it which lies beneath the scapula is not out of the surgeon's reach. The upper zone presents serious diffi- culties, yet it may be reached either in front, between the internal mammary and the axillary vessels (the internal mammary artery is a finger's breadth from the edge of the sternum, the axillary vein is 3-^- inches from the middle line of the sternum at the level of the first space, and 4f inches from it at the level of the second space), or from the axilla. The chest wall is thin here, and any space from the second to the fifth may safely be punctured, if the arm be held away from the side, and if care be taken of the branches of the axillary artery (the long thoracic artery lies two fingers' breadth from the edge of the pectoralis major). True adds the following rules for safe exploratory puncture of the lungs : in puncturing the upper zone in front, through the first or second space, direct your needle upward, backward, and outward ; in puncturing it from the axilla, go upward, backward, and inward. To reach the apex of the lung from behind, just grazing the upper border of the scapula, outside the suprascapular notch, and entering the chest through the second space, is anatomically possible, but he would rather not attempt it. Over the greater part of the lung, one may safely thrust a needle i inch backward, or i^ inch backward and outward. The neighbourhood of the root of the lung must be carefully avoided. The heart must be avoided by never puncturing within the left nipple-line, or within a breadth of three fingers on the right side of the sternum. A deep inspiration, separating the ribs, is favourable to puncture. The surgical landmarks of the posterior mediastinum are noted in the chapter on inflammation of that region. 4" SURGERY OF THE CHEST. Congenital Malformations. Among congenital malformations of the chest,i we have to note the presence of gaps or clefts in the sternum, and deficiencies in the chest wall from arrested growth of the ribs. In a case lately under the care of one of my colleagues at the Metropolitan Hospital, there was on the left side of the chest a gap of four or five inches in diameter, with entire absence of bone. These gaps, like some other congenital defects, are usually on the left side of the body. Two instances of this deformity are recorded by Dr. Abercrombie in the Transactions of the Clinical Society, 1893. It was at one time believed that there is such a congenital malformation as a heart without a pericardium, but the dissections that estab- lished this belief were really cases of densely adherent pericardium. There is a trivial deformity of the chest, which may be worth noting here, a protrusion of the lower costal car- tilages on the left side, below the level of the breast, in women. I have seen three instances of it. Two of the patients came up from the country in great alarm, and all three believed they had disease of the breast, or some internal growth pushing the ribs forward. I have never seen this prominence of the ribs on the right side, or on both sides. It seems therefore to be due not to tight lacing, but to some want of symmetry of growth. Cervical ribs, though they can hardly be called deform- ities of the chest, may be mentioned here. The best ' Pierre Marie has just published a valuable Clinical Lecture " Deformations Thoraciques dans quelques Affections Medi- cales," which includes an account of certain general congenital malformations of the chest which may accompany arrest of development of the heart or the central nervous system, " Le9ons de Clinique Medicale," Paris, 1896. SURGICAL LANDMARKS. 5 clinical account of them that I know has lately been given by Tilmann.^ They are more often found post mortem than noted during life. Thus, Griiber collected notes of 45 post mortem examinations, but only 2 clinical observations; and Pilling (1894) recorded 92 instances, all post mortem. They are more often double than single, but are seldom quite symmetrical. The cervical rib may not extend beyond the transverse process of the vertebra ; or it may extend beyond it, but not join the first rib, or may join the bony part of it ; or it may join the cartilage of the first rib ; or it may have a car- tilage of its own, fused with the cartilage of the first rib. Of 26 cases during life, collected by Tillmann, 13 had their attention called to the presence of the rib during the course of a long illness: 13 suffered pain from it. Ten gained relief from treatment without operation ; three underwent operation successfully. All the patients were above 20 years old : he therefore supposes that a cervical rib, though present at birth, does not cause pressure-symp- toms till some wasting illness, or the advance of age, has thinned the patient. In some cases, the brachial plexus is compressed, so that the patient has pain, weakness, chilliness of the arm, prickling sensations in it, loss of the sense of touch, even wasting of the limb. In others it is the subclavian artery that bears the brunt of the pressure : the radial pulse is weak, or wholly absent, the arm becomes cold, mottled, and dusky; gangrene has occurred, and even subclavian aneurysm. It is to be noted that these troubles of circulation tend toward recovery by the establishment of a collateral blood-supply. Fischer is of opinion that even if an aneurysm occur, it tends toward ' Die Klinische Bedeutung der Halsrippen. " Deutsche Ztschr. f. Chir.," 1895, xli, parts 4 and 5. 