Part 41

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.