295. Wounds penetrating the wall of the chest, and implicating any part
or portion of its cavity or contents, are among the most dangerous of
injuries. They require in their treatment a more careful attention and
a greater extent of knowledge than most others which befall mankind.
The means which the improved methods of auscultation have afforded
cause the progress of the symptoms which follow to be less obscure,
and lead to a less doubtful practice than formerly; while they render
a knowledge of this branch of medical science an essential part of the
education of a surgeon.
296. _Incised_ or _punctured wounds_, from swords, lances, bayonets,
or knives, require a treatment _essentially distinct_ on many points
from that of _gunshot_ wounds, especially in the commencement. On this
early treatment so much depends, that details of the more serious or
more important cases are rarely found among the records of injuries
sustained on the field of battle, where so much is often to be done,
and so few are to be found to do it.
The simplest of the more serious results from injuries not penetrating
the chest is the occurrence of inflammation, either of its lining
membrane, giving rise to what is called _pleuritis_, or of the
substance of the lung, termed _pneumonia_, or of both, constituting
what has been named _pleuro-pneumonia_; but many severe blows on the
chest are not followed by such serious consequences.
On the 17th August, 1808, in the act of leaving the village of
Colombeira to ascend the heights of Roliça, a soldier was shot in the
leg: he jumped up three or four feet, and made a considerable outcry.
A second was struck at the same time by a ball on the shoulder, which
did not penetrate, but gave him great pain. A third received a ball on
his buff-leather belt, on the right breast. The noise made by these
two blows was unmistakable. I saw this man fall, and supposed he was
killed: the ball, however, had only gone through his belt, and made a
mark on his chest, over the cartilage of the fourth rib, the hardness
and elasticity of which had prevented further mischief. He recovered
in a short time, spat a little blood in the night, and after a large
bleeding was enabled to accompany me on the 20th to Vimiera, ready for
the fight next morning.
A soldier was struck on the hill of Talavera,[4] on the breast-plate
by a ball, which, as he believed, had gone through his body. He was
as white as a sheet, and desperately frightened. On opening his coat,
I found the ball had indented the breast-plate, and made a round,
red mark on the skin, without going deeper. I did not see him again
for several days, until after crossing the bridge of Arzobispo, on
the retreat to Truxillo. He was then engaged in disemboweling a fine
fat wild hog, among a herd of which we had, unluckily for them, just
fallen. He recognized me at once; said that, as I told him, he had
been more frightened than hurt; that he had been bled largely and well
physicked, and after two or three days had thought no more of it. I am
bound to add that, in gratitude, he offered me a leg of the pig, which,
having nothing to eat, I could not but accept. It supplied a dinner for
three others who are now no more.
[Footnote 4: The Duke of Wellington received a blow from a spent ball
at the same time, near the left clavicle.]
A soldier of the 40th Regiment slipped from the ladder on which he was
attempting to scale the wall near the great breach of Badajos, and fell
on his cartridge-box, which hurt his left side so much as to render him
unable to move for some time. On the 8th of April he was much worse.
The part injured was painful to the touch; the difficulty of breathing
considerable; cough hard, with little expectoration; pulse 90, skin
hot, appetite gone, tongue white. V. S. ad ℥xvj, and aperients. 9th.
Better; pain less; expectoration more in quantity, and viscid. V. S.
ad ℥xii; antimonials. 10th. Pain still felt on coughing; expectoration
reddish; difficulty of breathing greater. Pil. cal. et antim. c. opio;
V. S. ad ℥xvj. He gradually recovered (his mouth having become slightly
sore) from what was manifestly an attack of pneumonia. A gentleman, in
1835, fell from his shooting-pony on his powder-horn, which bruised his
right side from the seventh to the last rib, and, as he said, knocked
the breath out of his body, and hurt him so much as to render him
incapable of walking from one room to another from pain in the side,
back, and thigh. No bones were broken. The pain, on the second day,
was augmented on breathing and on attempting to cough. The third day
he was purged, and blooded to sixteen ounces, which gave some relief;
but as the symptoms increased on the fourth day, he was more carefully
examined. His right side could not bear pressure. The respiratory
murmur was distinct, but accompanied by a crepitating rhonchus under
the part injured. Cough troublesome; expectoration mucous, viscid,
and of a reddish tinge. Antim. p. tart. and sulphas magnesiæ, every
four hours. V. S. ad ℥xiv. On the fifth day, the symptoms being little
altered, he was cupped on the part affected to fourteen ounces. On
the sixth, the pain was only felt on coughing, or on drawing a very
full breath; expectoration redder and thicker; pulse quicker. The
rhonchus was quite as distinct. V. S. ad ℥xij, and the medicines to be
continued. After this he quickly recovered and the natural respiration
became distinct.
