Another form of pneumocele is the later consequence of injury, the soft, crackling, or crepitating tumor presenting beneath the skin and returning the usual breathing sounds when auscultated. It may increase and diminish in size with the respiratory movement. Such a hernia may occur beneath a scar or through ruptured intercostal muscles. It is of small surgical consequence, and, if troublesome, may be retained by a suitable pad.
The lung is occasionally ruptured by a violent concussion of the chest, as is also the heart. Its consequences will be emphysema, pneumohemothorax, with vomiting of blood, and later infection.
The later consequences of hemothorax, simple or uncomplicated, may be troublesome pleuritic adhesions, by which freedom of respiration is impaired, and, it may be, chest motions interfered with and chest development limited. The pleural surfaces are usually gradually drawn toward each other by the development of granulation tissue and its subsequent contraction and condensation.
Wounds of the Diaphragm.
—The diaphragm may also be lacerated by the compressing effects of violent blows, either upon the chest or abdomen. In consequence there may be passage of viscera (hernia) from either cavity into the other. Accurate recognition of these cases will scarcely be possible, but the development of distinct abdominal symptoms or noticeable displacement of the heart or of the abdominal viscera may lead to exploratory section, which shall reveal the location of the rent and possibly permit of appropriate repair or suture.
Injuries to the Thoracic Duct.
—The thoracic duct is occasionally injured by penetrating wounds, while, at the base of the neck, it has been known to be divided in the course of the removal of deep and adherent tumors. In the latter case the escape for a short time of the milk-like chyle, which it carries, will give evidence of the injury. Several cases on record show the comparatively innocent nature of the injury and its tendency toward spontaneous recovery without the necessity for further intervention. The very low pressure of the fluid in the duct is a contributing cause to this exemption from serious harm. Should the duct become obliterated near its upper end doubtless collateral circulation will enable the right and smaller duct to take up its work and continue it.
Injuries to the Upper Nerve Trunks.
—In regard to injuries of the upper nerve trunks in the chest it is necessary to add but little to statements made regarding injuries to the same nerves in the neck. The writer has collected over fifty cases of destructive injury to the pneumogastric, in over one-half of which recovery followed. It has been shown that unilateral resection of the vagus is almost devoid of danger, though when it is required the nerve is rarely in a normal condition. Unless the nerve be attacked or involved below the branch which forms the recurrent laryngeal, laryngeal symptoms may be certainly expected. Irritation to the cervical sympathetic is usually followed by dilatation of the pupil, widening of the palpebral fissure, some degree of protrusion of the bulb, and paresis of that side of the face, while absolute sympathetic paralysis, such as follows division, will produce dilatation of the pupil, ptosis, and increased flushing of that side of the face. The sympathetic nerve may have to be extirpated in certain cases of excision of malignant tumors. Again, it has been deliberately resected, as recommended by Jonnesco and others, for the cure of epilepsy, of exophthalmic goitre, and of glaucoma. This will demonstrate the fact that injury to it is not necessarily of itself a severe accident.
In certain injuries to the chest branches of the brachial plexus will be divided or compromised, or displaced by fragments of bone or otherwise. When nerve pressure can be recognized the compressing cause should be removed. If a nerve be divided every attempt should be made to suture it.