Sarcoma of rib and pleura, result of injury by a base-ball. (Dennis.)
Carcinoma of the chest wall is generally the result of extension from cancer of the breast or of some other epithelial structure. Advancing carcinoma spares nothing, and may not only perforate the chest but involve the lung beneath, with or without later ulceration, and the occurrence of pneumothorax.
Fig. 510
Skiagram of a large sarcoma of the thorax and humerus, whose bloodvessels were injected previous to taking the x-ray picture. (Lexer.)
While these are the more common forms of tumor of this region there are no known growths which may not occasionally be met here.
Treatment.
—The treatment for all these tumors is extirpation. With benign growths outside of the ribs proper this is usually a simple matter. When the whole or nearly the whole thickness of the chest wall is involved it becomes then a serious problem how far to proceed in the effort to extirpate. This is true alike whether sternum or ribs are involved. The entire sternum may be separated from its surroundings and lifted out of place, and this would be justifiable when dealing with an osseous or cartilaginous growth. If, however, it were distinctly sarcomatous it would be hardly worth while. If in such an operation the pleura be spared and air not admitted to the pleural cavity almost anything is allowable. If, however, it appear that it will be necessary to open the pleural cavity caution should be observed. Of late years, however, less hesitation has been felt in this regard, and Parham and others, including myself, have shown that extensive portions of the thoracic wall may be resected without the necessity for employment of the elaborate operative methods suggested by some recent experimenters. For instance, Sauerbruch has devised a “pneumatic cabinet,” the patient’s head resting outside when the anesthetizer administers the anesthetic. The balance of the body rests within the cabinet, which is sufficiently large to accommodate the operator and two or three assistants, and which, being closed, is subjected to a lowering of atmospheric pressure equivalent to 10 Mm. of mercurial column, or to a difference in atmospheric level of 1000 to 1200 feet. The patient breathing air at external pressure does not suffer the collapse of the lung, thus exposed, which would otherwise take place. The operation being completed within the cabinet, the dressings are applied and hermetically sealed, and the door then opened and pressure equalized. Subsequent dressings can be made in the same way. Thus has been afforded a scientific method of doing that which the experience of many American surgeons has shown to be only theoretically indicated. Sauerbruch’s device is ingenious in theory and complicated in operation.
A simpler method is to apply the Fell-O’Dwyer apparatus over the face and thus keep up artificial respiration. It is not, in theory, so ideal as to open the trachea and practise this procedure as is done in the experimental laboratory, but is much simpler and will usually suffice, should anything of the kind be required.
A malignant tumor of the chest wall whose overlying skin is seriously involved, and whose removal would leave a defect which it would not be possible to cover with integument, should not be disturbed. It might be possible in certain cases to partially transplant the breast in such a manner as to permit closure of a defect thus made. Nevertheless it is questionable if any cancer advanced to the extent of requiring this procedure is to be considered operable.