Chapter XVIII: Part 18

The pulse is quick and sharp, occasionally full and hard, at the commencement of this complaint in young and healthy persons, although it is sometimes small and weak from the beginning, where there is little general power; but this rarely occurs in cases of injury, and is not to be relied upon in opposition to other symptoms.

The _cough_ is usually dry in the commencement of idiopathic pneumonia, rarely recurring by paroxysms, and is without any particular indication; it is soon, however, accompanied with a slight mucous expectoration, which, after some twenty-four or forty-eight hours, begins to assume certain and peculiar characters of the utmost importance as indicating the existence and the different stages of the disease. On the second or third day the expectoration becomes bloody. Each sputum, spit, or _crachat_ of the French is composed of mucus intimately combined with blood--that is, not simple streaks or striæ of blood, as in catarrh; nor is it pure blood, as in hemoptysis. Each sputum is either of a yellow, or rusty, or even red color, according to the quantity of blood intimately mixed with the mucus. These sputa are at the same time tenacious and viscous, adhering so intimately together as to form a homogeneous transparent whole, readily gliding, however, from the basin in which they are held on sufficient inclination being given to it. At this period or stage of the disease, the sputa adhere strongly to each other, but the mass is not sufficiently viscid to stick to the sides of the vessel. When no further change takes place in the sputa the inflammation rarely passes beyond the first stage of obstruction or engorgement, or swelling. When they attain to a more viscous state, and adhere to the inside of the vessel in which they have been received, the progress of the inflammation to the second stage, or that of hepatization, may be feared. In almost every case where the viscidity of the expectorated matter increases, respiration becomes dull or bronchial, percussion of the chest yields a duller sound than before, and the inflammation has attained its highest degree. The expectoration, after being some time stationary, changes its character. If the complaint is to terminate by resolution, or by death, or to pass into a chronic state, the redness and viscidity gradually diminish, and at last disappear. If the rust color and the viscidity should return, there has been a relapse, which the reappearance of the other symptoms will show. When the inflammation is of the most serious nature, and about to terminate fatally, the expectoration diminishes, and at last ceases. In some cases it only diminishes because it cannot be discharged; it accumulates in the trachea, in the larynx, and in the bronchi, until the patient is destroyed. In some rare cases the matter secreted is spit up nearly to the last, and in others, still more rare, the approach of death in the last stage is characterized by a brown expectoration which cannot be mistaken for either of the others which preceded it. If the pneumonia pass into the chronic state, the expectoration becomes yellowish, or somewhat greenish, and at last is purely catarrhal.

Delirium is not an uncommon symptom when the inflammation of the lung is intense in persons of powerful constitutions, particularly during the exacerbation of fever in the night. It yields with the other symptoms when relief is obtained. When, however, it comes on at a later period of the complaint, or when the accompanying fever is not purely inflammatory, or in persons weakened by exhaustion and privation, it is usually a fatal symptom if continued. When mild, it often occurs after repeated and efficient bleedings, which have subdued, but not entirely removed the disease; and yields to opiates and gentle stimulants, by which the pain is removed, although it sometimes remains in a milder degree than before.

The ear discovers, soon after the commencement of the disease, that the natural murmur cannot be distinctly heard, it having been at first partly obscured, and after a time entirely superseded by a peculiar noise, called a crepitating or crepitous rattle or rhonchus. In its purest state it has been likened to the sound of a lock of hair rubbed close to the ear, or to that made by rumpling a fine piece of parchment; or again, to that which is produced by what under ordinary circumstances is called the crepitation of salt, when scattered in small quantities on red-hot coals. This crepitating rhonchus is heard at first in a small part of the lung, generally at the lower rather than at the upper part; it marks the first stage of the disease. It is not of long continuance; the vesicular murmur is either restored, or the crepitating rhonchus ceases to be heard, in consequence of the second stage to this, or that of hepatization, having commenced; the small air-vesicles are no longer pervious; the sound of the breathing, which is now heard, is that of the air more forcibly driven into the larger bronchial tubes causing _bronchial respiration_, which is no longer a vesicular or crepitating, but a whiffing sound, like that caused by blowing forcibly through a quill, or as if little gusts of air were blown in or blown out. The voice betrays to the ear of the auscultator another sign; it descends into the pervious bronchi, and being conveyed to the ear through the solid lung, gives rise to that peculiarity of voice called _bronchophony_, a correct knowledge of which can only be acquired by repeated observation.

When the inflammation of the lung is confined to a small and deeply-seated spot, auscultation may not at first reveal the evil; or it may possibly be overlooked, through the sound part of the lung becoming more active, and giving forth in consequence a stronger and more puerile breathing, which may mislead the listener.

