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.

323. Mr. J. Bell had so alarmed all military surgeons by stating, in his able discourses on the Nature and Cure of Wounds, that emphysema was “peculiarly frequent in gunshot wounds of the chest, both at the orifice of entrance and of exit of the ball,” that they thought of little else. They could not withstand the brilliant manner in which this remarkable error—for error it is—was expressed. To such of us as had served in the first part of the war in Portugal it was no longer a bugbear; we slept in peace after the battles of Roliça and Vimiera, of Corunna, of Oporto, and Talavera—laughing, perhaps, a little at the credulity of the surgical portion of mankind; for the opening made by a musket-ball rarely admits of emphysema. A slanting wound made by a pistol-ball may sometimes give rise to it. After long and tortuous wounds made by swords or lances it is seen more frequently, but then it takes place shortly after the receipt of the injury.

A soldier, at the battle of Albuhera, was wounded in the right side of the chest by a sword, which had passed slantingly under the shoulder-blade, from which injury he did not suffer much, until the whole side as well as the body and neck began to swell and impede his breathing, which was effected with some difficulty and with any ease only when sitting up. The external wound was enlarged until I could distinctly hear the air rush out and see the part where the weapon had penetrated between the ribs; upon which he declared himself relieved, when the wound was closed by compress and bandage. It did not unite, however; active inflammation of the cavity of the chest ensued, requiring frequent and considerable losses of blood for its suppression. At the end of three weeks the man was sent to Elvas, in a favorable state for recovery.

324. When an opening is made into the cavity of the chest in the dead body, the lung recedes from the pleura lining its wall, for some distance; it is said to collapse; but this does not take place in anything like the same extent in the living body; and if the continued admission of air through the wound be prevented, it scarcely takes place at all; or, should it have done so, the air is usually absorbed and the lung quickly recovers its natural dimensions and functions. Neither does a wound in the chest, when kept open, usually cause this collapse to the extent which it is generally supposed to do in the living body. The lung can be seen in motion and performing its office, although imperfectly, as it does not fill the cavity of the pleura. When the lung has been wounded by a ball actually going through its substance, it does not necessarily collapse; and abrasions or deeper injuries of its surface lead to no such result. To cause the complete collapse of a living lung, its surface must be compressed by a fluid, as in empyema, or by confined air, as in emphysema or in pneumothorax.

In extreme cases, when the patient can no longer lie down, but sits up, supported, in the greatest agony of respiration, approaching to suffocation, the face and lips swollen and blue, the pulse almost imperceptible and countless, an opening should be made into the chest by a small trocar and canula, for the purpose of evacuating the highly compressed and compressing air, and to allow the expansion of the lung after its evacuation. When this compressed air has been drawn off, as in the case of Lord Beaumont, the compressing power being removed, the lung expands in part, if not entirely, in spite of the breach in it, and the mediastinum and heart return to their natural situation, the distress in breathing is removed, the failing circulation is restored, and the opposite lung resumes its functions.

The course then to pursue in such extreme cases is merely to puncture the chest, evacuate the air, withdraw the canula, and close the opening. The life of the patient having been thus saved, time is given for the wound in the lung to heal under the usual inflammatory processes, provided it will do so without a recurrence of the mischief. This, if it should take place, must be met by another puncture, or the opening in the chest should be made permanent in order to equalize the pressure of the air in the cavity.

The incisions (the “taillades” of the French) into the cavity of the chest formerly recommended, should only be resorted to when the means indicated have failed, which they will rarely do when combined in the first instance with an antiphlogistic treatment, aided by sedatives, and if necessary by cordials.

The advantages to be derived from auscultation in these cases are evident. Its value has been sufficiently shown, and the ear or the stethoscope should be resorted to at least three times in every twenty-four hours, in every case, however trifling it may appear to be, until the absence of danger has been ascertained.