Lieutenant Cooke Tylden Patterson, of the Light Division, was struck
on the left breast by a musket-ball, on the morning of the 15th of
July, 1813, in front of the village of Vera, in the Pyrenees. He fell
on his back breathless, as if he were killed. While waiting the order
to advance, he had been reading Gil Blas in Spanish, and on receiving
it, had hastily put the book in the breast pocket of his coat. The
ball had struck this, but, unable to penetrate it, had fallen on the
ground at his feet, completely flattened on one side, and marked with
the impression of the braid of his coat. A piece of the cover of the
book, about the size of a half-crown, was driven in, and the leaves
throughout were indented by the ball. It was some days before the
effects of the blow entirely subsided.
A soldier of the 97th Regiment was struck at the unsuccessful assault
of Fort Christoval, opposite Badajos, by a musket-ball, which went
through his brass breast-plate and coat, drove his shirt through the
skin, and against the sternum, which it was not able to penetrate. He
fell, and was supposed to be killed, but he soon recovered and ran to
the rear. The ball was found flattened between his shirt and coat. The
part of the chest was very black next day, the spot struck by the ball
being much bruised. It was necessary to bleed him largely. When the
integuments are painful, although merely bruised, the diluted tincture
of arnica is a useful application, and Scheele’s hydrocyanic acid, six
drops to an ounce of water, is said to be efficacious.
Major Lightfoot was struck by a musket-ball on the left breast; it
went through his clothes, the integuments and the outer part of the
great pectoral muscle, and slanted inward for three inches toward
the sternum, to which distance its track could be followed. It was
evident that the ball had neither lodged nor penetrated, for no serious
symptoms ensued. In all probability it had been ejected the way it went
in by the elasticity of the cartilages of the ribs near the sternum.
297. In order to understand, or to become in any way acquainted with
the changes from the natural structure which are going on under
derangement in the chest, even from simple injuries, it is always
necessary to have recourse to auscultation, and sometimes, although
more rarely, to percussion, if the external parts are not too tender.
Under all circumstances both sides of the chest should be examined
by the stethoscope. As the ordinary breathing of an individual is
rarely sufficiently strong to enable the auscultator to hear it with
distinctness, the patient should be desired to inspire fully and
more quickly than usual, without much effort, and without noise from
the mouth or nose, or retaining his breath. The inspiration and the
expiration are both to be carefully observed.
When the ear is firmly and equably applied to the chest of a healthy
young person, a very distinct and long-continued sound is heard at
the moment of inspiration, and another at that of expiration. This
is called the _vesicular_ or _respiratory murmur_, and is dependent
on the air fully permeating and distending the air-vesicles of the
lungs. It has been poetically compared to the sound of a gentle gale
rustling in a thick summer foliage--to the whisper of a retiring wave
on a sandy beach in a calm day. It is soft, scarcely sonorous, equable,
and during inspiration continuous. In childhood it is louder than in
adult persons, arising probably from the greater activity of the lungs
in young than in elderly people. This is called, and especially when
perceptible in adults, _puerile respiration_, as opposed to their
ordinary, or what in old persons may be called _senile_. It is more
marked during inspiration.
When the stethoscope is applied in the situation of the great bronchial
passages, as over the first bone of the sternum, under the clavicle,
in the center of or between the shoulder-blades, a different sound
is usually but not always distinguishable, when the patient breathes
fully, arising from the passage of the air through these bronchial
tubes. It is compared to the noise made on blowing through a reed or
quill, and is called _bronchial or tubular respiration_. When heard
in other parts of the chest, it is a morbid sound. If the stethoscope
be applied over the trachea, the sound is louder, rougher, and more
intense, and is called _tracheal_ respiration. On listening over the
trachea during speaking, the voice sounds as if it were passing into
the ear, and the words are distinct--_tracheophony_. This, if heard in
any other part of the chest, is a sign of disease, for in the natural
state the voice is heard only to resound through the chest, but the
words are not heard if the other ear be stopped. When heard, the sound
has been called _pectoriloquy_, and is supposed to imply the existence
of a cavity at that part; but the word is unnecessary, or, if used, it
means that the cavern or hollow communicating directly with the trachea
gives forth a similar or nearly similar sound, a _natural_ sound in an
_unnatural_ position. The essential difference between _bronchophony_
and _tracheophony_ in the investigation of disease is, that in the
latter the voice apparently speaks through the stethoscope into the ear
of the auscultator, while in the former it is heard with scarcely less
distinctness, but at the distal end of the instrument. Over the larynx
it is louder, hoarser, and rougher.
