Chapter XVII: Part 17

In the second kind of protrusion, or that which usually although not necessarily takes place when the first or active inflammatory symptoms are on the decline, the tumor is formed of the substance of the brain. It has been supposed that in whatever manner a case of hernia cerebri may arrive at a favorable termination, there must inevitably be a loss of brain proportionate to the extent of the protrusion--a conclusion which the experience of the Peninsular war did not confirm, while it may lead to the establishment of an erroneous practice for the too early removal of the protrusion. The loss of a portion of one of the hemispheres of the brain is now known to occasion little or no inconvenience in many instances, either to the intellectual or corporeal faculties; nevertheless, as the precise quantity of brain which a person may lose with impunity has not been ascertained, it may be as well not to deprive a patient of any, provided its removal can be dispensed with; and that it may be so dispensed with, the practice of that war gave positive proof in several instances, by the protruded part being gradually withdrawn within the skull, the wound having afterward healed by the ordinary processes of nature.

There were three cases of recovery from a protrusion of the brain after the battle of Toulouse.

Bernard Duffy, 40th Regiment, aged twenty-four, was wounded on the 10th of April, and admitted into the Caserne de Calvete Hospital, on the 13th, with fracture and depression of the upper part of the os frontis. Some portions of detached bone were removed; he was largely bled and purged.

On the 14th, he complained of severe pain in the head, giddiness, dimness of sight, and drowsiness. The pupils were much dilated; pulse 60, and full. An incision was made down to the bone, and the divided arteries were allowed to bleed freely. One perforation was made by the trephine, and the whole of the detached and depressed pieces of bone, which were of considerable size, were removed, one of them having penetrated the dura mater.--15th. Has less pain in the head; pulse full and slow; pupils dilated, with a tendency to coma, but he is sensible when spoken to. V. S. ad ℥xxiv. Continue the purgatives.--18th. Is less drowsy; pupils more contracted. The surface of the dura mater is sloughy, and a small, dark-colored excrescence is rising up through the opening in the cranium.--22d. The fungus cerebri has considerably increased in size during the last few days; in other respects he is doing well.--24th. The wound looks clean; the discharge is healthy. The fungus increases in size, and is rather above the edges of the wound; some sloughs have separated from it, and it has now a red and tolerably clean appearance.--26th. The wound granulates regularly; the excrescence seems to enlarge rather at the base than at the upper part; it was touched slightly with lunar caustic without any pain or unpleasant symptom being produced.--30th. Continues doing well. The pupils are still somewhat dilated, but contract readily on the admission of light; appetite good; bowels regular; and the patient says he has no complaint. Discharge from the wound healthy; the fungus is prevented from increasing by a slight application of the argenti nitras every second day. He has not required any medicine for some time past.--May 6th. The wound has closed around the fungus, which is a little above its edges; it is touched slightly every day with lunar caustic or the sulphate of copper. The pulsation of the brain elevating and depressing the fungus is perfectly distinct; no constitutional derangement. Was discharged cured to Bordeaux.

William Donaldson was admitted, on the 13th of April, 1814, into the Dépôt de Mendicité Hospital, having received a gunshot wound in the head on the 10th of April, which fractured the right parietal bone to a considerable extent. The brain protrudes; pulse quick and small; bowels open. V. S. ad ℥xvi.--14th. The pulsation of the brain is evident, and the protrusion increases; he complains of no particular pain; the discharge is profuse, and of a thin, black, watery quality; pulse 90; bowels freely open. V. S. ad ℥xvi. Continue the purgatives.--15th. The pulse and bowels natural, the protrusion has scarcely increased; discharge profuse, and still gleety; a small compress was laid over the dressings, and a bandage was lightly applied.--16th. Pulse and secretions natural; the wound looks more healthy; the discharge something better in appearance; the fungus does not increase.--19th. Is doing well, and does not complain of pain; functions natural; the protrusion somewhat less; discharge good. A small quantity of cloth has come away.--21st. Discharge improved. Continue the purgatives.--26th. The protrusion evidently diminishes, and begins to heal at the edges.--30th. The hernia cerebri has considerably diminished; secretions natural; a small quantity of bone has come away; discharge diminished.--May 4th. The wound is healing rapidly; the patient is now permitted to get out of bed, and has half diet. Another very small piece of bone has come away.--10th. The wound is now nearly healed.--Between the 15th and the 25th several small pieces of bone came away.--On the 26th, on introducing the probe, a small piece of bone followed it; and on further examination a large piece was felt quite loose, and was removed by incision. Discharged cured to Bordeaux.

Gentle pressure was made on the protrusions, according to the feelings of the individuals, in both these cases; when made too firmly, it gave rise to swimmings and pain in the head, retardation of the pulse, a sense of sickness and fainting, and on one occasion to syncope. Pressure could only be borne when very lightly applied while the protrusion was increasing, but could be gradually augmented when it became stationary, and during its diminution and secession. The pressure was continued until after the wound had healed.

