305. The first and most essential remedy in the treatment of pleuritis
and pneumonia from injury is bleeding, which should be resorted to in
every case, whenever the febrile excitement is really inflammatory.
All old people, under such circumstances, unless in a cachectic state,
bear at least one bleeding well; they often bear more; and no fact is
more important, in opposition to the opinions commonly entertained on
this subject. In young people, who have not been reduced in health
and strength by privations and hard service, the bleeding should be
repeated until the desired object has been effected; the quantity
required to be drawn in inflammation, particularly after _injuries_,
is often very great. It may almost become a question, in some cases,
whether a patient shall be allowed to die of the disease, or from loss
of blood; for convalescence is rapid in proportion as the inflammation
is of small extent, and has been early subdued. As the first stage
of pneumonia only lasts from twelve hours to three days before it
passes into the second, and the second from one day to three before
matter begins to be deposited, no time should be lost to prevent these
evils taking place, if the patient is to be saved, without incurring
a risk, from which few escape with health, even if life be ultimately
preserved. Bleeding in inflammation of the pleura, in _young_ and
_healthy_ persons, should therefore be effected with an unsparing
hand, until an impression has been made on the system--until the
pain and the difficulty of breathing have been removed--until the
patient can draw a full breath, or faints; and the operation should be
repeated, from time to time, every three or four hours, according to
the intensity of the recurrence, or the persistence of the essential
symptoms. The pulse does not often indicate the extent or severity
of the inflammation, although it often expresses the amount of the
constitutional irritability of the person. It is sometimes exceedingly
illusory as a guide, and is never to be depended upon in the earlier
stages of disease, when accompanied by pain and great oppression of
breathing. Whenever the pulsations of the heart are proportionally
much stronger than those of the arteries, we may bleed without fear,
and with the certainty of finding the pulse rise; but if the heart
and pulse are both weak, the abstraction of blood will almost always
occasion complete prostration of strength, and may be fatal.
306. When many years ago in charge of a regiment of infantry, on the
top of the Berry Head, the outermost point of Torbay, the men thus
greatly exposed were attacked by pneumonia. According to the practice
taught in London, I bled my patients three and four times in the first
forty-eight hours. I first drew sixteen ounces, then fourteen, then
twelve, then abstracted, as the complaint continued, eight ounces; gave
tartar emetic, so as to keep up nausea; then calomel, antimony, and
opium, and lost my patients. I examined the bodies of all, and found
that they had lived to what is now called the third stage of pneumonia,
combined in almost all with pleuritis, with effusion, and the formation
of false membranes. The disease was essentially a pleuro-pneumonia,
varying in different degrees, as the pleura or the lungs were
principally affected; and I saw with regret that the disease had not in
any way been arrested; that the means employed had been insufficient.
What was to be done? My sixteen ounces of blood were increased to
thirty, but it would not do. It was evident that, to succeed, no limit
should be placed to the abstraction of blood in the first instance, but
the decided incapability of bearing its further loss. Every man was
therefore bled, when he came into the hospital, until he fainted, and
the bleeding was repeated every four hours, or even oftener, as long as
pain or difficulty of breathing remained; under this improved practice
all recovered.
The lesson learned at Berry Head was not forgotten during the five
subsequent years passed in British North America. The men were as
healthy, the winds were sharper and colder, the vicissitudes of all
kinds greater. Rum was cheaper, newer, and stronger than the gin of
Torbay. The local inflammations were often as severe, whether of the
pleura or of the lungs, and by no means less so of the bowels. A
grenadier, some six feet three inches high, broad, and well framed
in proportion, had drank a gallon of rum during the afternoon, and
very narrowly escaped, even with the loss of nearly as much of his
blood, abstracted in a few hours. His first bleeding was into the
washhand-basin, until he fainted, lying on his back, and the bleedings
were repeated as soon as he began to feel pain, and whenever he felt
a return of the pain he used to put his arm out of bed to have the
vein reopened, for Jack Martin was a very gallant fellow. This is
given as an extreme case, to be borne in mind under circumstances
somewhat similar, particularly after injuries. In common cases of
well-marked pleuritis from injury in strong and _healthy_ persons,
it is now not unusual to abstract blood by those who rely on its
efficiency, until the pain and difficulty of breathing are relieved,
or fainting is about to take place. The patient should be raised in
bed, the opening in the vein should be large, the flow of blood free.
The quantity will vary from sixteen ounces to three times that amount
in different people; but the important point is to repeat it as soon
as the pain or difficulty in breathing returns. It rarely happens that
one bleeding, to whatever extent it may be carried, will suffice to
remove the symptoms; and recurrence should be had to this remedy as
often as the pain and oppression require, and THE FORCE OF THE HEART
will bear it, especially during the first two or three days. It will
often be necessary to have recourse to it in smaller quantities for
the next four or six days, and again in less quantity on any return of
the inflammatory symptoms. Where the patient is likely to faint, he
should be bled in the recumbent position; and as it is advisable to
take away a sufficient quantity of blood, great care should be taken,
by arresting its flow for a time, by giving stimulants, by admitting
fresh air, and by sprinkling with cold water, to prevent syncope,
which is sometimes dangerous in elderly persons, who may be subject to
and who are not readily recovered from it. In the second stage of the
complaint, profuse and repeated bleedings do not answer as well; they
do not remove the evil which has occurred, although they may prevent
its increase. Blood should then be drawn in such quantity only as will
relieve the action of the heart, restless under its efforts to propel
the blood through a hepatized lung. The quickness of pulse, the cough,
the difficulty of breathing, must now be aided and relieved by other
means; for although the pulse is not a certain indication, on which
dependence can be placed in the early stage of this complaint, the
breathing generally is; and as long as the respiration is oppressed,
blood should be carefully abstracted, until it becomes manifest
that the effect has been to quicken the pulse, while it materially
diminishes its power, when it is forbidden.
307. A cupped and buffy state of the blood, together with a firm
coagulum, is a satisfactory proof of the propriety of bleeding in
the first stage of the disease; but after the effect of mercury on
the system has been produced, it cannot be depended upon with the
same degree of certainty. When the propriety of further venesection
is doubtful, the greatest advantage may be obtained from the use of
leeches and from cupping, particularly in cases of injury to the
chest. Leeches may be applied by tens and twenties at a time; and when
they have ceased to bleed into a warm bread and water or evaporating
poultice, they may be replaced by as many more, until the pain and the
oppression are removed. Cupping is always to be had recourse to when
leeches cannot be obtained, and, when well done, it is frequently to be
preferred; cupping to sixteen ounces will usually be found equivalent
to forty or more leeches. Both these means often relieve to a greater
extent, with less general depression, than a smaller quantity of blood
taken from the arm, and are, therefore, at such times more advisable.
When blood cannot be obtained from the veins, the arteries must furnish
it; and both temporal arteries have been opened with the best effect in
injuries of the chest, when blood could not be obtained from the arm,
or from the external jugular vein.
308. The effects of bleeding were of old found to be different under
different circumstances and in different climates. Asclepiades
remarks that while phlebotomy was fatal at Rome and at Athens, it was
beneficial in the Hellespont. Nevertheless, at a much later period,
Baglivi says: “In Romano, phlebotomia est princeps remedium in
plenritide.”
In the Crimea blood-letting has not been so favorably viewed, nor found
so serviceable nor so necessary; although the abstraction of smaller
quantities than those indicated above, and less frequently repeated,
has been found eminently beneficial, the difference being dependent on
climate and the impaired vigor of the sufferers.