When the vesicular murmur cannot be heard, when the _rhonchus_ or _crepitating râle_ or sound is not present, and bronchial respiration and bronchophony only can be distinguished, the case is one of great anxiety and danger. The second stage of hepatization is passing into the third, or purulent infiltration, of which auscultation shows no further signs, although the matter secreted may be expectorated, in proof of what has taken place. Pus is thus formed, which it is steadily maintained by some pathologists is not deposited in the form of abscess, but is infiltrated throughout the parenchymatous substance of the lung, finding its way into larger bronchial tubes, or being poured out from some parts of their secreting surface; the accuracy of this statement, however, as a rule, may be doubted, from some dissections having proved the reverse.

302. The effects of inflammation of the pleura are well marked; the first is to diminish, if not to annul, the secretion of the exhalation, or halitus, by which it is lubricated; so that its surfaces can no longer glide without noise upon each other. The patient is often made aware of the difference by some uneasy internal sensation; the auscultator, by a rubbing or creaking sound emitted as the inflamed pleuræ, no longer smooth and polished, rub against each other, and become covered by a thick, effused matter, although not actually separated by a liquid. It is a sound which cannot exist after separation has taken place by the intervention of a fluid, or after adhesions have formed; it is, therefore, an early and transitory sign, is frequently interrupted, and returns, as if by jerks, three or four times repeated in succession. The pleura when inspected, after being attacked by inflammation, shows at first but little sign of derangement on its serous surface. It quickly, however, exhibits numberless small vessels, carrying red blood, which are principally seated in the sub-serous cellular tissue, reddening the membrane more deeply in one part than another. These soon begin to take on a new action, leading to the deposition of coagulable lymph or fibrin, which adheres to the inflamed surfaces. These deposits soon assume the determinate form of very thin layers, constituting what are called false membranes; while a serous or sero-purulent effusion takes place, even to filling the cavity of the chest, and which may or may not be ultimately absorbed. When coagulable lymph is first deposited, and about to form a false membrane, it is soft, of a grayish-white color, and does not possess any appearances of organization. Red points are, after a time, perceived in it, which soon become red lines or streaks, on the surface. This organization of the lymph does not depend on the period which has elapsed from the commencement of the complaint. It is seen in the first day of the disease in some cases; it is altogether absent in others, and depends much on the state and habit of the patient. The lymph is sometimes deposited in small drops or spots; in others, in patches of a greater or less size, varying according to the extent of the inflammation which has produced them. When a false membrane is once fully formed, it becomes itself a secreting surface, and may go on augmenting its thickness to so great a degree as materially to diminish the cavity of the chest. I have seen the pleura with a solid deposit of this kind much more than an inch in thickness. In general, it is found in distinct layers, superimposed one upon the other. Whatever may be their thickness, they commonly admit of being separated from each other. The false membranes thus formed, resembling areolar tissue in their properties, may ultimately become cartilaginous, and even bony. When simple adhesions form between the pleuræ, they become lengthened with time; and, although they impede the motion of the lung at first, and may give rise to some uneasy sensations, they gradually become elongated, and give no further inconvenience. The fluid thrown out is serous; is often mingled with flocculi or lymph, which are seen floating in it; it is therefore more or less turbid, resembling whey. It is often nearly colorless and transparent; when the consequence of injury, it is often tinged with blood, forced out from the capillary vessels of the pleura, or of the false membrane, if not caused by the deposition of the fluid coagulated in the first instance after the receipt of the injury.

The quantity of fluid thus thrown out varies from an ounce to several pints; it gravitates according to the position of the patient, unless, when from old adhesions between the pleuræ, it is confined to particular parts. When the cavity of the pleuræ is free, and the fluid is in quantity, it compresses the lung, and diminishes its size by pressing or squeezing the air out of it; it is thus pressed toward the vertebral column, and so greatly diminished in size and augmented in density as to be useless for the purposes of respiration. While the lung is undergoing this compression to its utmost, the mediastinum also yields, and bulges into the opposite side of the chest, carrying the heart more or less with it; so that when the left side of the thorax is thus affected, the heart is seen and heard to beat on the right. The diaphragm now yields in turn, more on the left than on the right side, from the obstacle to its descent afforded by the liver. The intercostal muscles and ribs resist the internal pressure for a considerable length of time, even for weeks; they at last, however, yield; the ribs may even turn a little outward, while the interspaces in thin persons are said to fill out, so as to render that side of the chest nearly smooth, the size of that side, when measured, being larger than the other, in some instances even by two inches, but this rarely occurs unless the fluid within is purulent, and the disease of long standing.