6 SURGERY OF THE CHEST. a natural cure, by extension of coagulation, beginning in the hand, up the brachial artery until it reaches the sac of the aneurysm. He would therefore not interfere unless there be signs of pressure on the brachial plexus Should operation be necessary, the skin incision must be very carefully placed. If any muscles are attached to the rib, they must be loosed from it by subperiosteal resection (not that there is any other reason for saving the periosteum), and the surgeon must remember how near he is to the thin, loose pleura. In one case at least the operation has been followed by pneumothorax. Tilmann's own case is worth study. A woman, aged 44, had for seven years been conscious of pain in the left side of her neck, and had noted a hard nodule there, which seemed to be slowly growing larger, and was troublesome when she turned her head or lay down in bed. Latterly she had observed that the muscles of her thumb were wasted, and that her arm was weak and chilly, with shooting pains in it. About an inch above the middle of the clavicle was a bony growth, which felt about the size of a hazel-nut. It seemed to extend upward and backward toward the trans- verse process of the last cervical vertebra, and forward and downward beneath the clavicle, pushing the subclavian artery forward and upward. There were marked wasting and loss of power of the arm and hand, with some loss of faradic excitability. Pressure on the growth caused pain down the arm. The colour and warmth of the arm, and the radial pulse, were not altered. A free incision was made, exposing the growth. A few fibres of the scalenus anticus were found attached to it. The scalenus medius had its proper attach- ment, but was somewhat thinned out over the growth. The brachial plexus crossed over it, but was easily drawn out of the way toward the middle line. Some fibres of the scalenus medius were divided. The growth was cleared by subperios- teal resection, divided in front with a chain-saw, and removed piecemeal with the cutting-forceps. A very small opening was made into the pleura, but no harm came of it. The pains in the arm slowly disappeared after the operation ; but the arm was still wasted four months after it. SURGICAL LANDMARKS. 7 Deformities of the chest following curvature of the spine do not concern us here ; nor are we likely to adopt a suggestion lately made by a French surgeon, that one should correct the evil consequences of lateral curvature by resection of ribs. CHAPTER II. CONCUSSION AND CONTUSION OF THE CHEST. General injuries of the chest, without fracture of the chest wall or penetrating wound of the soft parts, are seldom dangerous to life. The vital organs are not ex- posed, like the abdominal viscera, to mortal injury by any slight contusion ; nor are they, like the brain, so delicate that even a slight concussion may be disastrous. Thus we are tempted to make light of a general injury of the chest, unaccompanied by fracture, or by a serious wound of the soft tissues. But, apart from the fact that very grave and even fatal results may follow a blow or a bruise over the chest which seemed in itself insignificant, the general injuries of the chest are sometimes attended by changes so unexpected and so obscure, that they need careful consideration. As with the abdomen, so with the chest, the pressure of a carriage- wheel, or of the buffers of a railway-truck, may, even without fracture or external wound, have strange consequences, beyond the reach of diagnosis or even of guess-work. A treatise on 'run-over' cases^ would form a valuable addition to the literature of surgery, on the lines of Kaufman n's recent work, 'A Manual of Accidental Injuries.' Experience of cases of simple contusion of the chest, without internal injury, teaches us, first, that children ■ Several valuable cases are given in Mr. Pitts' " Lectures on the Surgery of the Air Passages and Thorax in Children," "Lancet," October, 1893. CONCUSSION AND CONTUSION OF THE CHEST, g sometimes escape almost unhurt from accidents which would have given small chance of escape to adults : next, that the shock of these accidents is much severer in some cases than in others. There are several reasons for the frequent escape of small children when run over. They more readily roll or are pushed from beneath the wheel ; their ribs are more elastic than those of an adult ; the rounded shape of their chests offers greater resistance to pressure: finally, ^ since the wheel first ascends the chest slowly and heavily, and then rolls down more rapidly and less heavily from the other side, its passage would be quicker and lighter over the small round chest of the child. The shock from such an injury varies widely, but, as a