A Mirror of

acute

WITH By

mediastinal

Hospital Practice

emphysema

GENERALIZED EMPHYSEMA

^

F. A. B. SHEPPARD, f.r.c.s. (Edin.) CAPTAIN, I.M.S.

District Medical Officer, Madura

Acxjte mediastinal

emphy^n^ /-j^es 0f the by cruS17gJpiicated comt

^?mmon sequel to issevere frequently ?hest, but as it

other intra-thoracic damage it is not often that such cases are presented for treatment. In itself the condition calls for urgent surgical intervention as with each breath taken more air is forced into the relatively closed and restricted space of the mediastinum. As the blood returns to the heart from the lungs and the systemic circulation bears the brunt of the compression it is not surprising that signs of cardiac failure

THE INDIAN MEDICAL GAZETTE

746

and respiratory distress soon become obvious. To these effects are added, of course, those of surgical shock. If allowed to persist for anytime the pressure of air in the mediastinum may burst through one or both pleural cavities with the production of a tension pneumothorax. It is of course always possible that with any severe crush of the chest, both a mediastinal emphysema and a tension pneumothorax may occur simultaneously, the symptoms then being correspondingly severe. Sauerbruch (Sauerbruch and O'Shaughnessy, 1937) states that the accident may also follow attempts at artificial pneumothorax where the needle has been inadvertently introduced into a portion of the lung adherent to the chest wall. In the case reported below, it is interesting to observe that the injury appears to have given rise to a valvular defect in one of the root bronchi or in the lower trachea, with the result that while air was satisfactorily inspired, there considerable escape into the tissues on was

expiration. Simple opening of the space of Burns, as usually advised, cannot suffice since the deeper layer of fascia attached to the posterior surface of the manubrium sterni must be opened for adequate decompression of the mediastinum to occur.

Notes

oj

case

recorded

N., Hindu, aged 4 years, the son of a coolie, was admitted to hospital at 6-45 p.m. on 6th December, 1937, with a history of having been run over by a partially-loaded double bullock cart five hours before. Although it is difficult to believe that such an accident could occur without killing the child the parents persisted in the statement that the child had been climbing up the wheel of the cart, when the bullocks started to move, that he fell down and the right wheel had passed over his chest.

the child was restless and in a with short rapid and grunting respirations. The whole body Avith the exception of the lower iimbs was so extremely emphysematous that the bones of the chest and skull could not be clearly felt. The skin was shining except for the face and neck which were somewhat cyanotic and the eyes could not be seen because of the emphysema. The scrotum There was an abrasion of was enormously ballooned. the skin across the right half of the chest at the nipple line, but it was not possible to determine any fracture of ribs or sternum. Respirations were 60 to the minute and the pulse could not be felt at the wrist. On auscultation, the heart did not appear to be displaced but the beat was extremely rapid. It was not possible to ascertain whether air was entering both lungs. The child's condition was so grave that examination was necessarily very hasty and no time could be lost by taking an On

examination

desperate

condition,

picture. Operation.?To exclude the presence of tension pneumothorax both pleural spaces were punctured with a pneumothorax needle. The pressure was negative

2-ray

each side. The root of the neck was then infiltrated with 0.5 per cent novocain and a low collar incision was made through skin, platysma and deep fascia. The sternamastoid attachments were defined and the mediastinum opened by finger the dissection behind manubrium sterni. The result was dramatic. Air immediately gushed out and was seen to escape with each expiration. Hamiostasis was secured and the wound was loosely covered with gauze. The effect on on

[Dec.,

1939

the child was no less dramatic and he became calm and quiet and soon fell asleep. The extremities wrapped in cotton-wool and bandaged and the child returned to the ward. An x-ray photograph, taken immediately after the operation, revealed simple fracture of the second and third right ribs. The generalized emphysema diminished considerably by 10th December, but did not completely subside until after another few days. Air continued to escape from the wound for four day=The wound was allowed to close by granulation and the child was discharged cured on 19th January, 1938. Reference

Sauerbruch, F., and O'Shaughnessy, L. (1937) Thoracic Surgery. Edward Arnold and Co., London.

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Acute Mediastinal Emphysema with Generalized Emphysema.

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