The length of the sound in inspiration, as compared with that of
expiration, has been said to be as five to two. One is louder
and longer than the other, a difference requiring attention from
the circumstance that morbid sounds of great import are heard in
inspiration, which do not prevail during expiration. When any other
difference is perceptible between them, so that they more nearly
resemble each other in duration or in intensity, or when expiration is
prolonged, some structural alteration may be suspected in old persons,
some disease in young ones. When little or no respiratory murmur can
be heard after symptoms of inflammation have existed for some time,
the case is very serious, implying that effusion into the cavity, or
condensation of the lung, has taken place to a considerable extent.
298. The number of inspirations in a minute in the adult and elderly
persons varies from eighteen to twenty-two in a state of health: from
twenty-two to twenty-six in children. The stroke of the pulse is
generally as four to one. If the inspirations are eighteen, the pulse
will in general be seventy-two. Both may be slower, although they are
often quicker under disease. When the breathing is slower, it commonly
indicates some affection of the nervous system; when very rapid, some
important lesion within the chest.
The theory of percussion is founded upon three elementary sounds, which
are produced when a solid, a liquid, or a gaseous body is struck; all
others are varieties of these. The sensation of resistance which is
experienced at the same time bears an exact relation to the density of
these bodies--hence the resistance when a solid substance is struck is
greater than when a gaseous one is under percussion. The liver, the
thorax in a case of pleuritic effusion, and the distended stomach after
a long fast, afford good examples of these elementary sounds. To employ
percussion successfully, it is necessary that the strokes be uniform in
force and quickness, and that the finger or pleximeter be so applied to
the surface that no space exists between them, otherwise such a sound
will be elicited as may give rise to an incorrect diagnosis.
It having been stated that a sound lung never fills the bag of the
pleura, particularly toward the diaphragm, at least during ordinary
respiration, I requested Mr. Quekett, the Resident Conservator of the
College of Surgeons, to ascertain this by experiments on some sheep at
the moment of their being killed; and it appeared from them that the
base of the lung is always in contact with the surface of the diaphragm.
299. In ordinary expiration the chest diminishes in size. The ribs
which have been raised recede, by the elasticity of their cartilages,
and by the return of the ligaments, to their state of rest; the
elevated muscles become relaxed, while others belonging to the lower
part of the trunk and abdomen contract. The diaphragm is relaxed,
and pushed upward by the viscera of the abdomen, pressed upon by the
muscles of its wall, if it should not be drawn upward by the attraction
of the lung, which when distended endeavors by its elasticity to
return upon itself, and to occupy less space than the capacity of
the chest will afford. The lung, invested by an elastic, special,
and transparent membrane, and covered by the pleura pulmonalis, is
composed of an immense number of air vesicles, the largest being equal
in size to the fourth part of a millet-seed. These air vesicles,
crowded together, each communicating with a fine bronchial tubule, are
separated from each other into groups by a condensed cellular tissue,
thicker where it surrounds these lobules, which alternately form, when
aggregated together, a lobe, whence it is called interlobular tissue.
An artery and vein form a very minute net-work around each vesicle.
These vesicles may become filled with water; when dilated by air, they
constitute what is called emphysema of the lung. The lung in man is
constantly applied to the internal surface of the chest, the pleura or
serous membrane covering the lung being closely applied to the pleura
lining the wall, and one surface glides upon the other, moistened by
a secretion in just sufficient quantity to effect this object. If the
lower intercostal muscles of a young animal be removed to a sufficient
extent, the lung and the diaphragm may be seen applied to the inside
of the pleura lining the rib, and _ascending_ and _descending_ in
concert, the lungs moving vertically, not horizontally. The diaphragm
ascending, covered by its pleura, is in a similar manner applied to the
lower part of the wall of the chest, which had been filled by the lung
during inspiration. After death the lung remains closely applied to the
pleura, recedes on an opening being made into that membrane, and may
collapse, provided no adhesions exist to prevent it.
300. When inflammation of the pleura takes place, the gliding motion
is not effected silently, but with a peculiar noise, called by the
French _frottement_. When the lung is inflamed, the respiratory murmur
is changed in that part, or is overcome by a peculiar sound, which can
be distinctly investigated by the ear--_rhonchus crepitans_. Hence the
great value of auscultation.
