Nor should any malignant tumor of the chest wall be operated if, in addition to its own presence, there be indication of the involvement of the lymphatics or other structures within the chest, such indications including, for instance, cough, loss of voice, dyspnea, dysphagia, disturbance of pneumogastric control of the heart, displacement of the latter, or great accumulation of fluid in any of the chest cavities. The only exception to this statement is possibly when the lung has attached itself to its interior surface, but yet not so extensively but that removal of a small amount of lung tissue will not interfere with extirpation of the growth. Cases of recurring carcinoma where the chest wall is completely involved rarely justify operation.
TUMORS OF THE LUNG.
Tumors of the lung proper might be made amenable to surgery, in certain instances, if an exact diagnosis could be made. Occasionally this is possible, though but very rarely. Particles of lung tumor have been expectorated and their minute character recognized, so that actual diagnosis has been made. As in the abdomen, cancer of the thoracic viscera will usually lead to an accumulation of serous fluid, and, in both instances, thus obscure rather than simplify recognition. Quincke has shown that the presence in such pleuritic effusions of fat cells (hydrops adiposus) is significant, since they rarely if ever occur in any other exudates.
Primary tumors of the lung are usually sarcomas or endotheliomas. Carcinoma is exceedingly rare, save as secondary to cancer in the breast. Even sarcoma is itself usually secondary to disease in some other part of the body, metastasis having occurred through the blood channels, instead of through the lymphatics, as is the case with carcinoma. Tumors arising in the pleura may be of endotheliomatous type and are usually accompanied by the presence of bloody serum. Extremely rare tumors within the chest are those of dermoid origin, connected more often with the pleura than with the lung proper. These may suppurate and communicate either externally or internally. One known case mentioned by Dennis was that in which such a tumor communicated with a bronchus, so that the patient coughed up hair. Syphilitic gummas are also found in the lung, either in multiple small form or in masses of considerable size. They are slow in development and may give rise to no special disturbance. Dennis has described instances in which these growths have become encapsulated.
Two other forms of tumor are not very rare in this situation: one is that produced by actinomycosis; the other occurs in echinococcus disease and in the formation of hydatid cysts. The former, developing within the lung proper, tends to migrate toward its surface, to include the pleura, and finally to invade the chest wall. Such a tumor when exposed in either location can scarcely be differentiated from a breaking-down sarcoma, except by the recognition in it of the small, calcareous particles which are so pathognomonic of this disease. (See [Actinomycosis].) In the living patient the sputum will frequently contain these particles, while under the microscope the peculiar club-end, thread-like fungus formation may be recognized. The disease is usually of slow development, but occasionally, especially when mixed with a secondary infection, may be rapid. Significant tumors may also occur in other parts of the body. Actinomycotic tumors upon the surface may be attacked with curette and cautery. Injections of iodine are also of value. For actinomycosis of the lung proper potassium iodide and Lugol’s solution are indicated as well as copper sulphate.
Hydatid cysts occur within the lungs in about 10 per cent. of cases of echinococcus disease. Their contained fluid is alkaline, of low specific gravity, colorless, and contains the characteristic hooklets which are pathognomonic of this disease. A circumscribed collection of fluid within the chest, shown to be due to this condition, may be tapped or incised and drained. When occurring in the lung it not infrequently leads to secondary pyothorax, while operation for the latter may reveal the existence of the former. Any hydatid cyst of the lung which can be recognized, or be made accessible, may be treated by incision and drainage, the lung, if not already adherent, being first fastened to the chest. Inasmuch as the condition develops in the lower lobe and on the right side this is occasionally a practicable procedure. As the diagnosis is usually made only after the primary cyst has ruptured and small cysts are cast off, producing more or less pleuritic effusion, the attempt may still be made to do this by a free incision of the chest wall, perfecting the diagnosis and completing the procedure at this time.
THE HEART.
There is but little to be said about the heart in addition to that elsewhere stated, where such injuries as gunshot wounds, stab wounds, etc., are considered. Rupture of the heart without external injury is possible under conditions of fatty degeneration or softening produced in consequence of embolus or thrombus. Aneurysms of the heart are also known by which it is weakened and permitted later to give way. The final rupture is usually the consequence of some emotion or extra exertion, although it may occur with injury to some other part of the body, as after a blow upon the abdomen. Death may be instantaneous, or occur more slowly as the result of filling of the pericardial sac and rapidly increasing embarrassment of heart action.
Wounds of the heart produce syncope and shock, restlessness, extreme anxiety, with dyspnea and such disturbance of heart activity as to materially change the sounds heard on auscultation.
The treatment of such cases not primarily fatal should include opium narcosis, but not stimulants intended to excite the heart to extra activity. The operations justified under these conditions are elsewhere described.[50]