rule, it is severe. In children, there is sometimes to be noted an extraordinary swiftness of respiration. This may fairly be considered as part of the shock ; but it lasts in some cases long after the usual signs of shock have passed away. There may be no dyspnoea, no duskiness of face, nothing to suggest injury of the lung : only a rapidity of sixty or even seventy respirations a minute. I do not think this symptom is so marked in adults, and I believe it is not, by itself, any sign of serious injury. There need be no general extensive contusion of the chest to cause severe and even fatal shock. It may follow a blow from a spent bullet or fragment of shell in a battle. It has been said- that such injuries 'are at least as dangerous as penetrating wounds of the chest.' Even should this statement be somewhat exag- gerated, there are plenty of cases to show that a slight blow, limited to one part of the chest, may be followed 'Bijhr. " Ueber den Mechanismus der Rippenbriiche." 'Deutsch. Ztschr. f. Klin. Chir." 1894, 39> 251. ""Pirogoff. "Grundziiged. Kriegschirurgie." 1864. lo SURGERY OF THE CHEST. by shock out of all proportion to the injury, or even by death. There is no violent or frightful crushing of the chest to account for it. To these strange cases Ried- inger' gives the name 'Concussion of the Chest' — co7Ji7iiotio thoracica. For example, in the daily papers of Jan. 28th, of the present year, there is an account of the sudden death of a woman, aged 45, at whom a boy, aged 15, had thrown a stone. 'It struck her in the region of the heart, and she at once fell back, exclaiming. Oh my breast. Oh my breast.' She became unconscious, and died before help could be obtained." Riedinger gives the following cases, (i,) A man was dragging a heavy load behind him : the rope broke, he fell forward on his chest, and died at once. Post mortem, there was slight contusion of the chest wall, but no injury of heart or lungs (2,) A man, convalescent after diabetes, was struck on the chest with a stone thrown at him, and fell dead. (3,) An old man was suddenly struck on the upper part of the chest : he staggered back, fell, and died at once. Post mortejn, there was no injury of heart or lungs ; old valvular lesions ; cut head and slight extravasations in the pia mater. But such cases as these are evidently examples of heart-failure, from weakness or valvular disease of the heart. Riedinger sought by experiment to ascertain the exact character of the syncope which attends concussion of ' " Verletzungen und Chirurgische Krankheiten des Thorax und seines Inhaltes." " Deutsche Chirurgie," Lieferung 42. Stuttgart 1888. ^ Dr. Austin, of Lingfield, Surrey, has kindly sent me notes of the post moytcm examination. The right auricle was distended with blood ; the left auricle, and both ventricles, were empty. There was great hypertrophy of the ventricles, the left ventricle being fully an inch thick ; the tricuspid and mitral valves were incompetent, and there were vegetations on the mitral valve. CONCUSSION AND CONTUSION OF THE CHEST, ii the chest. SHght blows over the region of the heart had no marked effect on the blood-pressure ; it sank a little after each of them, but soon rose again to normal. A single heavy blow made it descend low at once, then it rose quickly ; a second made it sink even lower than the first, but it rose again ; after a third, it went lower than ever, and remained low for some time. Repeated heavy blows could not bring it below a certain level, and only caused irregular fluctuations. These fallings of the blood-pressure were not due to any direct com- pression of the heart itself; care was taken to avoid this. They were less marked, if the depressor nerves, and the vagi, or the cervical sympathetic, were previously divided. Concussion of the chest is a complex process. The fall of the blood-pressure after a blow is probably du<; to direct stimulation of the vagi : that it still occurs, though the vagi have been divided, must be due to direct compression of the heart : that it lasts for some time even after the blows have ceased, is probably due to the action of the depressor nerves and of the sympathetic, whereby more blood flows into the splanchnic vessels. If we are called to deal with a case of contusion of the chest with severe shock, but without evident fracture, wound, or internal injury, we must not wait to make a prolonged examination, but must proceed at once to treat the shock, much as we treat a case of syncope from chloroform, laying the patient flat wath his head lower than his body, using warmth, stimulants, hypodermics of ether or strychnine, or both, and very hot cloths, or the faradic current, over the heart. It may even be necessary to do artificial respiration. The external injuries in simple contusion of the chest, and simple superficial wounds of the soft parts, as a rule 12 SURGERY OF THE CHEST. heal rapidly; the intercostal and internal mammary ves- sels, being uninjured, are left free to carry on the work of repair. The superficial veins are hardly large enough to cause any large subcutaneous