In the following observations it is not intended to give a history of,
or even the whole of the symptoms and consequences of inflammation
of the pleura and the lungs; but only to draw attention to such of
the principal facts as it may be necessary to consider when these
inflammations and their consequences are caused by external injuries.
Acute idiopathic inflammation of the pleura usually commences by
rigors, preceded perhaps by some signs of general uneasiness, which
soon become those of great febrile excitement. Pain is early felt in
the side in the course of the sixth, seventh, and eighth ribs, or at
the point corresponding generally to the seat of the inflammation.
It is usually sharp and darting, is called a stitch, occupies rather
a small space, (the _point de côté_ of the French,) and is always
increased by drawing a full breath or by coughing. The breathing is
short, from the disinclination to fill the chest, by which the pain
would be increased; it is hurried, and sometimes takes place as if
by jerks, from the necessity for its repetition, in consequence of
the smallness of the quantity of air admitted at each attempt. When
the attack is very severe the patient tries to breathe with the
healthy side only, the lower ribs of the affected side being moved
but slightly, and with evident caution. If the inflammation have been
caused by extreme violence, pain will also be felt, particularly at the
part injured.
When inflammation has affected the pleura covering the diaphragm,
especially when caused by external violence, the pain will be felt
lower down, so as to lead to the suspicion that it is also abdominal.
When jaundice supervenes, it occurs from the extension of disease
through the substance of the diaphragm, as is occasionally seen in
wounds implicating the chest, the diaphragm, and the liver.
A cough is not a constant accompaniment of the first stage of disease;
when present, it is usually dry, slight, infrequent, and does not
attract attention, unless accompanied by a thin, frothy mucous
expectoration, indicating the presence of bronchitis; of pneumonia, if
reddish. The patient usually lies on his back while the pain is severe,
and has a great indisposition to turn fully on to the affected side.
At a later period, when effusion has taken place, the pain usually
subsides, and he turns on the side affected to relieve the difficulty
of breathing, caused by the pressure of the fluid on the sound lung
through the bulging of the mediastinum; but the manner of lying, or
_decubitus_, is of little importance, and should be subservient to the
feelings of the patient, who is sometimes comfortable only when raised
to nearly an erect position.
When the complaint is not subdued at an early period, an effusion of
serous fluid, more or less in quantity, takes place. The whole cavity
of the side affected has been known to be filled in from twenty-four
to forty-eight hours, giving rise to symptoms dependent on the degree
to which the effusion has taken place; _this_ is the evil which in
injuries penetrating the cavity of the chest is most to be feared. When
the external wound has been closed, or is so partially closed as not
to allow the escape of the effused fluid, it is commonly the immediate
cause of the death of the patient. Its secretion and early evacuation
are therefore the most important points to be attended to in wounds of
the chest.
The respiratory murmur becomes less distinct as soon as the pain
prevents the ordinary distention of the affected side of the chest,
and diminishes the quantity of air which usually penetrates the lung
in any given time. As soon as a thin layer of fluid commences to be
thrown out between the pleuræ, this murmur becomes fainter, and when
it is complete, it ceases. If the patient can bear percussion, the
side affected yields a dull, dead sound instead of the ordinary clear,
sonorous one of health. The position of the patient when erect, by
causing the fluid to descend, may allow of the respiratory murmur being
heard at the upper part of the chest; and it may be perceived in front,
but not behind, when he lies on his back, until the cavity is filled,
when the sound altogether ceases. At the spot in the back corresponding
to the root of the lung, or at any other point at which a previously
formed adhesion may retain the lung against the wall of the chest, some
respiratory murmur may yet be distinguished, until this part of the
lung shall also have yielded to the general compression, so as to be
temporarily impervious, or have become solidified under the continuance
and extension of disease. While this is taking place in the affected
side, the other lung is called upon to make up the work of aerification
of the blood; it labors harder, its functions become more energetic,
and that side of the chest is more distended; the respirations become
quicker, fuller, and louder, and the vesicular murmur is said to
resemble that of a child--in fact, to be _puerile_.
When the lung begins to be compressed by the circumambient fluid
and the respiratory murmur ceases, a peculiar modification of
the respiration through the large bronchial tubes may be heard,
constituting _bronchial_ respiration. It occurs in pneumonia, in
pulmonary apoplexy, and in tubercular disease when the lung is
solidified. When the voice is heard through the stethoscope in these
complaints, the peculiar sound emitted is called _bronchophony_.
