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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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