I had occasion, at Santander, to remove a portion of bone, including the upper part of the lambdoidal suture of the right side, from the head of a soldier of the Light Division, in consequence of symptoms of irritation having come on after an irregularity in drinking. He had been wounded by a musket-ball on the heights of Vera, which had fractured and depressed the skull at that part some weeks before. A piece of bone was depressed, and had irritated the dura mater at the part; the membrane had some matter upon its surface, and was evidently abraded. The operation gave relief, but a tumor soon sprang up, evidently composed of brain. The patient was again bled, purged, and starved; calomel and opium were given in moderate doses, and the protrusion ceased to increase; about the same time it changed color, became yellow, fetid, softer, and soon wasted away, pieces of dead matter separating at each dressing, until it sunk within the level of the skull; after which healthy granulations sprung up, and the wound healed.

In the fatal cases, paralysis, accompanied by stupor and other symptoms of compression of the brain, invariably supervened before death.

The preceding cases prove that persons may recover after having had a protrusion of the brain, without as well as with the loss of a portion of its substance, the difference in all probability between the cases being dependent on the degree of mischief which gave rise to them. In the fatal cases I have seen, the protrusion was manifestly a part of the substance of the brain, and firmer than the hemisphere beneath, which was soft, pulpy, and of a yellow and sometimes of a reddish color, the lateral ventricle being filled with a sero-purulent matter, pus being also spread over the surface and intermingled with the pulpy structure, into which the brain had been changed. The protrusion was the consequence of low inflammation of the brain; and greater caution had been necessary during the progress of the mischief than had been enforced. It was the observation of this, and of other circumstances not less important, which led me to enjoin that rigid system of management insisted upon in all cases of injury of the head. There can be no doubt that the formation of many of these protrusions was aided by the opening made in the dura mater, which would have restrained their growth if it had been sound. The dura mater therefore should never be opened if it can be avoided.

It has been proposed to destroy protrusions of the brain with escharotics, and by ligature; and more faith has sometimes been placed in the knife for their early removal than in the more deferred operations of nature. Greater reliance may, however, be placed on the efforts of nature, assisted by a methodical treatment of the low inflammatory state of the brain, and by such pressure at a later period as can be borne with comfort, and persisted in with propriety.

286. It has been supposed that abscess of the liver followed injuries of the head in a more peculiar manner than injuries of other parts of the body, an opinion upon which too much reliance should not be placed; for experience has induced me to think that unless the liver be really injured by a fall or blow, it only becomes affected in a secondary manner, in a similar way to the lungs or other viscera, or to the joints or other parts. The new disease in these cases is always insidious in its nature and progress, and for the most part fatal in its result, as has been explained at length, (Aph. 59, p. 62, et seq.)

287. When a person has received a serious blow on the head, which has given rise to an exfoliation of the bone, or to a very slight depression of the skull, he is rarely restored to his previous healthy and natural state. The scalp adheres firmly to the bone beneath, instead of sliding loosely over it, and a deep hollow is formed, which would imply that greater mischief had been done and a greater loss of bone had been sustained than had actually occurred. This is the more remarkable when pieces of bone have been removed. Major D., of the Indian army, was wounded on the left side of the forehead, at its upper part, by a musket-ball, at the assault of Maheidpoor. Several pieces of bone were removed, and the pulsation of the brain was evident under the discharge. The point of a little finger passes into the hole left by the cicatrization of the wound, to a greater extent than might be expected. This officer suffers from headaches, augmented or brought on by any exertion of body or mind. He cannot bear exposure to the heat of the sun. He can scarcely drink three glasses of wine without feeling their effect. Persons so afflicted can bear no great exertion of any kind. They fall down under exposure to heat. They are easily inebriated, rendered furious by a small quantity of liquor, and often become stupefied, comatose, or even die suddenly. In addition to these evils, which may be avoided by care, many are subjected to fits, which are apparently epileptic; and others suffer from such intolerable pain in the part injured, as well as in the head generally, as to be desirous of seeking relief by an operation, even at the risk of life.

These injuries are often accompanied during their progress by mental defects which time does not always remove. The memory is very often much impaired; it is frequently defective as to things as well as to persons. The sight of one or of both eyes may be impaired, or even lost. Ptosis, or a falling of the upper lid, is not an uncommon although a more curable defect. Speech is not only difficult, but the power of uttering certain words is often lost; a language is occasionally for a time forgotten, and a sort of conventional one has even been adopted, under my own observation. The more serious evils which befall these unfortunate sufferers are aberrations of mind, rendering some degree of restraint necessary, or a state of fatuity, which is not less distressing. These intellectual defects are often accompanied by various states of lameness or debility, from which there is but little hope of recovery. Pathologists have supposed that concussion of the brain is frequently accompanied by, and may indeed be essentially dependent on, small extravasations of blood in various parts of or throughout the brain, not larger than the point or head of a small pin, constituting, in fact, a derangement which, when general, is destructive of life, and, when partial, may sometimes be the cause of the various defects which follow injuries of the head.

288. It is an interesting fact that a person who has been shot in the head, or has fallen from the top of a house, so as to become insensible, has no knowledge of the circumstance; and when, after several days or weeks, he regains his senses, he has no recollection of the injury, or of having received the wound; or if he should have fallen from a height, he only remembers that he was aware he was about to fall, but of the actual descent, or of the injury, he knows nothing.