haemorrhage. Riedinger, however, notes a case of very extensive extravasation under the skin of the back after contusion of this region ; and blows over the breast may have a like result. The worst case of this kind I have ever seen was that of a young soldier whose horse in a fit of rage had seized him over the left breast. The whole breast, and the tissues round it, were distended and uplifted off the pectoral muscle by a profuse extravasation, and were for many days so tense that the skin seemed on the very point of breaking down ; but slowly the whole of the huge clot was absorbed, with- out suppuration. It is of the utmost importance that one should thoroughly cleanse and disinfect any lacerated wound of the soft parts. For if suppuration take place among or between the intercostal muscles, it may burrow quietly far and wide, prevented by the deep fascia and the pleura from making its way into the pleural cavity, and by the ribs and muscles from making its way outward under the skin. The internal injuries that may be caused by simple general contusion of the chest, even without fracture, range from the slightest rift in the pleura to the most extensive laceration of the lung. These injuries are more likely to happen if the accident comes very swiftly and unexpectedly, at a moment when the lungs are fully expanded, and the glottis closed.' Emphysema, pneumo- thorax, pleurisy with effusion, hernia of the lung, haemo- thorax, laceration of the heart or lung, rupture of the diaphragm — all these have been noted after simple con- 'Gosselin: Dechirures du Poumon. "Mem. Soc. Chir." i. 201. CONCUSSION AND CONTUSION OF THE CHEST. 13 tusion without fracture ; nor, if one or other of them occur in a case where the ribs or the sternum are frac- tured, does it follow that the fracture had anything to do with it. We are bound therefore not to think lightly of contusion of the chest merely because there is no fracture or external wound. I can find no evidence that contusion alone can bring about rupture of an intercostal or internal mammary artery; but, however this may be, the list of possible lesions is long enough to warn us to be watchful. Absolute rest in bed, immediate treatment of the shock, careful observation of the patient till one is sure that no internal harm has been done — all these precautions are necessary in every case of severe contusion. 14 CHAPTER III. FRACTURES AND DISLOCATIONS OF THE RIBS, COSTAL CARTILAGES, AND STERNUM. It is impossible to make a satisfactory division of the various injuries of the chest, or, having made it, to keep to it. Perhaps the best that can be done will be to devote this chapter to the simple fractures and dis- locations of the ribs, costal cartilages, and sternum, as they are in themselves, giving separate chapters to some of the grave dangers and troubles that may be caused by them, or may accompany or follow them. A case of simple fracture of the ribs, with extensive emphysema or profuse haemoptysis, presents itself to us, not as a case of fractured ribs, but rather as emphysema or- as wound of the lung. It is absurd to consider the emphysema or hsemoptysis as less important than the fracture ; it is just the wound of the pleura, or lung, that we have most to consider. Simple Fractures of the Ribs. There is so much valuable work on this subject in the writings of Malgaigne, Gurlt, Riedinger, Hamilton, Poland, and many others, that the experience of one surgeon is of little value. And the subject itself is so wide, that I do not attempt, even from the work of others, to treat it at length. The most frequent seat of fracture is somewhat toward one or other end of the rib ; and the rib most often broken is the fifth or sixth. Cases are recorded of FRACTURES AND DISLOCATIONS. 15 fracture of the eleventh or twelfth rib, by direct violence As regards unusual forms of fracture, it is certain that there is such a thing as true sub-periosteal fracture ; or the ex- ternal or internal surface alone, or the upper or lower border alone, may be fractured ; and in one case of this kind, the intercostal artery was lacerated. One or more ribs may be fractured, probably by muscular effort, remote from those broken by direct violence, A rib may be fractured in two places, and the fragment dis- placed inward. The usual division of fractures of the ribs into fracture by direct violence with internal dis- placement, and fracture by indirect violence with external displacement, is too strict to suit the complex character of these injuries. As Poland has pointed out, the same violence may act both directly and indirectly ; and in seventy specimens of fractured ribs, many of them plainly due to indirect violence, Bennet did not find one that showed outward displacement. Fracture of the first rib is very rare; but I have had one case where both first ribs were fractured, toward their middle, by a fall. Of 61 cases (Poland), 44 were between the fourth and the eighth ribs, 13 among the last four, and 4 among the first three ; in only 9 was the fracture limited to a single rib. As to complications, Poland found that of 136 cases, ro8 were free from complications, 16 had emphysema (4 of these also developed pneumonia, but recovered), 3 had hemoptysis with emphysema, 3 severe secondary in- flammation, 6 died at once from shock. These figures are more encouraging than those of Settegast,^ who gives 20 cases of fracture of one to four ribs : i died of delirium tremens, 3 suffered extensive emphysema, '" Langenbeck's Archiv.," 1879, xxiii., 274. i6 SURGERY OF THE CHEST. 