The remedy first to be administered, and most to be depended upon
in the first stage, is tartar emetic, which usually gives rise to
vomiting, purging, and possibly to sweating; it should not be omitted
because such effects are produced in the first instance. After a few,
perhaps three or four doses, the vomiting usually ceases, the stomach
tolerates its introduction, and its gradual increase from six to nine,
twelve, twenty, or more grains in the twenty-four hours, is often borne
not only with impunity, but with great advantage. Vomiting and purging
are not desirable, as the effects of tartar emetic are more rapid and
beneficial when they give rise to no particular evacuation beyond that
of general perspiration. The most valuable remark of Laennec on its
use is, “that by bleeding we almost always obtain a diminution of the
fever, of the oppression, and of the bloody expectoration, so as to
lead the patients and the attendants to believe that recovery is about
to take place; after a few hours, however, the unfavorable symptoms
return with fresh vigor; and the same scene is renewed often five or
six times after as many venesections. On the other hand, I can state
that I have never witnessed these renewed attacks under the use of
tartar emetic.” He further says that the same favorable results do not
occur from its use in pleurisy or in inflammation of serous membranes,
as in pneumonia.
309. Mercury is a remedy of the greatest importance in serous
inflammations, such as pleuritis, although of less value than tartar
emetic in the first stage of pneumonia, than which it would appear to
be more efficient in the later period of the stages of hepatization
and infiltration, though some physicians place entire confidence on
its efficacy in all. It is of most value when combined with opium.
Some suppose that the opium merely prevents the irregular action of
the mercury; others, in some papers printed in the journals for 1801,
state that opium has a distinct curative effect, being capable, when
given in large doses, of subduing inflammation, and more particularly
of allaying pain, relieving the cough and irritation, and of procuring
sleep; in which opinion I fully concur. Opium is highly advantageous in
irritable and nervous persons, and will frequently relieve the nervous
pain, the pleurodynia which remains after pleuritis, when nothing else
succeeds. Calomel in large doses is usually preferred to all other
forms, but a difference of opinion has occurred as to what is a large
dose; whether two, three, four, six, ten, or twelve grains are large
doses, and whether they shall be given every one, two, three, four, or
six hours. It has been attempted to solve this question by supposing
that in highly inflammatory cases in healthy persons, from three to
six, and even to twelve grains, may be given twice or three times a
day, with better effect than smaller ones more frequently repeated; but
this has not been made manifest.
In cases less inflammatory or complicated with gastric derangement,
the disease assuming more of a general than of a local character,
the excretions being vitiated, the skin dry and hot, and the tongue
loaded, from gr. iss to gr. iij of calomel, combined with three
grains of Dover’s powder, may be advantageously given every second or
third hour, the great object being to affect the gums as quickly as
possible. This is not effected in some cases by any of the quantities
given until after a considerable lapse of time, while in others it is
accomplished by less than half a dozen grains of the remedy. It has
not been ascertained that twenty-four or forty grains given in two or
four doses in twenty-four hours will affect the mouth more rapidly
than three grains every two hours for the same time, neither is it
less liable to cause irritation; while the third or half a grain of
opium given every two hours seems to keep up the effect of that remedy
with great advantage. It does not materially signify which method is
adopted in strong and healthy persons, although the smaller doses
are most satisfactory to all parties when the patient is weak and
irritable, while the large and less frequent doses often excite great
apprehension. It is argued that calomel in large doses never causes the
dysentery nor the severe ptyalism produced by smaller doses; that it
acts more quickly, and that after giving twenty grains, and repeating
it in six hours, any other medicines may be given without interfering
with it, although the strictest attention must be paid to diet,
generally confining it to very small sups of warm whey. Very serious
derangements do, however, follow the exhibition of the large as well
as of the small doses, inasmuch as it is impossible to know beforehand
what quantity will cause a severe salivation or diarrhœa, which it may
be difficult to arrest.
310. It may be concluded that, of the two heroic internal remedies,
tartar emetic and calomel, recommended for the cure of inflammation of
the chest, tartar emetic is the more appropriate for inflammation of
the lungs or pneumonia, provided it be not accompanied by symptoms of
gastric inflammation; in which case its use should be superseded by
leeches to the epigastrium, and saline aperients, lest the irritation,
vomiting, and purging should increase the evil. But care must be taken
that one inflammation shall not be allowed to increase, while attention
is principally paid to the other, and symptoms of irritation, the
_gastro-enterite_ of the French physicians, are not to be mistaken for
gastritis. Mercury, in the form of calomel, is more to be depended upon
in inflammation of the pleura, over which, as well as over inflammation
of serous membranes in other parts of the body, it exercises a
remarkable influence.
311. Blisters are never useful during the continuance of acute
inflammation of the chest, although their use is indicated when the
patient is much exhausted, the pulse weak, and the breathing continues
difficult; or in cases in which the disease proceeds slowly, or is
becoming chronic, when they often do much good. The same may be said
of dry cupping, mustard poultices, and other cutaneous rubefacients,
such as the ol. terebinth. used hot, which often do much good in
the commencement and termination of slight attacks, or of their
supervention on chronic disease, or after injuries.
In the acute stages simple drinks only should be allowed. As soon
as the inflammatory action has subsided, the lightest farinaceous
nourishment, gradually augmented by the addition of broths, jellies,
eggs, fish, and lastly of animal food, should be substituted. The
temperature of the room ought to be moderate and equal.
Inflammation of the lungs frequently terminates by the deposition of
a white or lateritious sediment in the urine, which is considered a
critical evacuation, not however to be relied upon, unless accompanied
by a remission of the important symptoms. A moderate diarrhœa and a
profuse perspiration are also signs of a favorable crisis.
312. Inflammation of the chest has been hitherto considered as
accompanied by inflammatory fever as an essential character, but
this is by no means always the case. In large cities, and among
troops after hard service, in which they have been subjected to much
privation, and in certain epidemics, the accompanying fever often
partakes of a low or typhoid character, and becomes infinitely more
dangerous. This modification of disease I have known from my earliest
years, in different climates, in all of which it proved most fatal.
It is a disease formed of a local inflammation accompanied by general
symptoms of a low asthenic type of fever, combined with those of marked
derangement of the stomach, intestines, or liver, as shown by a dry
black, or red black, or brown tongue, offensive breath, diarrhœa,
vomiting of a dark-colored or greenish fluid, watery or sanious
expectoration, great thirst, headache, a feeble and quick pulse, low
delirium, and great prostration of strength. It was marked, on the
banks of the Guadiana, by the discharge of lumbrici by the mouth and
by the anus. This disease has always appeared to arise from peculiar
circumstances, and to disappear when they ceased to exist; such as
great privations and exposure to cold and fatigue, the use of ardent
spirits without sufficient food, bad air, or other depressing causes.
It is sometimes epidemic. The fever is typhoid, the local inflammation
latent, and the symptoms of it masked. It may be complicated with
inflammation of the stomach and intestines; it may occur in cases of
erysipelas, or after wounds or injuries attended with large secretions
of purulent matter, or with other complaints. While the symptoms of low
fever are general and well marked, those of the latent affection of the
lung are not so prominent or even observable. The patient complains
but little, and sometimes not at all, of his chest, until attention is
drawn to it by a slight cough, and difficulty of respiration, attended
by a character of countenance which usually indicates embarrassment
in the functions of the lung. It may be brought on by a common
non-penetrating injury of the chest.
In typhoid pneumonia, general bleeding, if admissible, is to be had
recourse to with extreme caution, even in young and robust persons.
Local depletion is oftentimes useful, and perhaps ought to be alone
relied upon. The great dependence is on calomel and opium, and after
such local depletion as may be thought advisable, counter-irritation
by blistering, and the administration of stimulants, such as camphor,
ammonia, and wine, in small and repeated quantities. Mild aperients
only should be employed, and anodyne injections are frequently useful.
While auscultation has thrown a clear and steady light on the nature
of the mischief which is going on, it has added little or nothing
dissimilar to the practice pursued some forty years ago. The nature of
the hepatization or solidification which takes place in the lung in
typhoid pneumonia has given rise to some difference of opinion among
morbid anatomists, who incline to believe, from the rapidity with
which it takes place, and with which it is sometimes removed, that it
depends more on passive congestion, and on a typhoid alteration of the
state of the blood, than on an altered action in the vessels of the
part. This opinion does not seem to be fully supported by dissection,
unless it be generally admitted that gray hepatization, and the third
stage of disease of the lungs in pneumonia, mean simple congestion.
