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.