289. The trephine, which is worked by turning the hand, and makes therefore only a half turn, necessarily saws unequally; but the operator has the advantage of being able to press with it on any particular part as the sawing of the bone draws to a close, and can thus cut any portion of the bone which is thicker than the rest without wounding the dura mater. The division and yielding of the last layer of bone is very sensibly felt by the hand, and when sawing, the surgeon can use the trephine as a slight lever with great effect, by pressing on a particular part, or from side to side, and the inner layer of the vitreous table may be in this manner as much broken as sawn through. The piece to be removed should never be brought away in the crown of the trephine, but should be raised by the forceps and lever; whenever a rough edge of the inner table remains, it should be carefully rounded off with the lenticular or blunt-ended instrument commonly used for that purpose.

290. Whenever there has been a loss of the integuments or scalp, so that this part cannot be brought over the opening made by the removal of the bone, some fine soft cotton should be laid on the dura mater, so that a slight degree of support may be given to that membrane, more particularly when it is thought that it may not be necessary to examine it for two or three days. When circumstances appear to render a daily inspection necessary, the cut portions of the scalp should be brought over the opening, and retained by a slight compress and bandage kept constantly wet and cold. The dura mater usually changes color and becomes more red; a layer of lymph is seen adhering to it, from which granulations arise and spring up until they touch the scalp, to which they unite, or cicatrization takes place. When the patient dies early from other causes, and the calvarium has been raised, the discolored spot on the dura mater marks the place from over which the bone was removed. I have seen this in a state of slough, and the only apparent discoverable mark of disease.

One of the improvements in modern surgery is to be found in the restriction which has gradually been placed on the repeated use of the trephine on the same person, and on the removal of large portions of the skull. Cases are not, however, wanting in the older authors which would appear to justify the proceeding, although it may perhaps be said that they only show how great an extent of injury may sometimes be committed with impunity.

Saviard trepanned one person twenty times. Russ Martel and Le Gendre, surgeons to the King of Navarre, say that in the year 1686 they took away nearly both parietal bones, and the patient recovered and lived for thirty years afterward, half his body, however, being paralyzed. Marechal applied the trephine twelve times successfully, Gooch thirteen times, Desportes twelve times. Saviard says that he had under his care a woman whose parietal bones, together with a great part of the occipital and frontal, separated at the end of two years after a blow; the bones thus separated resembled a calvarium sawn off a dead person. No fungus or hernia took place, and she lived for several years afterward.

Dr. Drummond, deputy inspector-general of hospitals, has published the case of a seaman belonging to H.M.S. “Mutine,” who in 1845 fell down some stone steps at Sierra Leone, receiving a contused wound on the scalp, for which he was admitted into the Royal Naval Hospital at Plymouth in October of the same year. The bone, which was not supposed to have been injured, was then found to be denuded of its pericranium to some extent, (left side of occipital.) After an attack of erysipelas, followed by numerous purulent deposits under the scalp, necrosis went on rapidly; there was oozing of pus from beneath the diseased bones, and gaping of the coronal and sagittal sutures, the brain pulsating very distinctly in the spaces. In July, 1846, he was removed to Melville Naval Hospital at Chatham. During the six years he has been under observation, there have been repeated attacks of erysipelas, followed by profuse suppuration. Both tables of the bones have suffered in some places; in others only the external. About five square inches have been lost from the right side of the frontal, right parietal, and squamous part of the right temporal. The whole of the occipital to within a short space of the foramen magnum is deficient, with the exception of about two inches in the center of the bone, which are now undergoing the process of separation. On the left side, Dr. Drummond adds, there has been less destruction of the bones, but extensive caries was going on there, and fetid pus was being discharged from several openings at the date when the case was reported, (April, 1851.) At no point was there any tendency to reproduction of bone, or arrest of the disease.

291. The removal of a large portion of the skull may be necessary where the broken portions are deprived of their natural support and connections, but as little should be taken away as possible. When the loss of sense and motion is accompanied by fracture, and continues to increase rather than to diminish, after the necessary and usual means have been adopted for its relief, a piece of bone should be removed. If blood should be found in any quantity on the dura mater, it may be necessary to take away more bone to admit of its free discharge; for although the gradual pressure of the brain from within will tend to expel it, this object may not be attained in sufficient time, and the patient may be lost. The older surgeons in these cases were anxious to ascertain how far or to what extent the dura mater was separated from the skull, and they often removed large portions of bone accordingly; although their practice should not be implicitly followed, repeated observation has shown that modern surgeons have often fallen too much into the opposite extreme of doing nothing. When blood has been evacuated in this manner, the parts must pass from a state of inflammation into that of suppuration before the dura mater can again adhere to the superincumbent bone, and care must be taken that the matter shall have a free discharge. If symptoms of fever, followed by those of commencing compression, should supervene from the granulations arising from the dura mater filling up the opening and preventing its exit, they should be excised; or if the matter should have gravitated in a direction which does not admit of its being discharged, the opening in the skull should be increased so as to remove the impediment, and thereby lessen the danger.

