The Management of Stove-in Chest.

Opinion on the management of stove-in chest appears to be converging on intermittent positive pressure respiration as a definitive line of treatment. Since Barrett (1960) summarised the emergency treatment as comprising tracheo-bronchial clearance, tracheostomy and intercostal drainage of pleural cavities with an underwater-seal, a more positive attitude to the treatment ofthese patients has developed, based on a knowledge of the altered physiology. If paradoxical respiration has reduced the tidal volume to levels approaching that of the dead-space air, then when secretions accumulate in the bronchi (the “ wet-lung “ of Samson and Brewer 1946) asphyxiation is certain. It is therefore logical to reduce the dead-space air and clear the airway by tracheostomy. These principles were used by Carter and Guiseffi (1951), who treated seven patients with stove-in chest by tracheostomy alone, four of whom survived. Similarly if air or blood is accumulating in either pleural cavity it is logical to re-expand the lungs by underwater-seal drainage. Opinion is sharply divided concerning the action to be taken after this emergency treatment. Three main lines of treatment are used. Traction on the flail segment-Jones and Richardson (1 926) advocated traction on the sternum and Williams (1948) advocated pericostal traction on the flail ribs. Heroy and Eggleston (1951) elaborated the sternal traction technique and Proctor and London (1955) elaborated the costal traction technique. Schrire (1962) described a suction device which he named “ the limpet.” Internal fixation-Some surgeons feel that with antibiotic cover a stove-in chest should be opened, the pleural cavity cleared out, and the rib fractures immobilised. Klassen (1949) used intramedullary bone pegs in the ribs and Coleman and Coleman (1950) fixed the rib ends with wire sutures. Crutcher and Nolen (1956) described nine patients in whom intramedullary fixation was accomplished with small Rush pins. Sillar (1961) described a plate for screwing on to the sternum and fixing the flail anterior segment. Artificial respiration-Hagen (1945) described the treatment of multiple rib fractures with a Drinker respirator. Avery, M#{246}rchand Benson (1956), using hyperventilation with intermittent positive pressure respiration, diminished respiratory effort by putting their patients into alkalotic apnoea. This concept has been modified by Windsor and Dwyer (1961) who used