In pleuritic effusion, the voice, when carefully examined, sometimes
obtains a character not previously noticed, but of comparatively little
importance, called _œgophony_, a sound which may be easily confounded
with bronchophony, of the latter of which it is a modification more
often alluded to than observed. Laennec says: “Simple œgophony consists
in a peculiar resonance of the voice, which accompanies or follows the
articulation of words. It appears to be sharper than natural, more
acute and somewhat silvery, vibrating, as it were, on the surface of
the lung more as an echo of the voice than as the voice itself. It
rarely enters the tube of the stethoscope, less frequently traverses
it completely. It has besides another peculiar character, which is
constant, and from which I have taken its name. It is a trembling,
bleating, or shaking sound, like that of a goat, the tone of which
animal it greatly resembles. When it occurs near a large bronchial
tube, as in the root of the lungs, a more or less marked bronchophony
is often superadded.” This sound may pervade the whole side; it is
usually, however, most distinct near the inferior angle of the scapula,
the patient being erect. It only exists where the effused fluid is
small in quantity, and is never a dangerous symptom; its return,
after it has been present and has disappeared, is a sign that a part
of the effused fluid has been removed. It is a sign principally of
value in distinguishing between pleuritis and pleuro-pneumonia and
pure pneumonia, in which latter disease it is not heard, as in that
complaint fluid is not thrown out into the cavity of the pleura.
301. In pneumonia or inflammation of the substance of the lung, as
distinct from any implication of the pleura, which, however, most
frequently obtains after blows on, and in cases of penetrating wounds
of, the chest, the symptoms differ. The ordinary febrile symptoms are
similar to those of pleurisy, only more intense; they usually precede
for a day or two the local symptoms of difficult respiration, pain,
and cough. The dyspnœa varies in different people. In some it is only
a slight embarrassment of breathing, admitting of partial removal
by accelerating the number of the respirations, which are augmented
from twenty to thirty, forty, and upwards, and in children to sixty
and seventy, marking a great degree of distress and of extent of
inflammation, from which, when they are so frequent, persons rarely
recover. The patient can scarcely speak or lie down, and is obliged to
be supported in that which he finds to be the least uneasy position.
Pain is not always present; it is even said to be more frequently
absent when the substance of the lung is affected, and not the pleura.
That pain is not a necessary concomitant of pneumonia, is admitted, but
that it is usually present, and with great intensity in many cases,
cannot be doubted. When present, it is usually an early symptom, deep
seated below the sternum, under the breast, extending to the scapula.
When in the sides it is more acute and fixed, and is probably conjoined
with the pain of pleurisy.
The pulse is quick and sharp, occasionally full and hard, at the
commencement of this complaint in young and healthy persons, although
it is sometimes small and weak from the beginning, where there is
little general power; but this rarely occurs in cases of injury, and is
not to be relied upon in opposition to other symptoms.
The _cough_ is usually dry in the commencement of idiopathic pneumonia,
rarely recurring by paroxysms, and is without any particular
indication; it is soon, however, accompanied with a slight mucous
expectoration, which, after some twenty-four or forty-eight hours,
begins to assume certain and peculiar characters of the utmost
importance as indicating the existence and the different stages of the
disease. On the second or third day the expectoration becomes bloody.
Each sputum, spit, or _crachat_ of the French is composed of mucus
intimately combined with blood--that is, not simple streaks or striæ
of blood, as in catarrh; nor is it pure blood, as in hemoptysis. Each
sputum is either of a yellow, or rusty, or even red color, according to
the quantity of blood intimately mixed with the mucus. These sputa are
at the same time tenacious and viscous, adhering so intimately together
as to form a homogeneous transparent whole, readily gliding, however,
from the basin in which they are held on sufficient inclination being
given to it. At this period or stage of the disease, the sputa adhere
strongly to each other, but the mass is not sufficiently viscid to
stick to the sides of the vessel. When no further change takes place
in the sputa the inflammation rarely passes beyond the first stage of
obstruction or engorgement, or swelling. When they attain to a more
viscous state, and adhere to the inside of the vessel in which they
have been received, the progress of the inflammation to the second
stage, or that of hepatization, may be feared. In almost every case
where the viscidity of the expectorated matter increases, respiration
becomes dull or bronchial, percussion of the chest yields a duller
sound than before, and the inflammation has attained its highest
degree. The expectoration, after being some time stationary, changes
its character. If the complaint is to terminate by resolution, or by
death, or to pass into a chronic state, the redness and viscidity
gradually diminish, and at last disappear. If the rust color and
the viscidity should return, there has been a relapse, which the
reappearance of the other symptoms will show. When the inflammation
is of the most serious nature, and about to terminate fatally, the
expectoration diminishes, and at last ceases. In some cases it only
diminishes because it cannot be discharged; it accumulates in the
trachea, in the larynx, and in the bronchi, until the patient is
destroyed. In some rare cases the matter secreted is spit up nearly to
the last, and in others, still more rare, the approach of death in the
last stage is characterized by a brown expectoration which cannot be
mistaken for either of the others which preceded it. If the pneumonia
pass into the chronic state, the expectoration becomes yellowish, or
somewhat greenish, and at last is purely catarrhal.