A layer of blood is often extravasated very thinly over the whole surface of the brain and cannot be removed, although it may be absorbed. It is, on the other hand, often collected in larger quantity on the basis of the cranium, whence it will not be absorbed and cannot be removed. It may be extravasated without reference to the part on which the blow has been received, giving rise in the end to symptoms of epilepsy or apoplexy, for the relief of which no surgical operation can avail; but when a blow has been undoubtedly received on a part of the skull, and any sign of mischief can be perceived on or in that part, the removal of the bone is permissible.

292. The wind of a cannon-ball has been supposed to exert some influence on the brain when passing close to the head; there is, however, no valid foundation for the opinion. An officer of the fifth division was struck by a cannon-shot, during the assault of Badajos, on the right side of the head and face. It carried away the right eye and the whole face, the left eye hanging in the orbit, the floor of which was destroyed. A part of the lower jaw remained on the left side, but a great part of the tongue was gone. He had lost a large quantity of blood, but was quite sensible. In the middle of the next day he suffered much from the want of water to moisten his throat, which could not be procured. After a distressing delay of three or four hours under a hot sun, a small quantity was obtained, the arrival of which he observed; and while I was giving directions relative to its distribution, I felt a gentle tap on my shoulder, and on turning round saw this unfortunate man standing behind me, a terrific object, holding out a small cup for water, not one drop of which he could swallow. Alone among strangers, he felt that every kindness in our power to offer was bestowed upon him, and he contrived to write his thanks with a pencil, which he gave me when he pressed my hand at parting at eleven at night. I was glad at sunrise to find he had just expired.

293. When a portion of bone is as it were sliced off with the scalp and adheres to it firmly, the scalp and bone should be reapplied; and the cure will often be effected without difficulty. When the portion of bone cut off and hanging to the scalp, which is turned down, has but little adherence, it should be removed.

A German dragoon was brought to me in front of Madrid, who had received a slicing cut of this kind on the top and side of the head, which caused a portion of the scalp and parietal bone to be turned down over the ear, uncovering the dura mater. Replaced and retained in its situation, the flap and bone appeared to adhere, and the man recovered. In the case of a Portuguese soldier cut down by the French cavalry in a sortie during the second investment of Badajos, a portion of bone cut off with a flap was quite loose, and was removed. The patient did equally well.

In the museum of the Royal College of Surgeons there are ten skulls which have suffered from very severe slicing cuts. They appear to have been collected from the burial-place of some establishment for invalid soldiers in Germany. The portions of bone thus sliced, and they are large pieces, were once detached, and afterward reunited a little out of their proper places, so that the points of separation and of union can be distinctly seen. These fissures are all in a certain state of progress toward being filled up by bone, and the patients must have lived some months, if not years, after the receipt of their respective injuries; for bone is deposited apparently with difficulty and most carefully in all such cases, so as not to irritate the membranes of the brain. The opening in the first instance is filled up by granulations, over which a thin skin is formed; this afterward becomes firmer and harder, being in some cases, where the trephine had been used, a thin but strong membranous expansion extending from one edge of bone to the other. In others it is thicker and more solid, and in a few instances osseous matter is deposited in its circumference, so as in part to fill up the opening, the edges of the bony circle made by the trephine becoming gradually thinner as they appear to grow inward. It is common for an exfoliation to take place in such cases from the edges of the cut bone, and from the circle made by the trephine. It has been occasionally observed, after death, that the circular cut edge of the bone does not become thin in the manner described, but that a sort of ridge forms around and within it.

When the scalp is torn down without being much bruised, and a large flap extending from the occiput to the forehead falls down on the shoulder, covered with blood or dirt, the flap should be cleansed and restored to its place. When it is large, two or three sutures may be necessary to keep it in its proper situation. The flap may not entirely adhere under any management, but it will do so in parts; and care should be taken to evacuate at an early period any matter which may form by small but sufficient incisions made where required; this will in general be above and about the ear. When the flap is much bruised, the attempt at adhesion by close apposition will be useless until after suppuration has taken place, when a well-regulated pressure will do much toward expediting the cure.

294. Erysipelas occurs in two forms: when the skin has the ordinary redness characteristic of the complaint, and when the color of the skin is not altered or is whiter than natural, but puffed, tense, and shining, the inflammation being seated beneath the tendinous expansion of the occipito-frontalis muscle.

The general treatment should be regulated by the powers of the patient and the state of the constitution, (Aph. 24, page 39.) The local treatment of the first form essentially depends on puncturing the red and inflamed skin all over with the point of a lancet, assisting the flow of blood by warm fomentations. The punctures should be repeated, if necessary. The second form is to be treated by incisions, perhaps the greatest improvement of the surgery of the Peninsular war.