3 traumatic pleurisy, 4 pneumothorax and haemothorax, and 7 had injury of the lung. I do not remember to have had a death from simple uncomplicated fracture of ribs. The relation of old age, and of such wasting diseases as phthisis, scurvy or moUities ossium, to fracture of the ribs, and the strange brittleness of the bones in some individuals or some families, need be mentioned only. Two subjects may be considered at some length : these are, fracture of the ribs by muscular effort, and fracture in the insane. Malgaigne, in 1841, noted that 'spontaneous' frac- tures of the ribs usually occur on the left side, and toward the anterior end of the rib. Doubtless, in some of these cases, the rib is predisposed to fracture by old age or disease ; but the same thing may occur in young and healthy people. It has arisen from a severe fit of coughing ; after sneezing ; in the pains of labour ; on lifting a heavy load ; or swinging a scythe ; and during the performance of acrobatic feats. Gurlt ^ says of it, 'When we consider how great violence the ribs can with- stand, it is hard to understand the isolated fracture of one or two of them by mere muscular action. Yet I know of fourteen cases. Of these, ten were due to a violent cough ; one came from a resolute effort to keep back a sneeze, one from turning in bed, one from riding a restless horse, one from the patient's attempt to save himself from slipping. Age and general health have nothing to do with it. In three of the cases, two ribs, next each other, were broken ; in another case, the patient on three successive occasions broke one each time, each rib next the other. Usually the lower ribs ' " Ueber Knochenbruchen," i., 216. FRACTURES AND DISLOCATIONS. 17 are thus broken, the seventh to the eleventh ; and in ahnost all the cases they were broken far forward.' Two of Gurlt's cases will serve as examples of this curious accident. A strong, hearty man, aged 40, standing during a violent cough, was suddenly seized with a pain in his side so severe that he nearly fainted, and remained for some time unable to cough or move ; he had fractured the eleventh right rib, about the middle. A man, aged 39, in vigorous health, to stop a fit of sneezing, drew a deep breath and held it. At the moment of sudden expiration, he heard a rib give way, and was seized with severe pain in the left hypochondrium, difficulty in breathing, and agonizing cough ; there was an oblique fracture of the ninth left rib, about the middle. For fracture of ribs in the insane, we may take the figures given by Gudden,i Hearder,^ and Wiglesworth. Gudden, in 100 general post-mortem examinations of the bodies of the insane, found 16 cases of fractured ribs. The majority of the patients had died of general paralysis. In one instance there were 14 fractures, in another 23, in another 30. Hearder, in 20 similar examinations, found well-marked changes in the ribs in 9 cases ; they were thin, brittle, and poor in calcium salts. Wiglesworth, in 30 examinations, found only 8 cases where the ribs appeared perfectly healthy. In 17^ there were slight changes, chiefly vacuolation of the bone, ' the general failure of nutrition, so common in insanity, or with phthisis or senile decay ' ; in 3 only, were found ' clear and precise lesions, produced by con- siderable internal absorption, which renders the bone ■"Archiv. f. Psychiatrie," 1870. '"Journal of Mental Sciences," 1871. i8 SURGERY OF THE CHEST. very porous and brittle, and sets up the condition known as osteoporosis, probably having a causal connection with insanity.' In T870, Edward Ormerod wrote an admirable account of fractured ribs in two cases : one a woman, aged 58, acute mania ; the other a man, aged 46, general paralysis with melancholia. ' The bones were brittle and soft, allowing a scalpel to be passed through them. When bent, they snapped suddenly with a clean fracture without spHntering. All the strength of the bone lay in its outer shell of compact tissue, which yet was no thicker than cardboard.' The microscope showed fatty and granular degeneration of the whole bone, with dilatation of the Haversian canals. In 1890,1 Dr. Claye Shaw wrote a most valuable essay on the whole subject. He tested the breaking-weight of healthy ribs, fixing their heads in a vice, and hanging weights from their free ends. The average breaking weight of the eighth rib was about 15 lbs. for a man, 10 for a woman. ' It thus appears that ribs, taken fresh from a body, and supported only at one end, break under a comparatively small weight. Weight-striking machines are graduated up to 500 lbs., and we may reckon 300 lbs. as representing the force of a severe blow. Yet even a heavy, powerful man is unable, by the strongest blow he can give, to break an opponent's rib by a direct blow, unless it is delivered when the opponent is placed at a disadvantage, e.g., is turning sharply round.' The contrast between the light breaking-weight of a rib removed from the body, and the heavy direct blows in boxing, which yet do not break a rib, shows that '" St. Bartholomew's Hosp. Reports," xxvi., p. 15. See also Dr. Campbell's paper on this subject, "Brit. Med. Journ," September 28, 1895. FRACTURES AND DISLOCATIONS. 