When the patient survives the imminence of danger in which he is placed
by the attack of the disease, and the expectoration becomes copious,
with great emaciation, quick pulse, and hectic fever, a slight infusion
of senega or of cinchona with ammonia, with a mild and well-regulated
diet, and change of air and climate, answer best in aiding recovery.
A typhoid pleuritis is presumed to exist, as a distinct disease from
typhoid pneumonia, although the analogy between them is admitted to be
close; like it the disease is latent and more frequently pointed out
by the sinking of the powers of life than by any new suffering. The
signs of effusion may be discovered on auscultation, and the treatment
is essentially similar; blistering and counter-irritants being perhaps
more useful, if time be granted for their application.
313. Empyema, _from_ εν, _in_, _and_ πυον, _pus_,--a name given to
all collections of fluids in, and to the operation for evacuating
them from, the cavity of the chest. Empyema is not a special disease,
but the result of another; commonly of acute or chronic pleurisy, or
of injuries of the chest, which give rise to inflammation, ending
in suppuration. When it occurs from the effusion of a serous fluid,
constituting a local dropsy, it is usually the result of disease of
the heart, or of the great vessels, and is accompanied or preceded by
symptoms indicating the existence of those complaints, in which case
it is not likely to be benefited by any operation. The disease is then
denominated hydrothorax. The serous fluid is generally transparent,
although more or less tinged with blood, when thrown out in persons who
die within a few days after receiving a wound of the chest. It may, and
does occasionally, contain in these cases a large quantity of blood;
but an early effusion of blood is not uncommon in very acute cases
of pleuritis. It is usually more or less turbid when the result of
ordinary inflammation, although the presence of albuminous or purulent
matter is not constant. Whether colorless, transparent, turbid, or
purulent, it remains free from fetor, unless gangrene has occurred
internally, or some communication with the atmosphere has taken place
by an external opening.
While the fluid remains transparent, the appearance of the pleura is
little changed, but when it has become turbid in any great degree, or
flocculent, or purulent, the pleura has lost its natural appearance.
In its simplest character, when the fluid is puriform, particularly
if the inflammation have not been very active, it is covered with a
layer of whitish inorganic sediment, which can be scraped off by the
scalpel. This is sometimes quite red, as if loaded with blood which had
been deposited upon it. Whenever pleuritic symptoms continue beyond the
ordinary period of about three weeks, or, after a temporary abatement,
are followed by those of effusion, which are not in turn removed, the
occurrence of empyema may be suspected.
Empyema may form from a pulmonic abscess bursting, or a gangrenous
spot being detached and falling into the cavity of the pleura. An
abscess in the liver or other parts may also communicate with the
pleura, and abscesses formed from injury or otherwise in the wall of
the chest may also give rise to it. It is usually, however, caused by
acute inflammation, by penetrating injuries, or by the introduction
of foreign substances. It should, however, be borne in mind that when
it occurs from wounds, the external opening must have healed, or the
complaint would be simply a wound in the chest, with a discharge from
the cavity of the side affected. A true surgical case of empyema,
following an injury of the chest, in which the wound has healed, is not
to be ascertained but by the same means as in a case arising entirely
from internal causes, unless the protrusion of the cicatrix should
indicate the presence of matter behind it.
314. The symptoms by which the termination of inflammation in effusion
may be known: are dyspnœa, or difficulty of breathing, which is greater
when the effusion has taken place rapidly, less when it has been
gradual; subsidence of pain; inability to lie on the unaffected or
sound side, which subsides, or is entirely removed, after the operation
has been performed and the fluid evacuated, although it should be
replaced by air in consequence of the lung being unable to resume its
natural position. When the effused fluid has filled one side of the
chest, that side is evidently enlarged, and this can be distinctly
seen when the dilatation does not exceed half an inch, measuring by
a tape from the spinous process of a vertebra behind to the center
of the sternum. The ribs are nearly, if not quite, immovable, and
partially raised, offering a strong contrast to the active motion of
the ribs on the other side. The intercostal spaces in these persons
may be more or less filled up, rendering the whole surface smooth and
soft. In some very severe cases the external parts become edematous,
so that the ribs cannot be felt, and this sign, although not always
present, is certainly pathognomonic when it takes place at a late
period of the disease. When the effusion is into the left side of the
chest, the heart is frequently pushed over with the mediastinum to
the right side, and its pulsation can be seen and felt to the right
side of the sternum; or it may descend with the diaphragm into the
epigastrium--changes which are not so extensive or remarkable when the
effusion is into the right side, as the liver materially impedes the
descent of the diaphragm, and the heart is already in the left side,
in which it is sometimes raised rather than depressed. It is said
that if the hand be placed over the affected side, while the patient
speaks with a tolerably loud voice, and a strong vibration is felt in
the part, the case is not one of empyema; but this is as uncertain a
sign and as little to be depended upon as the dullness on percussion
which sometimes takes place under the sternum in empyema. The cough
and expectoration offer nothing peculiar, unless a communication exist
between the lung and the cavity of the chest, when the expectoration
in general becomes very fetid and disagreeable. The febrile symptoms
depend on the activity of the previous disease, and the rapidity with
which the effusion has taken place.
Night-sweats, it has been supposed, never accompany the hectic fever
of empyema, unless there be tubercles in the lungs or pleura--a remark
which cannot be depended upon.
315. Two symptoms have been insisted upon by older authors as
distinctive of effusion in the chest, which more modern ones are
disposed to doubt, particularly in the early stages of the disease.
One is an edematous swelling of the back, the other a protrusion of
the intercostal spaces. A third may be added when the effused fluid
is blood, which is that the edematous swelling becomes ecchymosed, or
red, or bruised looking, from the effusion of blood into the cellular
membrane beneath the skin, over the whole space occupied by the blood
within. That the first two symptoms do assuredly indicate the presence
of pus, cannot be doubted; and that the third is a sign that the
effused fluid is blood, has not been disproved; but it must be borne in
mind that they are late, not early symptoms, and the operation should
not be delayed until they are present, if other signs should appear to
demand its performance. Valentin was the first to notice the ecchymosis
of the side and back when the chest was full of blood, a sign which
Larrey particularly insists upon, but which certainly does not appear
so early as to be distinctive, when other symptoms exist which almost
render it certain. The swelling does not arise from transudation of
matter through the pleura, but from irritation transmitted through it,
as in any other deep-seated abscess. Dilatation of the chest is usually
an early symptom, although a considerable effusion may exist without
it, or with but a slight elevation of the intercostal spaces. When the
complaint is distinct, these spaces are elevated to a level with the
ribs, so that the surface becomes perfectly smooth and equal; a farther
protrusion is a very rare occurrence. Effusion indeed of serous fluid
to a considerable extent, so as to displace the heart, may take place
without the intercostal spaces being elevated, which is only believed
to occur when the intercostal muscles have become paralyzed. When the
matter has been evacuated, the muscles recover their tone, and the
intercostal spaces reappear.
In all cases of empyema in which the lung is so bound down by adhesions
that it cannot be expanded by the continued process of respiration,
a cure can only be accomplished by an alteration of the form of the
affected side of the chest, by which its cavity is diminished, and
often nearly obliterated. This is an effort of nature. The pleura
changes its character, becomes so thick as materially to diminish the
cavity, the diaphragm ascends, the heart leans to that side in many
instances, the spine curves, the ribs thicken and become flatter, and
close in upon each other, abolishing the intercostal spaces.
_Treatment._--As long as the febrile symptoms consequent on the
inflammation continue to any extent, medicines will be of but little
avail, and counter-irritants should be avoided. When they have
subsided, purgatives and diaphoretics may be tried, in combination
with tonics and a light but good nourishing diet. Blisters applied
frequently upon a large surface often do good. When these means fail,
the operation must be resorted to.