The scalp in such cases is in a state of general puffiness, causing the head to look considerably larger than usual, but without redness; it retains the impression of the finger. Incisions are to be made in the scalp from two to four or six inches in length, united by others, if necessary. The scalp will often be upward of an inch in thickness, and filled with a fluid partly serous, partly purulent. The small arteries bleed freely, and should be allowed to do so as long as may be desirable, when the hemorrhage should be arrested by pressure. The head should be fomented. The essential points are, to take off tension, and to allow the free discharge of any fluid which may be secreted. The moment the parts around a wound have become puffy, the surface of the wound changing from a red to a yellowish color, with a thin discharge instead of good pus, an incision should be made through them, and repeated, if necessary. It relieves the tension and the irritative fever, and prevents the delirium which would follow; which neither bleeding, purging, nor the other constitutional remedies which the state of fever may indicate will remove. If it should be neglected, suppuration and sloughing will extend under the tendon of the occipito-frontalis, or the fascia of the temporal muscle, and the greatest danger will be incurred from this additional cause.

LECTURE XX.

WOUNDS OF THE CHEST.

295. Wounds penetrating the wall of the chest, and implicating any part or portion of its cavity or contents, are among the most dangerous of injuries. They require in their treatment a more careful attention and a greater extent of knowledge than most others which befall mankind. The means which the improved methods of auscultation have afforded cause the progress of the symptoms which follow to be less obscure, and lead to a less doubtful practice than formerly; while they render a knowledge of this branch of medical science an essential part of the education of a surgeon.

296. _Incised_ or _punctured wounds_, from swords, lances, bayonets, or knives, require a treatment _essentially distinct_ on many points from that of _gunshot_ wounds, especially in the commencement. On this early treatment so much depends, that details of the more serious or more important cases are rarely found among the records of injuries sustained on the field of battle, where so much is often to be done, and so few are to be found to do it.

The simplest of the more serious results from injuries not penetrating the chest is the occurrence of inflammation, either of its lining membrane, giving rise to what is called _pleuritis_, or of the substance of the lung, termed _pneumonia_, or of both, constituting what has been named _pleuro-pneumonia_; but many severe blows on the chest are not followed by such serious consequences.

On the 17th August, 1808, in the act of leaving the village of Colombeira to ascend the heights of Roliça, a soldier was shot in the leg: he jumped up three or four feet, and made a considerable outcry. A second was struck at the same time by a ball on the shoulder, which did not penetrate, but gave him great pain. A third received a ball on his buff-leather belt, on the right breast. The noise made by these two blows was unmistakable. I saw this man fall, and supposed he was killed: the ball, however, had only gone through his belt, and made a mark on his chest, over the cartilage of the fourth rib, the hardness and elasticity of which had prevented further mischief. He recovered in a short time, spat a little blood in the night, and after a large bleeding was enabled to accompany me on the 20th to Vimiera, ready for the fight next morning.

A soldier was struck on the hill of Talavera,[4] on the breast-plate by a ball, which, as he believed, had gone through his body. He was as white as a sheet, and desperately frightened. On opening his coat, I found the ball had indented the breast-plate, and made a round, red mark on the skin, without going deeper. I did not see him again for several days, until after crossing the bridge of Arzobispo, on the retreat to Truxillo. He was then engaged in disemboweling a fine fat wild hog, among a herd of which we had, unluckily for them, just fallen. He recognized me at once; said that, as I told him, he had been more frightened than hurt; that he had been bled largely and well physicked, and after two or three days had thought no more of it. I am bound to add that, in gratitude, he offered me a leg of the pig, which, having nothing to eat, I could not but accept. It supplied a dinner for three others who are now no more.

[Footnote 4: The Duke of Wellington received a blow from a spent ball at the same time, near the left clavicle.]

A soldier of the 40th Regiment slipped from the ladder on which he was attempting to scale the wall near the great breach of Badajos, and fell on his cartridge-box, which hurt his left side so much as to render him unable to move for some time. On the 8th of April he was much worse. The part injured was painful to the touch; the difficulty of breathing considerable; cough hard, with little expectoration; pulse 90, skin hot, appetite gone, tongue white. V. S. ad ℥xvj, and aperients. 9th. Better; pain less; expectoration more in quantity, and viscid. V. S. ad ℥xii; antimonials. 10th. Pain still felt on coughing; expectoration reddish; difficulty of breathing greater. Pil. cal. et antim. c. opio; V. S. ad ℥xvj. He gradually recovered (his mouth having become slightly sore) from what was manifestly an attack of pneumonia. A gentleman, in 1835, fell from his shooting-pony on his powder-horn, which bruised his right side from the seventh to the last rib, and, as he said, knocked the breath out of his body, and hurt him so much as to render him incapable of walking from one room to another from pain in the side, back, and thigh. No bones were broken. The pain, on the second day, was augmented on breathing and on attempting to cough. The third day he was purged, and blooded to sixteen ounces, which gave some relief; but as the symptoms increased on the fourth day, he was more carefully examined. His right side could not bear pressure. The respiratory murmur was distinct, but accompanied by a crepitating rhonchus under the part injured. Cough troublesome; expectoration mucous, viscid, and of a reddish tinge. Antim. p. tart. and sulphas magnesiæ, every four hours. V. S. ad ℥xiv. On the fifth day, the symptoms being little altered, he was cupped on the part affected to fourteen ounces. On the sixth, the pain was only felt on coughing, or on drawing a very full breath; expectoration redder and thicker; pulse quicker. The rhonchus was quite as distinct. V. S. ad ℥xij, and the medicines to be continued. After this he quickly recovered and the natural respiration became distinct.