19 fracture of ribs in the insane is due not to the violence of their attendants, nor to any special structural changes in the bones, but to the way in which a restless or struggling patient throws himself into such a posture that a very slight pressure is enough. 'The dictum, that the ribs of the insane are more brittle than those of the sane, is true to a very limited extent only, and is almost confined to those affected with degenera- tion of the circulatory system.' Mr. Macnamara ^ agrees that there is no special disease of the ribs of the insane. ' I commenced my researches,' he says, ' fully expecting to meet with some interesting pathological changes in the bones, but I have been disappointed. For, as I worked on at specimens of this kind, I gradually arrived at the conclusion which I now hold, that neither the ribs nor other bones of insane patients are liable to any peculiar abnormal changes. It seems to me more probable that the injury has been caused by the attendants kneeling on the patients' chests to keep them from moving.' The weight of evidence seems to be against the occurrence of any definite changes in the ribs of the insane directly due to insanity. Also, it seems certain that an insane patient, already weak and wasted, may expose himself to fracture of a rib by a very slight pressure ; just as one has heard of fracture of a rib in an anesthetized patient, during the performance of artificial respiration. It is to be noted that Gudden and Hearder wrote a quarter of a century ago, when the treatment of the insane was very different from what it is now. The grave dangers and difficulties due to or accom- ' " Diseases of Bones and Joints," 3rd ed., p. 251. 20 " SURGERY OF THE CHEST. panying severe fractures of the ribs and injury of the whole chest^pneumonia, emphysema, pneumothorax, laceration of lung or heart, and other internal injuries — will be considered in chapters by themselves. A case of simple fracture, apart from all these troubles, runs a smooth course, and non-union is a thing almost impossible ; even Gurlt, in his great work on fractures, could find only three instances of it. It is in some cases almost impossible to determine whether a rib has or has not been fractured ; as when the patient is very fat, intolerant of the least pain of examina- tion, or half drunk. A blow with the fist is more likely to cause contusion than fracture ; a crush or run-over accident, if pain be felt about the middle of the rib, is more likely to be fracture than contusion. There is often no crepitus ; as when the rib is simply cracked across, or the broken ends have slipped one over the other, or the soft tissues have got between them. The right method of examination is to feel carefully, inch by inch, the whole accessible length of each rib ; and to lay one's whole hand, for some minutes, over the seat of pain, in the hope of catching a chance movement of the broken ends. One is not likely to learn anything from pressure on the two extremities of the rib. If, after the first suffering of the injury has passed off, the patient still complains of a sharp pain, always in the same place, worse on coughing or drawing a deep breath, and seizing him suddenly just at the end of the inspiration ; if his respiration is still quick and shallow, and he finds ease in one posture, and not in another, there is good reason for believing that one or more ribs are broken. The treatment of simple fracture of ribs, without other injuries, requires all common-sense methods that may best ensure rest in bed, easy breathing, light diet, FRACTURES AND DISLOCATIONS. 21 and freedom from cough and pain ; and it is of great im- portance that aged patients should not be kept long on their backs. The necessary restriction of the move- ments of the chest and of the broken ribs may be secured as well by a well-adjusted bandage as by strapping, if not better ; and this saves the patient from all irritation of the skin, and from the uncomfortable process of having the strapping finally removed. The bandage may be applied from the lower ribs upward, at a moment when the patient has just emptied his lungs of air; but this rule is not of great importance. To prevent the bandage from slipping down, the surgeon should first place a long strip of broad bandage, with a slit in the middle, over the patient's head, so that it lies round his neck, with the ends hanging down in front and behind ; then, having applied his bandage round the chest, over the strip, he turns up the ends of the latter over