303. After a time, and particularly in wounds of the chest, the effused fluid becomes purulent, the lung, compressed to a small, flattened surface, adheres to the spine by what was its root, if no adventitious attachments have retained it in a different position; and the pleura has become a thick, yellowish-white, irregular, honey-combed sort of covering for it, as well as completely lining the chest. The serous as well as the purulent effusion are both free from any unpleasant odor; unless a kind of gangrene has taken place, when the latter becomes very offensive, and of a greenish-black color, as well as the substance of the false membranes extending to and sometimes beneath the pleura covering the condensed lung, into which openings have even thus been made.

In some cases the surface of the pleura is covered with small tubercles, some as large as a filbert; in others it appears to have a reticular or honey-combed appearance; and in particular cases, large irregularities or excavations may be observed in it when much thickened, being evidently spots of ulceration, which, if they had proceeded, would have ended by allowing passage to the matter outward, until it formed an external abscess, implicating in all probability one or more of the ribs; thus giving rise to an exfoliation which, by being separated internally, might in time be the cause of further mischief, if not previously covered by a thin layer of false membrane. When chronic pleurisy succeeds to a more acute attack, or they alternate with each other, particularly after penetrating wounds of the chest, several layers seem to be laid down one upon the other. This deposit is never so thick upon the pleura pulmonalis; nevertheless it is thick enough in most instances to prevent the lung from again dilating, the substance of it being generally quite permeable to, although so compressed as to be deprived of, air. It is then flattened, drawn upward toward its root against the mediastinum and spinal column, unless by some previous adhesion such a course has been prevented, and it adheres, as it has been often known to do, to the side of the chest. As that adhesion may occur in more than one spot, so may the effusions or deposits take place between them, constituting circumscribed sacs, and rendering the case more complicated.

304. The changes which take place in the structure of the lung in pneumonia are three in number: 1. Engorgement. 2. Hepatization. 3. Purulent infiltration. The formation of an abscess or vomica, and the occurrence of gangrene, may be omitted, as well as of chronic disorders, in the views about to be taken of the disease from injury.

In the first stage of inflammatory obstruction, or that of engorgement, the lung has assumed externally a livid-red or violet color. It is heavier and firmer than in its healthy state, and the natural feeling of crepitation, although greatly diminished, is not extinct. The lung retains the impression of the finger, and pits on pressure as if it contained a liquid, although air-bubbles can yet be distinguished in it, and its cellular or spongy texture is still to be observed. On cutting into it, a quantity of sanguineous or turbid fluid flows from it, mingled with numerous minute air-bubbles. In some places the color of the incised surface is darker and more compact, showing that some progress has been made toward the stage of hepatization. It nevertheless tears with greater facility than in a healthy state.

In the second stage, or that of the red softening of Andral, the hepatization of Laennec--the latter term being in most common use, from the lung assuming somewhat the appearance of liver in solidity and weight--the lung does not crepitate, no air-bubbles pass out of it, but a thick, bloody fluid exudes on pressure, and it sinks for the most part in water. The color is somewhat less red or violet than in the first stage, and lighter and more varied in color when cut into. The openings of the larger vessels and of the bronchi, when cut across, are observed as white specs; the interlobular tissue is thicker and more marked in lines running in different directions; while many little granular points can be discovered, especially with a glass, apparently of a more solid material than the surrounding parts.

The word solidity, or solidification, is sufficiently explanatory in contradistinction to the naturally pervious and crepitating state of the lung. Andral believed that hepatization arises from an excessive congestion of blood, and not from any deposition of lymph. It is not easy, however, to understand, in the present state of our knowledge, how acute inflammation can go on for three or more days without secretion and deposition being added to congestion. That hepatization, or impermeability to air, may take place in the typhoid pneumonia in twenty-four hours, and that it as suddenly seems to be removed, is hardly conclusive, as it shows merely that a thoroughly well-loaded lung ceases to be permeable to air until a part of the load shall have been displaced.

When the lung, inflamed to the second stage, or that of hepatization, is about to be restored to a state of health, a slight crepitation or crackling begins again to be heard at the end of each inspiration; and as this increases, (the rhonchus crepitans redux of Laennec,) the bronchial respiration and voice gradually, or after a time, diminish, until they entirely disappear; while a mucous râle or rattle commences, the index of that free expectoration by which pneumonia usually terminates.