Lieutenant Cooke Tylden Patterson, of the Light Division, was struck on the left breast by a musket-ball, on the morning of the 15th of July, 1813, in front of the village of Vera, in the Pyrenees. He fell on his back breathless, as if he were killed. While waiting the order to advance, he had been reading Gil Blas in Spanish, and on receiving it, had hastily put the book in the breast pocket of his coat. The ball had struck this, but, unable to penetrate it, had fallen on the ground at his feet, completely flattened on one side, and marked with the impression of the braid of his coat. A piece of the cover of the book, about the size of a half-crown, was driven in, and the leaves throughout were indented by the ball. It was some days before the effects of the blow entirely subsided.

A soldier of the 97th Regiment was struck at the unsuccessful assault of Fort Christoval, opposite Badajos, by a musket-ball, which went through his brass breast-plate and coat, drove his shirt through the skin, and against the sternum, which it was not able to penetrate. He fell, and was supposed to be killed, but he soon recovered and ran to the rear. The ball was found flattened between his shirt and coat. The part of the chest was very black next day, the spot struck by the ball being much bruised. It was necessary to bleed him largely. When the integuments are painful, although merely bruised, the diluted tincture of arnica is a useful application, and Scheele’s hydrocyanic acid, six drops to an ounce of water, is said to be efficacious.

Major Lightfoot was struck by a musket-ball on the left breast; it went through his clothes, the integuments and the outer part of the great pectoral muscle, and slanted inward for three inches toward the sternum, to which distance its track could be followed. It was evident that the ball had neither lodged nor penetrated, for no serious symptoms ensued. In all probability it had been ejected the way it went in by the elasticity of the cartilages of the ribs near the sternum.

297. In order to understand, or to become in any way acquainted with the changes from the natural structure which are going on under derangement in the chest, even from simple injuries, it is always necessary to have recourse to auscultation, and sometimes, although more rarely, to percussion, if the external parts are not too tender. Under all circumstances both sides of the chest should be examined by the stethoscope. As the ordinary breathing of an individual is rarely sufficiently strong to enable the auscultator to hear it with distinctness, the patient should be desired to inspire fully and more quickly than usual, without much effort, and without noise from the mouth or nose, or retaining his breath. The inspiration and the expiration are both to be carefully observed.

When the ear is firmly and equably applied to the chest of a healthy young person, a very distinct and long-continued sound is heard at the moment of inspiration, and another at that of expiration. This is called the _vesicular_ or _respiratory murmur_, and is dependent on the air fully permeating and distending the air-vesicles of the lungs. It has been poetically compared to the sound of a gentle gale rustling in a thick summer foliage--to the whisper of a retiring wave on a sandy beach in a calm day. It is soft, scarcely sonorous, equable, and during inspiration continuous. In childhood it is louder than in adult persons, arising probably from the greater activity of the lungs in young than in elderly people. This is called, and especially when perceptible in adults, _puerile respiration_, as opposed to their ordinary, or what in old persons may be called _senile_. It is more marked during inspiration.

When the stethoscope is applied in the situation of the great bronchial passages, as over the first bone of the sternum, under the clavicle, in the center of or between the shoulder-blades, a different sound is usually but not always distinguishable, when the patient breathes fully, arising from the passage of the air through these bronchial tubes. It is compared to the noise made on blowing through a reed or quill, and is called _bronchial or tubular respiration_. When heard in other parts of the chest, it is a morbid sound. If the stethoscope be applied over the trachea, the sound is louder, rougher, and more intense, and is called _tracheal_ respiration. On listening over the trachea during speaking, the voice sounds as if it were passing into the ear, and the words are distinct--_tracheophony_. This, if heard in any other part of the chest, is a sign of disease, for in the natural state the voice is heard only to resound through the chest, but the words are not heard if the other ear be stopped. When heard, the sound has been called _pectoriloquy_, and is supposed to imply the existence of a cavity at that part; but the word is unnecessary, or, if used, it means that the cavern or hollow communicating directly with the trachea gives forth a similar or nearly similar sound, a _natural_ sound in an _unnatural_ position. The essential difference between _bronchophony_ and _tracheophony_ in the investigation of disease is, that in the latter the voice apparently speaks through the stethoscope into the ear of the auscultator, while in the former it is heard with scarcely less distinctness, but at the distal end of the instrument. Over the larynx it is louder, hoarser, and rougher.

The length of the sound in inspiration, as compared with that of expiration, has been said to be as five to two. One is louder and longer than the other, a difference requiring attention from the circumstance that morbid sounds of great import are heard in inspiration, which do not prevail during expiration. When any other difference is perceptible between them, so that they more nearly resemble each other in duration or in intensity, or when expiration is prolonged, some structural alteration may be suspected in old persons, some disease in young ones. When little or no respiratory murmur can be heard after symptoms of inflammation have existed for some time, the case is very serious, implying that effusion into the cavity, or condensation of the lung, has taken place to a considerable extent.