316. It has not been satisfactorily decided whether the operation
for empyema was first performed on Phalereus, Jason, or Prometheus;
it is therefore said of all three that, being expected to die of an
abscess in the lungs declared to be incurable, they went into battle
for the purpose of getting killed; but being only run through the
body, they all recovered, in consequence of the escape of the purulent
matter through the holes thus made. The operation was performed by
Hippocrates and his successors, by the knife, by caustic, and by the
hot iron. Ambrose Paré was the first who recommended a trocar and
canula, and many instances of success in all ways are recorded. The
modern methods are by the trocar and canula, and by incision. Whenever
auscultation, percussion, or succussion give reason to believe that a
fluid is collected, which medicine has not been nor is able to remove,
the simple operation by the trocar and canula should be performed. If
fluid should pass through the small canula generally used by way of
exploration, a larger one may be introduced in its place if thought
advisable. In ordinary cases, the little wound should be closed
immediately after the evacuation of the fluid; it usually heals without
difficulty, and the operation may be repeated if necessary. Care should
be taken that the point of the instrument is perfectly sharp, or it
may separate the thickened false membrane from the inside wall of the
chest, and, by pushing it before it, prevent the fluid from passing
through the canula when the trocar is withdrawn.
317. The place of election, in England, for a _puncture_, in ordinary
cases, is usually between the fifth and sixth ribs, counting from
above, and between the sixth and seventh from below, and at one-third
the distance from the spinous processes of the vertebræ, or two-thirds
from the middle of the sternum. If there should be any protrusion of
the intercostal spaces, it may be a rib or two lower down. The point
of the instrument should be introduced a little nearer the lower than
the upper rib, and pressed on until all resistance has been overcome.
It is entered nearer the lower rib to avoid the intercostal artery,
and yet not touching the rib lest it should induce a too forcible
contraction of the intercostal muscles, by which the operator might be
inconvenienced.
If the person should be very fat, or the puffing of the integuments
considerable, it may not be easy to feel the ribs, in which case even
recourse should not be had to incision. When the arm is placed by the
side, and bent forward at a right angle so that the hand rests on the
ensiform cartilage, the inferior angle of the scapula will correspond
in general, but not always, with the interval between the seventh and
eighth ribs at the back part. The attachment, however, of the last
of the true ribs, the seventh, to the xyphoid cartilage, can always
be ascertained in front, and an error of importance cannot well take
place, as the object in making a puncture by measurement is to avoid
the diaphragm. Freteau, of Nantes, says that he performed the operation
on the left side between the tenth and eleventh ribs, and on the right
side between the ninth and tenth in more than thirty dead bodies, and
always opened into the cavity of the chest, commencing the incision
close to the edge of the latissimus dorsi muscle, or about three inches
and a half from the spine--an operation which in this place should
be done by incision, and not by the trocar. When there is reason to
believe that there is an extraneous body to be extracted, such as a
ball, the place of election is of importance, as it is desirable it
should be a little above the diaphragm in order to facilitate its
extraction; for although, by carefully shifting the position of the
patient, a ball or a piece of bone may be brought to rest against the
opening, it will not be easily taken hold of unless it lie upon the
diaphragm, a point which will be hereafter further elucidated. When an
external swelling indicates the presence of matter, and there is reason
to believe it communicates with the inside of the chest, the opening
should be made into the tumor, and is then called the “operation by
necessity,” which is not an uncommon occurrence after gunshot wounds.
It is not, however, always done in the most convenient place, and
should then be repeated lower down, which will also be sometimes
necessary in consequence of the matter collected in this way being cut
off by adhesions from the general cavity.
When the operation by incision alone was performed, the success was
certainly not great. In modern practice (after the operation by
puncture) it has been much greater, which may be attributed to the
operation having been had recourse to at an earlier period, or about
the end of the third week. After wounds penetrating the chest which do
not admit the effused fluid to flow out, it should be done much earlier.
It is possible that both sides of the chest may be affected; but both
sides may not be punctured in succession, for an error in puncturing
both, or even the sonorous or sound side instead of the dull or
affected side, has been almost immediately destructive of life.
318. The admission of atmospheric air into the cavity of the chest
during this operation has been much deprecated, and many inventions
have been recommended for its prevention, but it is scarcely possible
to prevent some air getting in. It is often seen to do so; it has been
proved by auscultation to have done so, and is usually absorbed in a
few hours. In one case which I saw it gave rise to distressing symptoms
from pressure on the lung, but was removed by a common syringe, to
the great relief of the patient. In all these cases two things must
be considered: Can the compressed lung expand so as to fill the chest
when the fluid is withdrawn? The answer must be, in many cases it is
so bound down by adhesions that it can dilate but slowly, if at all.
If it be asked whether a vacuum is formed in the chest, the answer
will be, no; and it will then be admitted, on consideration, that air
always finds its way into the chest, and never does harm to persons
in health. When mischief does ensue after an operation or an injury,
it usually occurs from the irritation caused in a particular state
of constitution, and not from the admission of air. A change in the
appearance of the discharge has been frequently found to follow, and
to depend upon, an accidental derangement of stomach, and to return
to its more normal state on the derangement being removed. If the
wound into a cavity can be closed and healed, the air will remain with
impunity until absorbed. If the wound cannot be healed, unhealthy
inflammation may be propagated from it to the whole cavity with which
it communicates, but this is not the effect of the admitted air.
Dr. H. M. Hughes has published several cases of pneumothorax in the
first part of the of the volume of “Guy’s Hospital Reports” for 1852.
In the sixth case, which he calls a genuine example of pneumothorax
from rupture of one or more of the vesicles of an emphysematous lung,
the patient died speedily; and, on examination, he says: “It is also an
interesting fact that no evidence of inflammatory action existed in
the pleura, as it indicates that air in a healthy serous membrane does
not excite inflammation;”--a Peninsular dogma I have been forty years
inculcating, and which I trust is at last admitted as an established
fact. How long it may be before it is generally taught, is another
matter; for surgeons, like other men, often adhere with tenacity to
preconceived opinions, however erroneous, particularly as they advance
in life and have ceased to desire to learn more than they already know.
319. In all cases of _serous_ effusion, there can be little doubt that
the fluid should be wholly evacuated and the wound closed. When the
fluid is _purulent_, a permanent drain should be early established. It
is not, however, common for the operation to be repeated several times
without the serous discharge becoming purulent; and, in such cases, it
usually becomes necessary at last to allow the wound to remain open
until the discharge shall cease of itself. Whenever more than one
opening is necessary, and the first is made between the fifth and sixth
ribs, the succeeding ones should be made lower down; so that when it is
thought right to leave the last puncture to become fistulous, it may be
made as near the diaphragm as may be thought consistent with the safety
of that part.
When a doubt exists as to the probability of more than one puncture
being sufficient, and it seems likely that a third, or even more, will
be required, the surgeon may anticipate this necessity by introducing a
piece of soft gum-elastic catheter through the canula into the chest to
the extent of about three inches, enough being left outside to admit of
its being secured by tapes and adhesive plaster; through this a certain
quantity of the fluid may be drawn off daily until it ceases to be
discharged. The elastic tube bends with the heat, and applies itself to
the inside of the ribs. If the lung should rub against it, which can be
ascertained by a blunt probe, the elastic tube should be removed, and
the external wound kept open by a softer plug. In all these operations,
care should be taken to prevent the occurrence of inflammation. The
accession of pain in the part, of difficulty of breathing, of fever,
should be met by the abstraction of a few ounces of blood by cupping,
by dry-cupping, by mercury in small doses, by rest, by diet, etc., and,
if a tube have been introduced, by its removal.
The propriety of injecting stimulating or even simple fluids into
the cavity of the chest has been often advocated, and as frequently
repudiated. Warm water or milk and water is certainly admissible, and
has been found very useful, particularly when there is an adventitious
cause keeping up the irritation, which may possibly be brought to the
opening by the sudden abstraction of the injection. Pieces of cloth
and bits of exfoliated bone have been floated out by throwing in an
injection of tepid milk and water. The opening, in a case of this kind,
should be made between the eleventh and twelfth ribs behind.
