Part 42
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.
_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.