298. The number of inspirations in a minute in the adult and elderly persons varies from eighteen to twenty-two in a state of health: from twenty-two to twenty-six in children. The stroke of the pulse is generally as four to one. If the inspirations are eighteen, the pulse will in general be seventy-two. Both may be slower, although they are often quicker under disease. When the breathing is slower, it commonly indicates some affection of the nervous system; when very rapid, some important lesion within the chest.

The theory of percussion is founded upon three elementary sounds, which are produced when a solid, a liquid, or a gaseous body is struck; all others are varieties of these. The sensation of resistance which is experienced at the same time bears an exact relation to the density of these bodies--hence the resistance when a solid substance is struck is greater than when a gaseous one is under percussion. The liver, the thorax in a case of pleuritic effusion, and the distended stomach after a long fast, afford good examples of these elementary sounds. To employ percussion successfully, it is necessary that the strokes be uniform in force and quickness, and that the finger or pleximeter be so applied to the surface that no space exists between them, otherwise such a sound will be elicited as may give rise to an incorrect diagnosis.

It having been stated that a sound lung never fills the bag of the pleura, particularly toward the diaphragm, at least during ordinary respiration, I requested Mr. Quekett, the Resident Conservator of the College of Surgeons, to ascertain this by experiments on some sheep at the moment of their being killed; and it appeared from them that the base of the lung is always in contact with the surface of the diaphragm.

299. In ordinary expiration the chest diminishes in size. The ribs which have been raised recede, by the elasticity of their cartilages, and by the return of the ligaments, to their state of rest; the elevated muscles become relaxed, while others belonging to the lower part of the trunk and abdomen contract. The diaphragm is relaxed, and pushed upward by the viscera of the abdomen, pressed upon by the muscles of its wall, if it should not be drawn upward by the attraction of the lung, which when distended endeavors by its elasticity to return upon itself, and to occupy less space than the capacity of the chest will afford. The lung, invested by an elastic, special, and transparent membrane, and covered by the pleura pulmonalis, is composed of an immense number of air vesicles, the largest being equal in size to the fourth part of a millet-seed. These air vesicles, crowded together, each communicating with a fine bronchial tubule, are separated from each other into groups by a condensed cellular tissue, thicker where it surrounds these lobules, which alternately form, when aggregated together, a lobe, whence it is called interlobular tissue. An artery and vein form a very minute net-work around each vesicle. These vesicles may become filled with water; when dilated by air, they constitute what is called emphysema of the lung. The lung in man is constantly applied to the internal surface of the chest, the pleura or serous membrane covering the lung being closely applied to the pleura lining the wall, and one surface glides upon the other, moistened by a secretion in just sufficient quantity to effect this object. If the lower intercostal muscles of a young animal be removed to a sufficient extent, the lung and the diaphragm may be seen applied to the inside of the pleura lining the rib, and _ascending_ and _descending_ in concert, the lungs moving vertically, not horizontally. The diaphragm ascending, covered by its pleura, is in a similar manner applied to the lower part of the wall of the chest, which had been filled by the lung during inspiration. After death the lung remains closely applied to the pleura, recedes on an opening being made into that membrane, and may collapse, provided no adhesions exist to prevent it.

300. When inflammation of the pleura takes place, the gliding motion is not effected silently, but with a peculiar noise, called by the French _frottement_. When the lung is inflamed, the respiratory murmur is changed in that part, or is overcome by a peculiar sound, which can be distinctly investigated by the ear--_rhonchus crepitans_. Hence the great value of auscultation.

In the following observations it is not intended to give a history of, or even the whole of the symptoms and consequences of inflammation of the pleura and the lungs; but only to draw attention to such of the principal facts as it may be necessary to consider when these inflammations and their consequences are caused by external injuries.

Acute idiopathic inflammation of the pleura usually commences by rigors, preceded perhaps by some signs of general uneasiness, which soon become those of great febrile excitement. Pain is early felt in the side in the course of the sixth, seventh, and eighth ribs, or at the point corresponding generally to the seat of the inflammation. It is usually sharp and darting, is called a stitch, occupies rather a small space, (the _point de côté_ of the French,) and is always increased by drawing a full breath or by coughing. The breathing is short, from the disinclination to fill the chest, by which the pain would be increased; it is hurried, and sometimes takes place as if by jerks, from the necessity for its repetition, in consequence of the smallness of the quantity of air admitted at each attempt. When the attack is very severe the patient tries to breathe with the healthy side only, the lower ribs of the affected side being moved but slightly, and with evident caution. If the inflammation have been caused by extreme violence, pain will also be felt, particularly at the part injured.

When inflammation has affected the pleura covering the diaphragm, especially when caused by external violence, the pain will be felt lower down, so as to lead to the suspicion that it is also abdominal. When jaundice supervenes, it occurs from the extension of disease through the substance of the diaphragm, as is occasionally seen in wounds implicating the chest, the diaphragm, and the liver.

