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 XXI.

GENERAL BLOOD-LETTING, ETC.

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.

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.