Dr. Wendelstadt, of Hersfield, in the year 1810, in the twenty-third
year of his age, suffered an attack of pleurisy, which became chronic,
and ended in effusion. After severe suffering for six months, he was
able to attend to his professional duties. The ribs of the right
side protruded, but the intercostal spaces did not; the whole side
was motionless on respiration taking place. The circumference of the
chest continued to increase, and fluctuation within became evident
on succussion. In June, 1819, having undergone another attack of
pleurisy, he submitted to the operation for empyema, as offering some
hope of preserving life. When a pint of fluid had been discharged,
the wound was closed, and he experienced great relief. The next day
a third of a quart was taken away twice in the day, and on the third
day as much more; but he thought this was too much, as he became
greatly exhausted, and feared that suffocation was impending. He was
recovered by stimulants. On the fourth day the fluid was thicker in
consistence, and fetid, and continued more or less so for a fortnight.
It was then allowed to flow as it would at each dressing. Astringent
injections were used for six weeks, but were then abandoned, and he
gradually recovered his strength. Thirteen years afterward, in 1830,
the wound was still open, discharging twice a day, sometimes only half
a drachm, sometimes three or four ounces daily. The right side had
altogether shrunk, and did not move on inspiration; he had no cough,
and was otherwise in good health; a piece of a rib became loose, and
was removed at the end of thirteen years, when the report of the case
terminated, the patient being in health.
It may be remarked on this case, that the admission of air did no harm;
that the lung remained compressed; that the whole side thickened and
flattened, as a consequence, so as to obliterate the cavity; but the
cure would not have been effected even then, if the piece of carious
rib had not been discovered and removed.
Mr. Winter, secretary to Admiral Sir C. Napier, was wounded by two
musket-balls, one in the arm, while the other entered between the
inferior edge of the left scapula and the thorax, which it penetrated,
fracturing a rib in its progress, and lodged. He fell, and spat up some
blood, and as symptoms of inflammation supervened in twenty-four hours,
he was bled largely; this was repeated frequently until these symptoms
were subdued. He was after a time sent to the Marine Hospital, Lisbon,
in a miserable plight, suffering from hectic fever, with a flushed
face, hot skin, glassy eye, great prostration of strength, cough,
restlessness, dyspnœa, and copious night-sweats. The wound discharged
a watery, sanious, fetid matter in quantity, and he was unable to do
anything but eat, and for food he had a great craving. From this state,
under good treatment, he gradually recovered his strength, and on the
18th of June, 1834, a piece of the rib was removed. The wound remained
open with a great purulent discharge, which kept him in a reduced
state; a little more than one year after the injury, he reached London,
and was taken into the Westminster Hospital. The left side of the chest
was flattened and contracted, and the lung was doing very little in
the respiratory way; the wound discharging a quantity of matter, which
he could readily evacuate by making the opening the dependent point,
but not otherwise. On enlarging the external wound, so as to make the
opening into the chest direct, I found a round-pointed gum-elastic
bougie could pass into it for four inches, and, on bending it down, for
six inches more, it having to pass over a thickened pleura, and false
membrane of an almost cartilaginous nature, for the extent of an inch,
before it could be felt to be in a large cavity. As it did not appear
that he had any chance of recovery, unless another opening were made
lower than the sixth rib, in a more dependent position, I proposed
the operation, but he would not submit; and after a time he left the
hospital and went into the country, where he died.
A non-commissioned officer, of the 2d Division of cavalry, was wounded
at the battle of Albuhera, on the 10th of July, 1811, in several
places, by the lances of the Polish cavalry; one of these penetrated
the left side of the chest behind, immediately below and in front of
the inferior angle of the scapula. He spat and coughed up blood, and
lost so much from the wound that he became insensible, the bleeding
having been stopped by a part of his shirt being bound upon it tightly
by means of his woolen sash. Brought to the village of Valverde, my
attention was drawn to him some days afterward, in consequence of the
difficulty of breathing having increased so that he was obliged to be
raised nearly to an upright position, as well as from his inability to
rest on the part wounded, round which a dark-blue inflammatory swelling
had taken place, the wound having closed. An incision being made into
it, a quantity of bloody purulent matter and clots of blood flowed from
it. The incision was then enlarged, so as to allow of a direct opening
into the cavity of the chest, which was kept open. The relief was
immediate. He was removed to Elvas, apparently doing well, some three
weeks afterward.
This case offered the nearest approach I have seen to the ecchymosed
edema described by Valentin as accompanying effusions of blood into the
cavity of the chest; and, as well as the following, is an instance of
operations, not by election, but by necessity.
A French soldier had been wounded at Almaraz by a musket-ball, which
went through the right side of the chest, in a line nearly horizontal
from a little below and to the outside of the nipple, backward. The
first symptoms having subsided, he gradually descended the Tagus to
Lisbon, where, after some months of continual discharge, the wounds
closed, first the back, and then the front. He did not recover his
strength, always looking sickly, and suffering from pain, difficulty
of breathing, and other inconveniences, which did not prevent his
walking about in the confined space to which he was doomed as a
prisoner of war. My attention was drawn to him in consequence of an
obvious fullness of the intercostal spaces, of the great difficulty
of breathing, and of a puffy inflammatory swelling which was forming
around and at the seat of the wound in front. Through this I made
an incision into the cavity of the chest, the walls of which, on
introducing the finger through the opening, appeared to be very much
thicker than usual. A large quantity of pus was discharged, and the man
was relieved, but this amelioration was not of long continuance, and he
gradually sank and died. On opening the body, the inside of the wall
of the chest was found to be half an inch in thickness, in consequence
of a firm deposition on the pleura, of a yellowish-ash color,
honey-combed or ulcerated, as it were, in plates, particularly where
the opening had been made. The lung was shrunk up from the anterior and
lower part of the chest, but adhered to the wounded part behind, and
was covered by a layer of false membrane of considerable thickness. The
wound through the lung could not be distinctly traced, from its being
diseased throughout.
At Santander, in October of the same year, 1813, I received some eight
hundred wounded in the affairs of Le Saca, Vera, etc. One of the
Light Division had been shot through the left side of the chest: the
posterior wound had closed, but a sufficiently large quantity of matter
was discharged through a small anterior one to show that there must
be some depot from which it proceeded. The wound was laid open into
the cavity of the chest, and free vent given to a quantity of matter.
Some small pieces of rib were discharged, and a bit of something like
the cloth of his coat also came away. He could lie on either side, and
hopes were entertained of his recovery, until after I left Santander
in December, to join the army in France, when he suffered a relapse of
inflammation, and died.
A soldier of the German Legion was wounded at Waterloo by a lance
between the sixth and seventh ribs of the left side. He spat up much
blood for several days, and was carried to Antwerp, where he remained
for several months, suffering from great difficulty of breathing and
other distress in his chest, which recurred from time to time, although
the wound had healed. He was admitted into the York Hospital, Chelsea,
in the spring of 1816, in consequence of an attack of inflammation,
of which he died. On examining the body, the lung of the right side
was found to be greatly inflamed, and full of purulent fluid, which
caused his death. The left or wounded side was found to contain a small
quantity of pus, the cavity being very much diminished by the great
thickening of the pleura and the falling in of the ribs, which were
thicker, greatly flattened, and changed in form; the lung, shrunk or
collapsed, was covered by a thick adventitious membrane, and bound down
against the spine, leaving a long, small space between the pleuræ,
which once had doubtlessly been full of matter. The mediastinum and
heart appeared to lean toward the left side, aiding in this manner in
the obliteration of the cavity, which must take place if a permanent
cure be effected in empyema. I have seen two cases in which this
obliteration appeared to be complete: one in a soldier, who had been
wounded in the chest; the other in a gentleman, the subject of empyema,
in private life. In both the spine was also distorted, the side wasted,
the nipple lower than the other. The breathing of the opposite side was
more marked and developed. It might have been called puerile.