A cough is not a constant accompaniment of the first stage of disease; when present, it is usually dry, slight, infrequent, and does not attract attention, unless accompanied by a thin, frothy mucous expectoration, indicating the presence of bronchitis; of pneumonia, if reddish. The patient usually lies on his back while the pain is severe, and has a great indisposition to turn fully on to the affected side. At a later period, when effusion has taken place, the pain usually subsides, and he turns on the side affected to relieve the difficulty of breathing, caused by the pressure of the fluid on the sound lung through the bulging of the mediastinum; but the manner of lying, or _decubitus_, is of little importance, and should be subservient to the feelings of the patient, who is sometimes comfortable only when raised to nearly an erect position.

When the complaint is not subdued at an early period, an effusion of serous fluid, more or less in quantity, takes place. The whole cavity of the side affected has been known to be filled in from twenty-four to forty-eight hours, giving rise to symptoms dependent on the degree to which the effusion has taken place; _this_ is the evil which in injuries penetrating the cavity of the chest is most to be feared. When the external wound has been closed, or is so partially closed as not to allow the escape of the effused fluid, it is commonly the immediate cause of the death of the patient. Its secretion and early evacuation are therefore the most important points to be attended to in wounds of the chest.

The respiratory murmur becomes less distinct as soon as the pain prevents the ordinary distention of the affected side of the chest, and diminishes the quantity of air which usually penetrates the lung in any given time. As soon as a thin layer of fluid commences to be thrown out between the pleuræ, this murmur becomes fainter, and when it is complete, it ceases. If the patient can bear percussion, the side affected yields a dull, dead sound instead of the ordinary clear, sonorous one of health. The position of the patient when erect, by causing the fluid to descend, may allow of the respiratory murmur being heard at the upper part of the chest; and it may be perceived in front, but not behind, when he lies on his back, until the cavity is filled, when the sound altogether ceases. At the spot in the back corresponding to the root of the lung, or at any other point at which a previously formed adhesion may retain the lung against the wall of the chest, some respiratory murmur may yet be distinguished, until this part of the lung shall also have yielded to the general compression, so as to be temporarily impervious, or have become solidified under the continuance and extension of disease. While this is taking place in the affected side, the other lung is called upon to make up the work of aerification of the blood; it labors harder, its functions become more energetic, and that side of the chest is more distended; the respirations become quicker, fuller, and louder, and the vesicular murmur is said to resemble that of a child--in fact, to be _puerile_.

When the lung begins to be compressed by the circumambient fluid and the respiratory murmur ceases, a peculiar modification of the respiration through the large bronchial tubes may be heard, constituting _bronchial_ respiration. It occurs in pneumonia, in pulmonary apoplexy, and in tubercular disease when the lung is solidified. When the voice is heard through the stethoscope in these complaints, the peculiar sound emitted is called _bronchophony_.

In pleuritic effusion, the voice, when carefully examined, sometimes obtains a character not previously noticed, but of comparatively little importance, called _œgophony_, a sound which may be easily confounded with bronchophony, of the latter of which it is a modification more often alluded to than observed. Laennec says: “Simple œgophony consists in a peculiar resonance of the voice, which accompanies or follows the articulation of words. It appears to be sharper than natural, more acute and somewhat silvery, vibrating, as it were, on the surface of the lung more as an echo of the voice than as the voice itself. It rarely enters the tube of the stethoscope, less frequently traverses it completely. It has besides another peculiar character, which is constant, and from which I have taken its name. It is a trembling, bleating, or shaking sound, like that of a goat, the tone of which animal it greatly resembles. When it occurs near a large bronchial tube, as in the root of the lungs, a more or less marked bronchophony is often superadded.” This sound may pervade the whole side; it is usually, however, most distinct near the inferior angle of the scapula, the patient being erect. It only exists where the effused fluid is small in quantity, and is never a dangerous symptom; its return, after it has been present and has disappeared, is a sign that a part of the effused fluid has been removed. It is a sign principally of value in distinguishing between pleuritis and pleuro-pneumonia and pure pneumonia, in which latter disease it is not heard, as in that complaint fluid is not thrown out into the cavity of the pleura.

301. In pneumonia or inflammation of the substance of the lung, as distinct from any implication of the pleura, which, however, most frequently obtains after blows on, and in cases of penetrating wounds of, the chest, the symptoms differ. The ordinary febrile symptoms are similar to those of pleurisy, only more intense; they usually precede for a day or two the local symptoms of difficult respiration, pain, and cough. The dyspnœa varies in different people. In some it is only a slight embarrassment of breathing, admitting of partial removal by accelerating the number of the respirations, which are augmented from twenty to thirty, forty, and upwards, and in children to sixty and seventy, marking a great degree of distress and of extent of inflammation, from which, when they are so frequent, persons rarely recover. The patient can scarcely speak or lie down, and is obliged to be supported in that which he finds to be the least uneasy position. Pain is not always present; it is even said to be more frequently absent when the substance of the lung is affected, and not the pleura. That pain is not a necessary concomitant of pneumonia, is admitted, but that it is usually present, and with great intensity in many cases, cannot be doubted. When present, it is usually an early symptom, deep seated below the sternum, under the breast, extending to the scapula. When in the sides it is more acute and fixed, and is probably conjoined with the pain of pleurisy.