Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE XX.

WOUNDS OF THE CHEST.

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.

[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.