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.