320. _Pneumothorax_ means an effusion of air and of the matter of a
tubercular abscess from disease into the cavity of the chest, or from
an injury or a wound in the lung. When pneumothorax is the consequence
of disease of long standing, the patient may be sensible of a sudden
pain, which does not abate, and which is accompanied by an equally
sudden increase of the difficulty of breathing, for which he cannot
account. He feels relief by lying on his back or on the affected side,
rarely on the other, although the difficulty of breathing may increase,
so as to render the further continuance of life doubtful, while the
prostration of strength is considerable. The muscles of respiration are
all in rapid and powerful action; the heart is displaced to the right
side when the complaint attacks the left, and it will be displaced
somewhat to the left when the right is affected; in some cases it
even descends into the epigastrium, or is otherwise removed from its
natural situation, even toward the axilla, although the left side is
supposed to be more obnoxious to this complaint than the right. The
pulse becomes exceedingly quick and small, countenance pale, nights
sleepless. The affected side is oftentimes evidently dilated, and the
intercostal spaces may be less marked, or partly filled up, when the
respiratory motion given to the parts under ordinary circumstances is
seen to be deficient. But these differences, as well as that which can
be obtained by comparing both sides by measurement, are not so marked
as when the cavity is filled with fluid, of which in pneumothorax there
is always a small quantity effused.
_Percussion_, beginning from above, in the erect position, will give,
in cases in which it is ascertained that respiration is null, a clear
tympanitic sound, as low as the level of the fluid, when it changes
abruptly to a dull sound, or that indicating the presence thereof.
If the patient be then placed in the recumbent position, the clear
sound can be heard above, the dull one below, demonstrating the change
in the situation of the air and fluid. _Auscultation_, in addition
to the absence of respiration, when the chest is fully expanded,
discovers no respiratory murmur; but a peculiar sound called _tintement
métallique_, or metallic tinkling, is heard at intervals, particularly
on the patient’s coughing, speaking, or breathing. It may be imitated
by dropping a pin into a large wine-glass, but it more nearly resembles
the sound of a jew’s-harp in the hands of a child: once heard it cannot
be mistaken. It is a sound distinctive of pneumothorax.
“Mr. Cornish, a medical practitioner, having suffered an attack
of pleuritis, nearly expired from suffocation on Monday, the 29th
December, 1828. He was lying on his right side, breathing most
laboriously; countenance sunk; pulse between 130 and 140; had had no
sleep for many nights. The action of all the respiratory muscles was
painful to behold; no perceptible difference in the size or shape
of the two sides. The _right_ emitted an extremely dull sound; the
_left_ sounded hollow throughout. The apex of the heart was beating
rather to the right of the right nipple. The respiration was loud and
rattling in the _right_ side; metallic tinkling distinct in the _left_;
expectoration muco-purulent, with specks of blood, and many black
particles. Mr. Guthrie, who saw him for the first time, made a short
incision between the sixth and seventh ribs, and cautiously opened the
pleura, when a rush of air issued forth with a hissing noise, strong
enough to have extinguished several candles. The patient turned on his
back, breathed with comparative freedom, and expressed his gratitude
for the operation. No fluid issued from the wound when made a dependent
opening. On the 31st, the difficulty of breathing and the metallic
tinkling had returned, the wound having closed. The wound was reopened
and enlarged; the pulse fell to 120; the metallic tinkling ceased to be
heard; the patient took some nourishment and an opiate at night.
“Jan. 1st, 1829.--Has slept several hours; breathing easy; pulse
reduced in frequency; appetite good. A canula was placed in the wound,
when large quantities of air came through it on each expiration; the
heart beat two inches nearer the central line of the thorax than
before. During the night he became greatly oppressed, and died next
day. On raising the sternum, the heart was found rather to the right
of the median line of the chest. The left lung was collapsed to
one-fifth of its natural dimensions. The vacant space was filled with
air, and about fourteen ounces of turbid serous fluid. The pleuræ
costalis and pulmonalis presented marks of inflammation of a few
weeks’ standing--viz., some thin false membranes, which were easily
separated by scraping with the scalpel. There were no marks of more
recent pleurisy. A tube was inserted into the trachea, and air blown
into the lungs. The left lung expanded to a certain extent, and air was
heard to bubble out, when an aperture was immediately recognized at the
division between the two lobes, through which the air rushed forth and
extinguished a taper that was held near it. The aperture was circular,
fistulous, and capable of admitting a crow-quill, and was found to
communicate with a very small excavation, formed by the softening down
of some tuberculous matter; into this small excavation a bronchial tube
was seen to enter. Thus, the communication between the trachea and the
cavity of the chest was distinctly traced. The left lung presented some
trifling tuberculation, but was not materially diseased.”
William Griffin, aged eighteen, was admitted into the Westminster
Hospital on September 14th. Ten days before his admission into the
hospital he discharged a pistol against the left side of his chest,
causing a wound corresponding to the middle of the eighth rib, from
which a very small quantity of blood escaped. The medical practitioner
who was called to him at the time _passed a probe to the extent of
four inches_ into the wound. The wound had nearly cicatrized, but he
became the subject of acute pain, diffused over the whole of the left
side of the chest, accompanied by fever and frequent cough, dyspnœa,
and inability of lying on the right side. After the lapse of a week he
was transferred by his surgeon to the medical wards under Dr. Roe, at
which time he had begun to expectorate purulent matter of an extremely
fetid character, occasionally mixed with blood. His respiration was
hurried, the right side of the chest expanding much more freely than
the left; the lower three-fourths of the affected side were dull on
percussion; tubular respiration could be detected at the upper part,
but at the lower no air appeared to enter; well-marked modifications of
voice existed over the whole of that side of the chest. By measurement
no difference in the relative size of the chest was observed, but
the intercostal spaces of the left side remained motionless daring
expiration. The heart could be felt feebly pulsating at the epigastrium.
October 15th.--He suffered from a violent paroxysm of coughing,
during which great dyspnœa suddenly came on. He sat propped up in bed;
respiration was almost ineffectual, his face livid and covered by a
cold, clammy sweat, pulse scarcely perceptible at the wrist, and his
extremities were becoming cold. On examining the chest, the left side,
before quite dull, now afforded tympanitic resonance on percussion,
which, together with the total loss of respiration and the presence
of metallic tinkling, proved the existence of pneumothorax. A trocar
was introduced between the sixth and seventh ribs, and was followed by
an escape of gas with about five drachms of pus, both of a very fetid
character; the canula becoming obstructed, a larger one was then passed
through the opening, but not more than half an ounce of pus escaped;
it was then withdrawn, and found to be blocked up by what appeared to
be disintegrated lung. Being greatly relieved, no further attempts at
evacuating the fluid were then made.
At night, during a paroxysm of coughing, six ounces of fetid pus
escaped by the opening, after which he felt relieved. A second gush of
sanious fluid, to the amount of five ounces, containing small masses of
sloughing membrane, subsequently took place. Cavernous respiration at
the upper half of the lung, mixed with gurgling and metallic tinkling.
Expectoration muco-purulent and offensive.
21st.--Has somewhat improved, but suffers from accessions of fever
toward evening, and perspires very profusely during the night; the
cough is less frequent, and he expectorates freely, the sputa being of
a purulent, fetid character. Scarcely any discharge from the side.
Nov. 5th.--Has remained in nearly the same condition until yesterday,
when he ceased to expectorate, and has since become much worse; his
skin is now intensely hot; face flushed; tongue brown and coated; pulse
jerking, but feeble and frequent; the opening in the chest has quite
healed.
A second opening was now made about an inch external to the former one,
and a canula introduced, but not more than one ounce of pus escaped,
the instrument becoming blocked up by portions of sloughing tissue;
during a paroxysm of coughing, which occurred a few hours afterward,
several ounces of fetid sanguineous pus were forced through the wound.
16th.--Since the last report he has been slowly sinking--is emaciated
to an extreme degree. The wound originally produced by the pistol-ball,
as well as those made by the trocar, have become fistulous, so that
during respiration the air passes into the chest, and is expelled
with as much freedom as that passing by the trocar. Expectoration has
continued very copious, about a pint and a half having been passed in
every twelve hours; large sloughs have formed upon the nates and hips,
his intellect wanders, and he has frequent syncope. Died on the 5th of
December.
