Erosion of sternum, the result of pressure of an aneurysm. Wood Museum. (Dennis.)
Fig. 506
Erosion of vertebræ, the result of pressure of an aneurysm. Wood Museum. (Dennis.)
The pressure of advancing tumors will sometimes cause surprising changes, not so much the result of ulceration as of mere absorption in the path of the advancing mass. Thus aneurysms will gradually erode the sternum or the ribs, and in time form bulging projections from within the chest, which may ultimately rupture and thus terminate the case. Even upon the vertebral column the effects of such pressure are pronounced. [Figs. 505] and [506] illustrate what may happen under circumstances just detailed.
Remarkable expressions of subcutaneous emphysema may be seen in certain cases of fracture of ribs, with perforation of the lung, air escaping into the tissues and puffing up the whole upper part of the body and neck, giving it an appearance and shape very different from the original. For this condition there is no particular treatment, save immobilization, by which respiratory efforts shall be limited. Ordinarily the tissue distention quickly subsides. Should, however, putrefactive organisms enter with the air there may arise emphysema, terminating in gangrene, with fatal septicemia.
Painful affections of the thoracic walls are associated with lesions, either of the intercostal nerves or the ganglia or special nerves with which they are connected, which produce intercostal neuralgia of various types, including that with its peculiar eruption known as herpes zoster, or as the laity call it, “shingles” (being a corruption of the Latin cingulum, meaning a girdle). Neuralgia may also be caused by inclusion of nerve branches in callus which is formed around a badly united fracture of the ribs. The diseases of the vertebræ which lead to softening and changes of shape will also permit of pressure upon nerve centres and trunks, which cause more or less pain, referred more often to the distribution of the nerves involved than to their origin. Thus the referred pains of spondylitis (Pott’s disease) are to be thus explained and are sometimes very pronounced. We give the term “neuralgia” to those painful affections for which there is no satisfactory explanation, and thus we are told that in intercostal neuralgia there are three points of tenderness, known as those of Valleix, whose determination confirms the diagnosis—the first being at the point of exit of the spinal nerve from the vertebral canal, the second in the axillary line, and the third close to the costosternal articulation. Abrams has shown that if a freezing spray be applied over the first spot the neuralgia will at once subside if it be of peripheral, but not if of central origin. Again, if one pole of the galvanic current be placed on the affected side and the other upon any one of the above spots the pain, if neuralgic, will disappear. If the current employed be the Faradic, and the pain subside, its cause is located in the muscles, as the induced current does not influence the pain of a genuine neuralgia. (Dennis.) So far as the treatment of these painful affections is concerned it is rarely surgical; although it was the relief afforded by the accidental stretching of an intercostal nerve which first suggested to Nussbaum the utility of nerve stretching as a more general procedure, and it was thus introduced to the profession. The treatment of herpes, i. e., of that form of neuralgic affection which is characterized by the appearance of papules which soon become vesicular, which collect in clusters and appear along the course of certain intercostal nerves, is rarely surgical. It is not difficult to distinguish this from ordinary eczema, which does not follow the nerve distribution and is not accompanied by the severe pain of herpes.
THE MEDIASTINUM.
MEDIASTINITIS.
The principal interest attaching to diseases in either mediastinum pertains to the consequences of spreading infection, which will be practically always of the phlegmonous type, and which will produce clinical expressions varying much with its location and the direction of its course. These are included under the general head of acute or chronic mediastinitis, which might be the result of an extension from above, as from cervical abscesses, spondylitis of the cervical vertebræ, deep cervical phlegmons, and the like; or the result of perforation, or of foreign bodies impacted in the esophagus or elsewhere; or may again come from the osseous structures of the chest proper, spine, ribs, and sternum. Doubtless certain cases of subphrenic abscess are the result of suppuration begun in the mediastinum. Instances are also occasionally seen after typhoid and the other infectious and contagious fevers.