the bandage, pinning them so that they hold it in its place. We should remember that a bandage may cause pain instead of alleviating it. A man^ broke his tenth left rib by falling against a table : when lying on his back, he was free from pain ; but when a circular bandage was applied, he suffered so much pain that it had to be removed. In this case, there was marked displacement, which disappeared, with a crepitus, when he coughed. In such cases, a bandage must not be used ; and the patient will be healed just as well without it. Fractures of the Costal Cartilages. It is seldom that the costal cartilages are fractured, and when this occurs there are usually other injuries of the parts beneath. They are, as a rule, fractured ' See Nelaton's " Lectures on Surgery," Atlee, 1855, p. 156. 22 SURGERY OF THE CHEST. by direct violence, though a few cases have also been noted of fracture by muscular effort. The fibrous and calcareous degenerations of old age may be predisposing causes. The usual site of fracture is about the juncture between rib and cartilage ; but this is not a true joint, and we must therefore reckon the lesion as a fracture, not a dislocation. The most common cause is a fall against some such obstacle as the edge of a table ; and the cartilage most likely to be fractured is the eighth ; those next above it are more often broken than those below it. Usually, the sternal fragment is displaced in- ward, and the costal fragment outward. Non-union is very rare, but some few cases have been recorded. In one, suppuration occurred round the broken ends, which i^ecame the seat of necrosis ; they were resected, but the wound did not heal, and the patient died a few months later of tuberculosis. The following cases from Gurlt illustrate the usual course of fracture of the costal cartilages : — 1. A man, after general contusion of the chest, suffered pain and slight dyspnoea, and the 4th right costal cartilage was found driven backward and downward ; deep inspiration reduced it, but expiration again displaced it. There was no external bruise. It was reduced, kept in place with a bandage, and healed without any trace of displacement. 2. A young man struck the right side of his chest against a balustrade ; ten days later, his surgeon found a fracture of the 5th right costal cartilage, about an inch from the sternum. When the patient stood up, the inner fragment was thrown forward, but went back on gentle pressure or on deep inspiration ; it was most prominent when he lay on his left side, less when he lay on his back, least when he lay on liis right side. Two different bandages were tried, but failed. Finally, a soft compress and an elastic bandage were applied, with an elastic air-pad ; with these, the fracture healed in twenty days without the least deformity. 3. A man, aged 33, was knocked down with a blow on the chest, and next day was feverish, with pain, made worse by FRACTURES AND DISLOCATIONS. 23 every movement of respiration. There was a hard bruise, with a very painful central spot ; the 4th costal cartilage was fractured about half an inch from the sternum ; the inner fragment was depressed, and freely movable. By means of a compress, bandage, and tight flannel vest, the pain was re- lieved and the displacement lessened. The fracture healed in a month, with a slight smooth oval thickening of the injured cartilage. A very severe crush of the chest may cause extensive fracture of the costal cartilages, and yet the patient may recover. The case has been recorded of a child, 7 or 8 years old, crushed between a cart and a wall, in whom every cartilage down one side was fractured. The sternal fragments were displaced forward; they went back on gentle pressure, but it was hard to keep them in position. A man,i after a like accident, had fracture of all the cartilages of both sides, ' so that his chest felt like that of a body on the post-mortem table, when the costal car- tilages have been divided to remove the sternum.' The left clavicle was also dislocated at its acromial end. His state on admission seemed hopeless. He was bled and bandaged, and in twenty-five days made a good recovery, with only slight deformity. Non-union of fractured costal cartilage has been noted, but is very rare. The exact process of union has been explained in more ways than one. Riedinger is of opinion that the cartilage itself takes no part in it ; the fragments lie inert, rounded off, one over the other, separated by fibrous tissue ; a callus of spongy bone, with large lacunae, is formed round them, and in the angle between them. The treatment of a fractured costal cartilage is a matter of careful reduction and fixation, with restriction of the chest with a well-adjusted bandage. 'If we cannot reduce ' Sir Chas. Bell, "Middlesex Hosp. Reports," 1816, viii., p. 171. 