[Illustration:
_A._ Section of the lung, made vertically.
_B._ Section of the abscess communicating by the sinus,
_C_, with the circumscribed cavity,
_D_, in which the bullet had been lodged after its entrance by the
sinus, _E_.
_F._ The sinus by which the ball had passed into the pleural cavity,
_G_. Opposite the 7th and 8th ribs the lung is quite adherent.
_H._ The ball.]
_Sectio cadaveris._--The pleural cavity of the left side contained
about ten ounces of purulent matter mixed with blood, and floating in
it were numerous masses of white, curd-like matter, at the bottom of
which, in the angle formed by the diaphragm with the spine, was found
a pistol-ball partly covered by albuminous matter and discolored.
Fluid injected into the left bronchus was found to issue freely from
an opening at the most depending part of the lung, communicating with
a small cavity, the interior of which was lined by the same thick
membrane met with in cases of chronic phthisical disease; from the
upper part of this cavity two other sinuses were formed, the one
passing externally and terminating by an adhesion of the lung with the
ribs at the point where the ball had entered; the other was longer
and more tortuous, passing deeply in the substance of the lung, and
ending in a large abscess capable of containing five or six ounces of
pus. The lung was at its lower part firmly attached to the ribs by
intervening false membrane, while the upper part was free, and had
become compressed toward the spinal column. The substance of that part
of the lung not involved in the abscess was infiltrated with pus, and
the greater number of the bronchial tubes were filled up by masses of
curdy matter similar to those found floating in the effused fluid. The
natural division of the lung into lobes was quite destroyed by the
pleuritic adhesions of one to the other, while the pleura lining the
parietes was covered by rugged layers of false membrane of irregular
thickness, but readily detached. No trace of tubercular deposit
could be found, and the lung of the opposite side was quite healthy.
Since the first publication of these cases the operation has been so
frequently and, in many instances, so successfully performed, as to
leave no doubt of the advantages to be derived from it.
321. Lord Beaumont was wounded by a pistol-ball on the 13th of
February, 1832, when standing sideways. It entered the right side of
the chest a little below the nipple, appeared to pass under the lower
end of the sternum, just above or about the xyphoid cartilage, and
to have lodged in the cartilage of the last of the true ribs of the
left side near its junction with the bone, in consequence of a round
projection at that part resembling a pistol-ball, but which, on being
exposed, showed only a knob of cartilage which might have been a
natural formation; no further steps were therefore taken. The injury
had been received about four o’clock--it was now five; he could lay
flat on his back; had little or no pain or oppression.--Seven o’clock:
Breathing became oppressed, and accompanied by pain; vesicular murmur
distinct in both lungs; pulse 96; bleeding to thirty-two ounces.--Nine
o’clock: Difficulty of breathing; the pain greater; was again bled
until the pulse failed, although he did not faint; the relief
great.--Half-past ten: Oppressive breathing again returned; pulse very
low and quick; thirty-six leeches applied; relief obtained.--Half-past
twelve: Thirty-six more leeches.--Half-past two: Thirty leeches were
again applied. In all, four pints of blood were taken from the arm, and
one hundred and two leeches were applied to the chest, the bleeding
being encouraged afterward; during the first ten hours live grains of
calomel and four of the compound extract of colocynth had been given,
and now forty minims of Battley’s solution of opium were administered.
14th.--Eight o’clock: Slept after four o’clock; on waking took an
aperient draught, and is much easier; pulse 120, soft, small, and
weak.--Three P.M.: On the dyspnœa returning twenty-one leeches were
applied, and the oppression was relieved; an enema given, which acted
freely.--Half-past twelve: A returning oppression relieved by eleven
leeches; calomel repeated, and thirty minims of solution of opium.
15th.--Eight A.M.: Slept at intervals; little or no expectoration, no
blood; thinks he would faint if he sat up in bed; pulse 130, soft,
small, and weak; little pain; lies tolerably flat; respiratory murmur
distinct on both sides.--Nine P.M.: Oppression returned; twenty-four
leeches; repeat calomel and colocynth; an enema, after which the bowels
became free.--Evening: Six grains of calomel, and opium draught.
16th.--Eight A.M.: Had forty-eight leeches applied at intervals twice
during the night; slept at intervals, and is easier; no pain in the
chest; pulse 108.--Evening: An enema; six grains of calomel, and one
grain of opium.
17th.--Eight A.M.: Slept during the night, and is better; pulse 108,
soft; breathes freely; no pain.--Evening: Has had leeches applied
twice during the day, making in all 245, and each time with relief; an
enema,--calomel and opium as before.--Twelve at night: More oppression,
and, as the pulse was fuller and quicker, a vein in the arm was opened,
but only four ounces of blood could be obtained.
18th.--Eight A.M.: Slept at intervals, although very restless; pulse
120, fuller; oppression in breathing returning; bleeding to twenty
ounces, which caused him to faint; senna draught.--Evening: Has been
much relieved by the bleeding; blood cupped and buffy; twenty leeches;
enema; calomel and opium. In the night, at two o’clock, the dyspnœa
returning, twenty-two leeches were applied, and thirty minims of
solution of opium given.
19th.--Eight A.M.: Easier, quieter, better; pulse 110, soft; can
lie quite flat on his back. The wound discharged so little that the
external parts were dilated inward toward the sternum, until the
pulsation of an artery could be seen, perhaps the internal mammary,
which it was not thought advisable to disturb; respiratory murmur not
distinct at night; enema; calomel, opium, and twenty leeches.
20th.--At three in the morning, being greatly oppressed, thirty leeches
were applied, and at eight o’clock twenty more, which quite relieved
him, but left him in a state of great exhaustion, sick, and faint. A
little arrow-root relieved the faintness; discharge from the wound
free, and accompanied by _air_; bowels open.--Ten at night: Calomel,
and forty minims of the solution of opium.
21st.--Eight A.M.: Has now, for the first time, a hope of life: pulse
112, soft; no pain; can turn on his side, but fears to hurt himself;
wound discharges freely; has had a small piece of bread for the first
time.--Four P.M.: Restless, but better; senna and sulphate of magnesia
mixture.--Eight P.M.: Oppressed; pulse 120; twelve leeches; calomel,
and thirty minims of the solution of opium, at night.
23d.--Oppression at night relieved by six leeches; slept afterward;
breath slightly affected by the mercury, which was omitted in
consequence; ten grains of the compound extract of colocynth given at
night, with thirty minims of the solution of opium.
25th.--Free from pain; breathes easily and without difficulty; can
turn in bed with ease; slept well; the discharge from the wound is
free; takes farinaceous food, oranges, tea, etc. He gradually improved
until the 13th of March.--On the previous Friday, the 9th, he removed
from Bond Street to Mount Street; and on the 13th, amused himself by
washing all over in a small back room without a fire; caught cold, and
acquired a troublesome cough, which was quieted on the 14th, at night,
by opium.--On the 15th, A.M., it was evident that some mischief had
been done; pulse 120; breathing difficult; was bedewed with a cold
sweat; respiratory murmur indistinct on both sides; on the left, not
heard below the fourth rib; although the whole side sounded sonorously,
it evidently contained air, the _tintement métallique_ being very
remarkable. The wound having closed very much, and the distance to
the left cavity of the pleura under the sternum being considerable, a
piece of sponge tied around the eye of a small gum-elastic catheter was
introduced, so as to enlarge the track of the ball, and give passage to
the air from the left side of the chest. This was done at five o’clock
P.M., and at ten, on its being withdrawn, air rushed out in a very
manifest manner, to his great relief. The metallic tinkling, which was
distinct before the instrument was withdrawn, instantly ceased, but
could be reproduced by closing the opening. The small gum catheter was
therefore reintroduced with the eye projecting beyond the sponge, and
retained, air passing through it; cough very troublesome.
