Hemothorax may be idiopathic or traumatic. In the former case it is an expression of malignant disease, or of advanced septic lesions which have permitted erosion of bloodvessels and escape of blood. It may also result from rupture of an aneurysm, and will then prove fatal. It is seen in surgical cases in connection with injuries to the chest wall or its contents, as in compound fracture of a rib or perforation of a rib fragment into the chest, with injury to the lung.
In case of the sudden escape of fluid into the chest, with symptoms of collapse and lung compression, it may be assumed that an acute hemothorax affords the explanation. Fluid accumulating rapidly under any circumstance is more likely to be blood than serum. The exploring needle may be relied on to furnish the deciding test, in addition to the ordinary physical signs afforded by auscultation and percussion.
Pyothorax is frequently referred to as empyema, the latter term indicating a collection of pus in a previously existing cavity, and, by common consent, made to refer to the pleural cavity unless some other be mentioned. Empyema is seldom a primary condition. Generally it is the result of a hydrothorax, which has become contaminated either by direct or by indirect access of germs. Under these circumstances it indicates the conversion of a relatively innocent collection of serum into a collection of pus, with all its attendant dangers. It may be looked for in cases of perforating injury of the chest, e. g., compound fracture of the ribs, gunshot wounds, and the like.
While returning the ordinary physical signs met with in fluid collections in this location, and being discoverable with the exploring needle, empyema has this additional feature, that the pus may, when long retained or accumulated in large amount, burrow and attempt to escape through whatever path may offer least resistance. In this way strange freaks will occur, as when it escapes behind a mammary gland and pushes the latter forward, thus forming a large retromammary abscess, which requires not merely the ordinary incision, but a thoracotomy and ample drainage as well. It may penetrate at other points and thus escape. The most remarkable illustration that the writer personally has known of this travelling of pus was in a colored man, in whom it perforated the diaphragm, then separated the peritoneum from the abdominal wall over a large area, collected in large amounts between the peritoneum and the abdomen in front, and even extended down into the pelvis. This man had such a peculiar abdomen that he was supposed to have dropsy. When the trocar was inserted there was a discharge of over a pailful of almost pure pus.
In addition to the ordinary embarrassment which a considerable amount of pus thus collected causes, there should be reckoned the peculiar septic and toxic features, which can be easily accounted for by the nature of the contained fluid. Pyothorax will nearly always have septicemic in addition to local features, which give it an individuality of its own.
The operations practised for relief of these conditions are discussed at the conclusion of this chapter.
THE ESOPHAGUS.
Anatomically, the esophagus is a musculomembranous tube with downward projection into the thorax, its uppermost portion blending with the lower constrictor of the pharynx, the tube proper beginning at the level of the cricoid cartilage, and opposite the sixth cervical vertebra. Its conclusion opposite the tenth dorsal vertebra marks the cardiac orifice of the stomach. In its upper portion it is placed centrally, then inclines a little to the left, and, at the level of the third dorsal, lies about half an inch to the left of the middle line. This furnishes the reason for approaching it upon the left side in doing external esophagotomy. From here it passes to the middle line again until opposite the ninth vertebra, where it once more inclines a little to the left. It has an anteroposterior curve corresponding to the shape of the spine. Between it and the trachea, in the neck, lies the recurrent laryngeal nerve. Its nervous supply is derived from the sympathetic and the pneumogastric, and its lymphatics connect with the mediastinal nodes, the latter point being of importance in connection with cancer of the esophagus. Its average caliber is about three-quarters of an inch, save where it is crossed by the left bronchus and at the diaphragmatic opening. There is also a slight constriction at its upper opening.
CONGENITAL MALFORMATIONS OF THE ESOPHAGUS.
Congenital malformations include its absence, at least throughout some of its course. Communication between it and the treachea, so-called tracheo-esophageal fistula, has been noted. Its upper portions, into which may open the incompletely closed branchial clefts, are also subject to malformations with incomplete obliteration of the latter and consequent diverticula. Irregular dilatation is also occasionally of congenital origin, as well as acquired, in the latter case being due to fatty degeneration of muscle fibers. These dilatations should be differentiated from those which are mostly found on the proximal side of any constricted tubular passage, and which are produced by accumulation and distention from behind of whatever should be passed through it.