Malformations may also be produced by injuries or certain occupations. Extensive burns may cause cicatricial contraction; contusions may produce paralyses, and more serious lacerations may leave extensive scars, which will gradually warp the chest out of shape. Burns, for instance, which may involve the axilla and the upper arm, may be followed by such dense scars as to limit the motion of the arm. Skin grafting should be resorted to early in the treatment of lesions thus produced.
Tight lacing is the source of a mild form of thoracic deformity, by which the chest capacity is reduced, the respirations made peculiar in character, the liver displaced downward, and the general welfare of the individual materially affected. Influence of the right-hand habit is frequently quite apparent in that the right side of the chest becomes overdeveloped as compared with the left. This may be seen in a large number of workmen who use heavy tools especially with the right hand. Certain occupations, as well as sports, lead to constant assumption of the stooping position, with the inevitable round shoulders and drooping head so apparent in bicycle riders.
Tattooing.—As a local expression of a bad habit, or in some instances almost of a criminal instinct, tattooing may be mentioned. This is seen usually upon the chest and arms. It is a prevalent custom among sailors, and is regarded by alienists and anthropologists as a habit indulged in by criminals and the insane. La Cassagne has spoken of tattooing as “an uninterrupted and successive transformation of an instinct.” Among the inhabitants of the Pacific Islands it is almost a mutual practice, and among them the tattoo marks are often found upon the back and upon the sexual organs. The materials usually employed are lamp-black, indigo, and India ink for the black or blue tints, and cinnabar or carmine for the red. Practised as it is by the unschooled and the ignorant it may be followed by all forms of local infection, while syphilis has been thus transmitted.
For the removal of tattoo marks many methods have been suggested, but few have been found satisfactory. The minute particles of pigment have become so deeply lodged that, like powder marks, it requires infinite patience in their detection with the lens and individual removal, or those portions of the skin must be destroyed which contain them. Mechanical methods should be limited to localized stains, unless a plastic operation is preferred, and, after removal of the affected area, healthy skin may be transplanted by one of the plastic methods or we may resort to skin grafting. Actual cauterization with strong caustics or with the actual cautery will be followed by superficial sloughing, which may remove the disfigurement. It is questionable, however, if the resulting scar will be considered much of an improvement upon the previous condition.
INJURIES TO THE THORAX AND ITS CONTENTS; CONCUSSION OF THE CHEST.
As a result of a severe blow made by a blunt object there may result a form of concussion or commotion, similar in its results to the conditions which were formerly described in the cranial cavity as concussion of the brain, but which are now known to be due to reflex vasomotor disturbances, by which blood pressure is seriously affected and extreme degrees, perhaps fatal, of shock or collapse produced. It is possible for fatal injuries thus produced to leave little or no evidence that may be discovered at the autopsy. Hence the term concussion of the chest may be retained as descriptive of what has taken place, and implying serious symptoms produced through the agency of the nervous system, especially through its sympathetic plexus. In such instances the heart is seriously affected and may continue to beat feebly for some time, as in shock from other injuries.
Severe blows upon the chest also disturb the function of respiration, and it is possible that asphyxia, even to a fatal degree, may result from a momentary paralysis of the entire respiratory apparatus thus produced. In such cases artificial respiration will be required. In many instances patients will complain of not merely distress, but severe pain, which may require local anodyne measures as well as the administration of an opiate.
Contusion of the chest leaves more visible and lasting effects upon the tissues of the chest wall. Thus extensive hemorrhages may result and hematomas form, or ribs may be broken, with or without injury to the pleura, or internal hemorrhages may occur, as from a ruptured intercostal or internal mammary artery, the consequences of such injuries not necessarily appearing at the time, but developing later. Along with these injuries to the chest there may occur other injuries to the abdominal viscera or to other portions of the body. Something will depend upon the distention or relative emptiness of the lungs at the time of injury, and whether there may have been at the same time a sudden closure of the glottis, in which case, by an external blow, something resembling an explosive effect may be produced within the air passages. The degree of stomach distention may also have its own effect. Laceration of lung tissue will usually be shown by appearance of bloody froth at the mouth, as well as by more or less dyspnea. Rapidly developing symptoms of pressure upon the lung would indicate the accumulation of blood within one pleural cavity and cause the ordinary physical evidences of the presence of fluid. The diaphragm may be ruptured, and the proper viscera of one cavity be displaced into the other. When emphysema of the tissues of the chest occurs it is usually safe to assume that a rib has been fractured, even though the injury cannot be located or even otherwise recognized.
A series of later lesions may result from such contusions, which may be of serious character. Thus there has been described a so-called contusion pneumonia, whose symptoms are similar to but milder than those of the genuine disease. It is a result of inflammatory and hemorrhagic infiltration. It may lead to a pleuropneumonia, with subsequent hydrothorax or pyothorax, or these may take place more directly and without its occurrence. The products of this disease afford foci in which, later, tuberculous expressions are commonly met. It has been shown experimentally that the blood serum of animals subjected to severe injuries of the chest and abdomen has well-marked toxic properties. Thus the appearance of sugar or albumin in the urine or of other toxemic indications may be perhaps explained.