24 ■ SURGERY OF THE CHEST. the displacement, if permanent pressure fails, if a deep inspiration does not reduce it, if we gain nothing by turning the patient on to the sound side, or by putting pillows under his back, we have come to the end of our resources, and must let the fracture heal with deformity.' Dislocations of the Ribs. It is plain from the shape, texture, and attachments of the ribs that they are easily fractured but not easily dis- located. As to separation of the head of a rib from its articulations with the spinal column, this is a wonder of the posf mortem room, and it has not been found possible to produce it on the dead body. Nine or ten instances have been collected by Riedinger from various sources. In one only, was it unaccompanied by other severe injuries. The subjects of it were young, the oldest being 44. From the fact that in five of them the eleventh rib was dis- placed, and in three of them the twelfth rib, it is plain that the displacement is due to great external violence. I need not say that it is more likely to be found after death than made out during life. Dislocation of a costal cartilage from the sternum is also very rare. I lately saw a case, where the fourth left cartilage was slightly displaced forward, and movable : it was easily replaced, but would not stay in position. Out of 19 cases collected by Riedinger, the fourth cartil- age was dislocated in 6 : the fifth in 4 : the sixth in 4 : the fourth, fifth and sixth all together in 3 : and the second in 2 (one of these was double). As a rule, the cartilage is dis- placed forward, a displacement which cannot be produced on the dead body, and I do not know of 3.ny post mortem example of it. 'Sir Charles Bell has seen it produced by violent extension of the arms during exercise with dumb-bells : Bransby Cooper saw a luxation of the fifth FRACTURES AND DISLOCATIONS. 25 and sixth cartilages in a Ijoy, produced by the constant action of the pectorals in kneading bread. '^ In some cases, it is hard to decide whether the cartilage was dislocated or fractured. The forward displacement is easily reduced. In one case, where three cartilages were thus displaced, reduction was effected by arching the back over pillows placed under it. The backward displacement is more rare, more serious, and more diiificult to reduce. The usual method of pressure on the sternum, while the patient takes a deep breath, may fail. Nor can much be expected from the ingenious method of Negretti, who, when everything failed, dashed cold water over the patient's face, and effected reduction during the gasp for breath that followed. The lower cartilages, the sixth to the ninth, may, it is said, be displaced : but probably these are cases of fracture, not of dislocation. From the cases quoted by Poland, it appears that the displacement is due to sudden violent effort (lifting a heavy weight, struggling to avoid falling) and is not easily reduced. Forward and backward displacements have both been recorded. Fracture and Dislocation of the Sternum. These injuries are so dangerous, and of such great interest, that they have at all times had a special attraction for surgeons, and there has gathered round them a great wealth of literature. They are seldom seen alone : Gurlt, in a collection of more than fifty thousand fractures of all kinds, found only fifty-two fractures of the sternum; Lonsdale," in a similar collection of nearly two thousand, found only two. Even in combination with other injuries 'Poland, "Holmes' and Hulke's System of Surgery." i. 817. = "Amer. Journ. Med. Sciences," 1S62, p. 411. 26 SURGERY OF THE CHEST. (fractured spine or ribs) they are still very rare. One might suppose that a bone so exposed and presented to all sorts of violence would often be broken, but the exquisite curves and elasticity of the ribs and their cartilages allow pressure on the sternum to be at once distributed far and wide away from it. Messner^ has found that in the dead body of a child you can make the sternum touch the spine without breaking any bone, and in the bodies of older people can bring them within an inch or two of each other. Again, the sternum moves not only with the costal cartilages, but also to some slight extent upon them, and may thus yield a little to any crushing weight ; and through early life the sternum itself is elastic, and not yet welded together. Hence, out of all the recorded cases of fracture, only three occurred in patients less than twenty years old. The unusual forms of simple fracture (longitudinal, oblique, partial, comminuted, and so forth) are so rare, that the only form to be noted here is that which occurs between the manubrium and the rest of the bone. Fracture or displacement of the ensiform cartilage must also be considered. Compound fractures of the sternum do not come from protrusion of the broken bone through the skin,2 but only from wounds of the chest wall. In the usual form of displacement of the sternum, the bone gives way at, or just about, the line between the manubrium and the rest of the bone. The upper fragment is depressed, the lower fragment rides over it ; the second ribs usually go with the manubrium. Is this a fracture, or a dislocation ? Poland speaks of it as the latter. 'The symptoms are liable to be ' " Elasticitat der Knochen," 1880. ^Gurlt found only one recorded case where this happened. Plate i. .,1 '