Delirium is not an uncommon symptom when the inflammation of the lung
is intense in persons of powerful constitutions, particularly during
the exacerbation of fever in the night. It yields with the other
symptoms when relief is obtained. When, however, it comes on at a later
period of the complaint, or when the accompanying fever is not purely
inflammatory, or in persons weakened by exhaustion and privation, it is
usually a fatal symptom if continued. When mild, it often occurs after
repeated and efficient bleedings, which have subdued, but not entirely
removed the disease; and yields to opiates and gentle stimulants, by
which the pain is removed, although it sometimes remains in a milder
degree than before.
The ear discovers, soon after the commencement of the disease, that
the natural murmur cannot be distinctly heard, it having been at first
partly obscured, and after a time entirely superseded by a peculiar
noise, called a crepitating or crepitous rattle or rhonchus. In its
purest state it has been likened to the sound of a lock of hair
rubbed close to the ear, or to that made by rumpling a fine piece of
parchment; or again, to that which is produced by what under ordinary
circumstances is called the crepitation of salt, when scattered in
small quantities on red-hot coals. This crepitating rhonchus is heard
at first in a small part of the lung, generally at the lower rather
than at the upper part; it marks the first stage of the disease. It
is not of long continuance; the vesicular murmur is either restored,
or the crepitating rhonchus ceases to be heard, in consequence of the
second stage to this, or that of hepatization, having commenced; the
small air-vesicles are no longer pervious; the sound of the breathing,
which is now heard, is that of the air more forcibly driven into the
larger bronchial tubes causing _bronchial respiration_, which is no
longer a vesicular or crepitating, but a whiffing sound, like that
caused by blowing forcibly through a quill, or as if little gusts of
air were blown in or blown out. The voice betrays to the ear of the
auscultator another sign; it descends into the pervious bronchi, and
being conveyed to the ear through the solid lung, gives rise to that
peculiarity of voice called _bronchophony_, a correct knowledge of
which can only be acquired by repeated observation.
When the inflammation of the lung is confined to a small and
deeply-seated spot, auscultation may not at first reveal the evil;
or it may possibly be overlooked, through the sound part of the lung
becoming more active, and giving forth in consequence a stronger and
more puerile breathing, which may mislead the listener.
When the vesicular murmur cannot be heard, when the _rhonchus_ or
_crepitating râle_ or sound is not present, and bronchial respiration
and bronchophony only can be distinguished, the case is one of great
anxiety and danger. The second stage of hepatization is passing into
the third, or purulent infiltration, of which auscultation shows no
further signs, although the matter secreted may be expectorated, in
proof of what has taken place. Pus is thus formed, which it is steadily
maintained by some pathologists is not deposited in the form of
abscess, but is infiltrated throughout the parenchymatous substance of
the lung, finding its way into larger bronchial tubes, or being poured
out from some parts of their secreting surface; the accuracy of this
statement, however, as a rule, may be doubted, from some dissections
having proved the reverse.
