TREATMENT Of wounds Of THE OHEST-WALL. 479 



infection is liable to extend in the loose connective tissue which 

 surrounds the great vessels, the trachea, and oesophagus, and may 

 reach the chest, causing septic pleuritis. Wounds complicated 

 with fracture of the first rib often produce similar results. The great 

 vessels of the neck and the nerves may, moreover, be injured, producing 

 severe or fatal bleeding, respiratory difficulty and cardiac disturbance. 

 Violent shocks to the chest-walls may injure the axillary vessels 

 and nerves and produce paralysis, while similar conditions also occur 

 in fractures of the scapula and humerus. Wounds complicated with 

 fracture of the scapula and humerus are frequently fatal, septicaemia 

 soon appearing in consequence of direct infection of the wound. 

 Coldness and paralysis of the affected limbs point to thrombus 

 formation in the vessels, while paralysis alone suggests injury of 

 nerve stems. Such serious results are, however, in great part pre- 

 vented by the protection afforded by the stout thoracic fascia. Where 

 the shoulder-joint is not injured, mere muscular wounds often heal 

 well. Even where the wound passes under the shoulder as far as 

 the joint, recovery usually occurs without affecting the movement 

 of the limb. 



The lameness is important in forming a prognosis : as long as 

 it is not marked, and no symptoms of fever exist, healing may be 

 expected, even where the muscles are extensively lacerated. Danger 

 of pleurisy is not great. The emphysema sometimes occurring in 

 these muscular lesions must not be supposed to depend upon the 

 thorax being perforated ; nor must moderate acceleration of breathing, 

 determined by injury of the accessory respiratory muscles, be mis- 

 taken for pleurisy. 



Treatment. After bleeding has ceased, the wound should be 

 carefully examined to discover its extent and the possible presence 

 in it of foreign bodies, which, if present, should he thoroughly removed. 

 The parts are then cleansed ; in deep injuries of the anterior surface 

 of the chest, extending towards the middle line, particular provision 

 must be made for the escape of wound discharges in order to prevent 

 infection of the sternum. It is well to lay open any pockets or 

 make counter openings. Drains or setons are introduced if required. 

 Where larger vessels, especially veins, are exposed, after-bleeding 

 may result during the first three days, but seldom later. It is, t here 

 fore, advisable, whenever possible, to ligate injured vessels, to (ill 

 large wounds with antiseptic tampons, and carefully to watch the 

 progress of the case. Irrigation with lukewarm antiseptic solutions 

 should be continued for several days (sublimate 1 in 3,000, carbolic 

 acid 1 in 50). Cold solutions should only be used while bleeding 



