stab wounds, or gunshot injuries with or Purchase Diamox without
retained missile, and sometimes with complicating
injuries of the heart, mediastinum, diaphragm, or
the abdominal organs, particularly the stomach,
colon, spleen, or liver.
Duval states "that bullet wounds of the lung are
either fatal at once by Acetazolamide Diamox reason of injury to a large
vessel, or comparatively benign ; the wound is either
aseptic or seldom followed by grave infection. To
this single factor their slight severity is due." — •
Further, he states "from a surgical point of view
bullet woimds are of little interest, as they do Diamox Sequels 500 Mg not
demand operative interference." But bullet wounds
and stab wounds will be the injury Diamox 500 in civil practice,
and the)- will be of interest to the civil surgeon.
The problem before us is — shall we operate in
all cases of stab or gunshot Purchase Diamox Online wounds of the chest, or
shall we wait for the complications of hemor-
rhage, pneumothorax, or infection to ensue? If it
were not for the occurrence of infection we might
formulate : Early operation is indicated, a, when
there is a rapidly increasing pneumothorax (from
a valvelike opening ) ; b, when the rib has been
splintered by the bullet, and the fragments press
on the pleura, or have been driven inwards ; c,
when hemothorax is large and seems to be increas-
ing. Late operation is indicated : a, at any time
when the pleural cavity appears to be infected; b,
after six or seven days, when the patient's condi-
tion is excellent and he has been well studied, to
re'nove clot or missile.
The crux of the situation, however, hinges on
the matter of infection. If we wait until the
patient is in excellent shape to stand the operation
we may lose the opportunity to Diamox Mg so cleanse the
pleural cavity that aseptic conditions can be estab- Buy Diamox
lished. If we operate in all patients immediately,
we will lose many from shock, and the mortality
of the total will rise.
Shock must be met first. The patient should not
be handled roughly or rushed to the x ray room.
The chest should be immobilized immediately on
arrival, however slight Diamox 125 Mg the injury may appear to be.
The patient should be placed in bed, kept warm,
and the wound dressed, and quiet assured by the
aid of morphine. He should remain in the ward,
propped up in bed and only examined immediatelv
if serious signs, such as those of persistent hemor-
rhage or asphyxiation pneumothorax suggest the Diamox Acetazolamide
necessity of an immediate operation. Elliot in his
interesting paper published in 1919 states that the
reflex reaction to the chest wound causes a strong
muscular contraction of the walls of the Generic Diamox bronchioles
producing the early cyanosis and dyspnea. Rest
and morphine soon allav this spasm in most cases.
If prolonged reflex constriction of the bronchial
musculature occurs with cyanosis, dyspnea, and Diamox Generic
inspiratory retraction, operation is not well borne. Diamox Buy
The diagnosis of hemorrhage and pneumothorax
depends on the usual well known signs with the
variations so well described by Bradford and others,
viz.. the elevation of the diaphragm, the small size
of the chest, the tendency to complete or partial
collapse of the lung in any area, the compensatory
emphysema above and other known physical signs.
The important point for the surgeon to determine
is whether the hemorrhage is continuing or is pro-
gressive. If from the location of the wound of
entry injury of the abdominal viscera is suspected
immediate operation should be done. In those cases
where all goes well and the proper surroundings
618
MVLLER: GUNSHOT INJURIES OF CHEST.
[New Yor
Medical Joub
and skill are available there seems no reason why
we should not routinely open the thorax in from
five to eight hours after the injury in cases even
where there is moderate hemothorax or Order Diamox Online where there
is a retained missile. I admit that the mere reten-
tion of a missile is a debatable indication for opera-
tion but the dangers Iv Diamox of fibrosis, Buy Cheap Diamox abscess, or bronchi-
ectasis are Diamox Tablets too real to be disregarded. It has been
noted by Diamox 500mg all of us that hemorrhage and infection
are the causes of nearly Order Diamox all the fatalities and many
of the fatal hemorrhage cases are probably beyond
help by reason of large vessel injury and death
before operation can be attempted. But I am cer-
tain that some patients die who could have been
saved by prompt thoracotomy. Early operation
should avoid most of the fatalities from infection. Tablet Diamox
Where there has been delay and infection of the
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