302. The effects of inflammation of the pleura are well marked; the
first is to diminish, if not to annul, the secretion of the exhalation,
or halitus, by which it is lubricated; so that its surfaces can no
longer glide without noise upon each other. The patient is often
made aware of the difference by some uneasy internal sensation; the
auscultator, by a rubbing or creaking sound emitted as the inflamed
pleuræ, no longer smooth and polished, rub against each other, and
become covered by a thick, effused matter, although not actually
separated by a liquid. It is a sound which cannot exist after
separation has taken place by the intervention of a fluid, or after
adhesions have formed; it is, therefore, an early and transitory sign,
is frequently interrupted, and returns, as if by jerks, three or four
times repeated in succession. The pleura when inspected, after being
attacked by inflammation, shows at first but little sign of derangement
on its serous surface. It quickly, however, exhibits numberless small
vessels, carrying red blood, which are principally seated in the
sub-serous cellular tissue, reddening the membrane more deeply in one
part than another. These soon begin to take on a new action, leading
to the deposition of coagulable lymph or fibrin, which adheres to the
inflamed surfaces. These deposits soon assume the determinate form
of very thin layers, constituting what are called false membranes;
while a serous or sero-purulent effusion takes place, even to filling
the cavity of the chest, and which may or may not be ultimately
absorbed. When coagulable lymph is first deposited, and about to form
a false membrane, it is soft, of a grayish-white color, and does not
possess any appearances of organization. Red points are, after a
time, perceived in it, which soon become red lines or streaks, on the
surface. This organization of the lymph does not depend on the period
which has elapsed from the commencement of the complaint. It is seen
in the first day of the disease in some cases; it is altogether absent
in others, and depends much on the state and habit of the patient.
The lymph is sometimes deposited in small drops or spots; in others,
in patches of a greater or less size, varying according to the extent
of the inflammation which has produced them. When a false membrane is
once fully formed, it becomes itself a secreting surface, and may go on
augmenting its thickness to so great a degree as materially to diminish
the cavity of the chest. I have seen the pleura with a solid deposit
of this kind much more than an inch in thickness. In general, it is
found in distinct layers, superimposed one upon the other. Whatever may
be their thickness, they commonly admit of being separated from each
other. The false membranes thus formed, resembling areolar tissue in
their properties, may ultimately become cartilaginous, and even bony.
When simple adhesions form between the pleuræ, they become lengthened
with time; and, although they impede the motion of the lung at first,
and may give rise to some uneasy sensations, they gradually become
elongated, and give no further inconvenience. The fluid thrown out
is serous; is often mingled with flocculi or lymph, which are seen
floating in it; it is therefore more or less turbid, resembling whey.
It is often nearly colorless and transparent; when the consequence of
injury, it is often tinged with blood, forced out from the capillary
vessels of the pleura, or of the false membrane, if not caused by the
deposition of the fluid coagulated in the first instance after the
receipt of the injury.
The quantity of fluid thus thrown out varies from an ounce to several
pints; it gravitates according to the position of the patient,
unless, when from old adhesions between the pleuræ, it is confined
to particular parts. When the cavity of the pleuræ is free, and the
fluid is in quantity, it compresses the lung, and diminishes its size
by pressing or squeezing the air out of it; it is thus pressed toward
the vertebral column, and so greatly diminished in size and augmented
in density as to be useless for the purposes of respiration. While the
lung is undergoing this compression to its utmost, the mediastinum also
yields, and bulges into the opposite side of the chest, carrying the
heart more or less with it; so that when the left side of the thorax is
thus affected, the heart is seen and heard to beat on the right. The
diaphragm now yields in turn, more on the left than on the right side,
from the obstacle to its descent afforded by the liver. The intercostal
muscles and ribs resist the internal pressure for a considerable length
of time, even for weeks; they at last, however, yield; the ribs may
even turn a little outward, while the interspaces in thin persons are
said to fill out, so as to render that side of the chest nearly smooth,
the size of that side, when measured, being larger than the other, in
some instances even by two inches, but this rarely occurs unless the
fluid within is purulent, and the disease of long standing.
303. After a time, and particularly in wounds of the chest, the
effused fluid becomes purulent, the lung, compressed to a small,
flattened surface, adheres to the spine by what was its root, if no
adventitious attachments have retained it in a different position; and
the pleura has become a thick, yellowish-white, irregular, honey-combed
sort of covering for it, as well as completely lining the chest.
The serous as well as the purulent effusion are both free from any
unpleasant odor; unless a kind of gangrene has taken place, when the
latter becomes very offensive, and of a greenish-black color, as well
as the substance of the false membranes extending to and sometimes
beneath the pleura covering the condensed lung, into which openings
have even thus been made.
