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.