March 17th.--Better; pulse 100; bowels open; cough easier;
expectorates freely a _rouillée_, or reddish muco-purulent matter.
18th.--Easier and better; breathing on the left side not heard below
the fourth rib; discharge free; the permanent gum catheter taken out,
but passed in daily. After this he slowly recovered, and continued to
enjoy good health until the summer of 1854, when he died of what was
supposed to be ulceration of the stomach, being an admirable instance
of the treatment to be followed in such cases. When there is not an
opening to enlarge, one should be made with the trocar.
It has been stated by the latest writers on pneumothorax, that
tympanitic resonance on percussion, and the absence of respiration, are
not pathognomonic signs of pneumothorax, as these physical signs may
exist without it, and pneumothorax may exist without them. The metallic
tinkling, in addition to the absence of all appearance of disease in
the abdomen, will be conclusive of the presence of this disease.
322. Emphysema, from εν and φυσαω, to inflate; the diffusion of air
into a part of or throughout the cellular tissue of the body. It
has been said to take place after a wound of the chest, but without
an injury of the lung, from the air passing through the wound into
the cavity during inspiration; and by accumulation and subsequent
compression under the act of expiration, giving rise to all the
symptoms of the disease; a complaint more theoretical than real.
Emphysema, as a medical disease, is opposed to the surgical disease,
in not being an extravasation of air into the cavity of the chest,
but a dilatation of the air-cells formed for its reception. It is of
two kinds, _Vesicular_ and _Interlobular_--vesicular when dependent
on the enlargement of one or more air-cells; interlobular when, from
the sudden rupture of an air-cell, the air has found its way into the
interlobular structure of the lung. A third and very rare kind has been
added, in which air, being extravasated under the pleura, has raised it
in the form of a pouch. The morbid appearances these diseases afford,
and the symptoms they give rise to, do not fall within the range of
surgical skill; and are not frequently within the controlling power of
medical science and ability.
Emphysema is free from redness, and is distinguished from edema, or
the swelling containing a serous fluid which is also colorless, by its
not pitting on pressure, or retaining the mark of the finger. It is,
on the contrary, elastic; and the displacement of the air, on pressing
on the part, gives rise to a peculiar noise, resembling the crackling
of a dry bladder partly filled with air on its being compressed,
usually called crepitation. This swelling extends as the air introduced
increases in quantity until the whole of the areolar tissue of the body
may be fully distended.
Emphysema most commonly occurs from fractured ribs, a point from one
or more of which abrades the surface of the lung. Through the opening
thus made, the air escapes into the sac of the pleura, and thence by
the side of the broken part of the ribs into the cellular membrane.
The distress in breathing arises from the air being diffused over the
surface of the lung, which it gradually causes to collapse under the
pressure exercised by the act of expiration; while, at the same time,
the mediastinum yielding, the opposite lung suffers in a similar way,
although to a less extent, until the aerification of the blood is so
greatly obstructed as at last to interfere with life, unless relief be
obtained by the equalization of the pressure made on the lung by the
compressed air in the cavity of the pleura, with that exercised on the
inside of the lung through the glottis.
In ordinary but not severe cases of fractured ribs, a slight degree
of emphysema is frequently observed over the injured part, implying
that the lung has been wounded; such a case requires the application
of a compress, wetted with a little spirit and cold water, retained by
a bandage. The great art in the treatment of broken ribs by compress
and bandage consists in their proper application, which can only be
ascertained by the feelings of the patient. The application of a broad
flannel bandage, so as to restrain the motions of the chest, and to
cause the sufferer to breathe by the diaphragm, has been recommended
from the earliest periods of surgery; but many persons with injured or
broken ribs cannot bear the pressure of a bandage, while others derive
much ease from its use. A tight bandage generally disagrees when the
injury has been sustained at the lower part of the chest, and is more
frequently useful when the fracture is above the fifth or sixth rib.
When the emphysematous swelling extends so as to invade a considerable
portion of the body, the further diffusion of air should be prevented
by punctures made through the skin in such places as may be thought
necessary, and in extreme cases even by incisions; but these are
things more often spoken of and written about than practiced, or than
are even necessary.
323. Mr. J. Bell had so alarmed all military surgeons by stating, in
his able discourses on the Nature and Cure of Wounds, that emphysema
was “peculiarly frequent in gunshot wounds of the chest, both at the
orifice of entrance and of exit of the ball,” that they thought of
little else. They could not withstand the brilliant manner in which
this remarkable error--for error it is--was expressed. To such of us as
had served in the first part of the war in Portugal it was no longer
a bugbear; we slept in peace after the battles of Roliça and Vimiera,
of Corunna, of Oporto, and Talavera--laughing, perhaps, a little at
the credulity of the surgical portion of mankind; for the opening made
by a musket-ball rarely admits of emphysema. A slanting wound made by
a pistol-ball may sometimes give rise to it. After long and tortuous
wounds made by swords or lances it is seen more frequently, but then it
takes place shortly after the receipt of the injury.
A soldier, at the battle of Albuhera, was wounded in the right side
of the chest by a sword, which had passed slantingly under the
shoulder-blade, from which injury he did not suffer much, until the
whole side as well as the body and neck began to swell and impede
his breathing, which was effected with some difficulty and with any
ease only when sitting up. The external wound was enlarged until I
could distinctly hear the air rush out and see the part where the
weapon had penetrated between the ribs; upon which he declared himself
relieved, when the wound was closed by compress and bandage. It did
not unite, however; active inflammation of the cavity of the chest
ensued, requiring frequent and considerable losses of blood for its
suppression. At the end of three weeks the man was sent to Elvas, in a
favorable state for recovery.
324. When an opening is made into the cavity of the chest in the dead
body, the lung recedes from the pleura lining its wall, for some
distance; it is said to collapse; but this does not take place in
anything like the same extent in the living body; and if the continued
admission of air through the wound be prevented, it scarcely takes
place at all; or, should it have done so, the air is usually absorbed
and the lung quickly recovers its natural dimensions and functions.
Neither does a wound in the chest, when kept open, usually cause this
collapse to the extent which it is generally supposed to do in the
living body. The lung can be seen in motion and performing its office,
although imperfectly, as it does not fill the cavity of the pleura.
When the lung has been wounded by a ball actually going through its
substance, it does not necessarily collapse; and abrasions or deeper
injuries of its surface lead to no such result. To cause the complete
collapse of a living lung, its surface must be compressed by a fluid,
as in empyema, or by confined air, as in emphysema or in pneumothorax.
In extreme cases, when the patient can no longer lie down, but sits
up, supported, in the greatest agony of respiration, approaching to
suffocation, the face and lips swollen and blue, the pulse almost
imperceptible and countless, an opening should be made into the chest
by a small trocar and canula, for the purpose of evacuating the highly
compressed and compressing air, and to allow the expansion of the lung
after its evacuation. When this compressed air has been drawn off, as
in the case of Lord Beaumont, the compressing power being removed, the
lung expands in part, if not entirely, in spite of the breach in it,
and the mediastinum and heart return to their natural situation, the
distress in breathing is removed, the failing circulation is restored,
and the opposite lung resumes its functions.
The course then to pursue in such extreme cases is merely to puncture
the chest, evacuate the air, withdraw the canula, and close the
opening. The life of the patient having been thus saved, time is
given for the wound in the lung to heal under the usual inflammatory
processes, provided it will do so without a recurrence of the mischief.
This, if it should take place, must be met by another puncture, or the
opening in the chest should be made permanent in order to equalize the
pressure of the air in the cavity.
The incisions (the “_taillades_” of the French) into the cavity of the
chest formerly recommended, should only be resorted to when the means
indicated have failed, which they will rarely do when combined in the
first instance with an antiphlogistic treatment, aided by sedatives,
and if necessary by cordials.
The advantages to be derived from auscultation in these cases are
evident. Its value has been sufficiently shown, and the ear or the
stethoscope should be resorted to at least three times in every
twenty-four hours, in every case, however trifling it may appear to be,
until the absence of danger has been ascertained.