In some cases the surface of the pleura is covered with small
tubercles, some as large as a filbert; in others it appears to have
a reticular or honey-combed appearance; and in particular cases,
large irregularities or excavations may be observed in it when much
thickened, being evidently spots of ulceration, which, if they had
proceeded, would have ended by allowing passage to the matter outward,
until it formed an external abscess, implicating in all probability one
or more of the ribs; thus giving rise to an exfoliation which, by being
separated internally, might in time be the cause of further mischief,
if not previously covered by a thin layer of false membrane. When
chronic pleurisy succeeds to a more acute attack, or they alternate
with each other, particularly after penetrating wounds of the chest,
several layers seem to be laid down one upon the other. This deposit
is never so thick upon the pleura pulmonalis; nevertheless it is thick
enough in most instances to prevent the lung from again dilating,
the substance of it being generally quite permeable to, although so
compressed as to be deprived of, air. It is then flattened, drawn
upward toward its root against the mediastinum and spinal column,
unless by some previous adhesion such a course has been prevented, and
it adheres, as it has been often known to do, to the side of the chest.
As that adhesion may occur in more than one spot, so may the effusions
or deposits take place between them, constituting circumscribed sacs,
and rendering the case more complicated.
304. The changes which take place in the structure of the lung in
pneumonia are three in number: 1. Engorgement. 2. Hepatization. 3.
Purulent infiltration. The formation of an abscess or vomica, and
the occurrence of gangrene, may be omitted, as well as of chronic
disorders, in the views about to be taken of the disease from injury.
In the first stage of inflammatory obstruction, or that of engorgement,
the lung has assumed externally a livid-red or violet color. It is
heavier and firmer than in its healthy state, and the natural feeling
of crepitation, although greatly diminished, is not extinct. The lung
retains the impression of the finger, and pits on pressure as if it
contained a liquid, although air-bubbles can yet be distinguished
in it, and its cellular or spongy texture is still to be observed.
On cutting into it, a quantity of sanguineous or turbid fluid flows
from it, mingled with numerous minute air-bubbles. In some places
the color of the incised surface is darker and more compact, showing
that some progress has been made toward the stage of hepatization. It
nevertheless tears with greater facility than in a healthy state.
In the second stage, or that of the red softening of Andral, the
hepatization of Laennec--the latter term being in most common use,
from the lung assuming somewhat the appearance of liver in solidity
and weight--the lung does not crepitate, no air-bubbles pass out of
it, but a thick, bloody fluid exudes on pressure, and it sinks for the
most part in water. The color is somewhat less red or violet than in
the first stage, and lighter and more varied in color when cut into.
The openings of the larger vessels and of the bronchi, when cut across,
are observed as white specs; the interlobular tissue is thicker and
more marked in lines running in different directions; while many little
granular points can be discovered, especially with a glass, apparently
of a more solid material than the surrounding parts.
The word solidity, or solidification, is sufficiently explanatory in
contradistinction to the naturally pervious and crepitating state of
the lung. Andral believed that hepatization arises from an excessive
congestion of blood, and not from any deposition of lymph. It is not
easy, however, to understand, in the present state of our knowledge,
how acute inflammation can go on for three or more days without
secretion and deposition being added to congestion. That hepatization,
or impermeability to air, may take place in the typhoid pneumonia in
twenty-four hours, and that it as suddenly seems to be removed, is
hardly conclusive, as it shows merely that a thoroughly well-loaded
lung ceases to be permeable to air until a part of the load shall have
been displaced.
When the lung, inflamed to the second stage, or that of hepatization,
is about to be restored to a state of health, a slight crepitation or
crackling begins again to be heard at the end of each inspiration;
and as this increases, (the rhonchus crepitans redux of Laennec,) the
bronchial respiration and voice gradually, or after a time, diminish,
until they entirely disappear; while a mucous râle or rattle commences,
the index of that free expectoration by which pneumonia usually
terminates.
In the third stage of morbid change, or that of purulent infiltration,
the lung is of a lighter color, from the intermixture of a new matter
in its substance, although in the first degree it preserves its
firmness and granular structure. The new secretion is of an opaque,
straw or yellow color, and puriform in its nature. This is discoverable
more particularly in spots; but as the disease proceeds, it pervades
the whole substance of the lung, which becomes softer and more moist,
and is easily broken down by the fingers, the granular structure having
disappeared. It is more or less a purulent sort of sponge, in which all
of the lung that can be perceived under a strong light may be resolved
into small blood-vessels, bronchial tubes, and interlobular septa.
These three degrees or stages of inflammation may be met with in the
same lung, for the most part gradually intermingling one with the
other. The lower part of the lung being ordinarily first affected,
is usually the seat of the purulent infiltration of the third stage;
while in the tubercular affection, which ends in phthisis, the disease
commonly begins in the upper part.
Resolution or recovery from even this, the last of the morbid changes
which have been observed, may take place, although it is less likely to
do so after idiopathic than traumatic inflammation, in which the lung
was previously healthy, and the constitution unimpaired.