In the third stage of morbid change, or that of purulent infiltration, the lung is of a lighter color, from the intermixture of a new matter in its substance, although in the first degree it preserves its firmness and granular structure. The new secretion is of an opaque, straw or yellow color, and puriform in its nature. This is discoverable more particularly in spots; but as the disease proceeds, it pervades the whole substance of the lung, which becomes softer and more moist, and is easily broken down by the fingers, the granular structure having disappeared. It is more or less a purulent sort of sponge, in which all of the lung that can be perceived under a strong light may be resolved into small blood-vessels, bronchial tubes, and interlobular septa.

These three degrees or stages of inflammation may be met with in the same lung, for the most part gradually intermingling one with the other. The lower part of the lung being ordinarily first affected, is usually the seat of the purulent infiltration of the third stage; while in the tubercular affection, which ends in phthisis, the disease commonly begins in the upper part.

Resolution or recovery from even this, the last of the morbid changes which have been observed, may take place, although it is less likely to do so after idiopathic than traumatic inflammation, in which the lung was previously healthy, and the constitution unimpaired.

LECTURE XXI.

GENERAL BLOOD-LETTING, ETC.

305. The first and most essential remedy in the treatment of pleuritis and pneumonia from injury is bleeding, which should be resorted to in every case, whenever the febrile excitement is really inflammatory. All old people, under such circumstances, unless in a cachectic state, bear at least one bleeding well; they often bear more; and no fact is more important, in opposition to the opinions commonly entertained on this subject. In young people, who have not been reduced in health and strength by privations and hard service, the bleeding should be repeated until the desired object has been effected; the quantity required to be drawn in inflammation, particularly after _injuries_, is often very great. It may almost become a question, in some cases, whether a patient shall be allowed to die of the disease, or from loss of blood; for convalescence is rapid in proportion as the inflammation is of small extent, and has been early subdued. As the first stage of pneumonia only lasts from twelve hours to three days before it passes into the second, and the second from one day to three before matter begins to be deposited, no time should be lost to prevent these evils taking place, if the patient is to be saved, without incurring a risk, from which few escape with health, even if life be ultimately preserved. Bleeding in inflammation of the pleura, in _young_ and _healthy_ persons, should therefore be effected with an unsparing hand, until an impression has been made on the system--until the pain and the difficulty of breathing have been removed--until the patient can draw a full breath, or faints; and the operation should be repeated, from time to time, every three or four hours, according to the intensity of the recurrence, or the persistence of the essential symptoms. The pulse does not often indicate the extent or severity of the inflammation, although it often expresses the amount of the constitutional irritability of the person. It is sometimes exceedingly illusory as a guide, and is never to be depended upon in the earlier stages of disease, when accompanied by pain and great oppression of breathing. Whenever the pulsations of the heart are proportionally much stronger than those of the arteries, we may bleed without fear, and with the certainty of finding the pulse rise; but if the heart and pulse are both weak, the abstraction of blood will almost always occasion complete prostration of strength, and may be fatal.

306. When many years ago in charge of a regiment of infantry, on the top of the Berry Head, the outermost point of Torbay, the men thus greatly exposed were attacked by pneumonia. According to the practice taught in London, I bled my patients three and four times in the first forty-eight hours. I first drew sixteen ounces, then fourteen, then twelve, then abstracted, as the complaint continued, eight ounces; gave tartar emetic, so as to keep up nausea; then calomel, antimony, and opium, and lost my patients. I examined the bodies of all, and found that they had lived to what is now called the third stage of pneumonia, combined in almost all with pleuritis, with effusion, and the formation of false membranes. The disease was essentially a pleuro-pneumonia, varying in different degrees, as the pleura or the lungs were principally affected; and I saw with regret that the disease had not in any way been arrested; that the means employed had been insufficient. What was to be done? My sixteen ounces of blood were increased to thirty, but it would not do. It was evident that, to succeed, no limit should be placed to the abstraction of blood in the first instance, but the decided incapability of bearing its further loss. Every man was therefore bled, when he came into the hospital, until he fainted, and the bleeding was repeated every four hours, or even oftener, as long as pain or difficulty of breathing remained; under this improved practice all recovered.

The lesson learned at Berry Head was not forgotten during the five subsequent years passed in British North America. The men were as healthy, the winds were sharper and colder, the vicissitudes of all kinds greater. Rum was cheaper, newer, and stronger than the gin of Torbay. The local inflammations were often as severe, whether of the pleura or of the lungs, and by no means less so of the bowels. A grenadier, some six feet three inches high, broad, and well framed in proportion, had drank a gallon of rum during the afternoon, and very narrowly escaped, even with the loss of nearly as much of his blood, abstracted in a few hours. His first bleeding was into the washhand-basin, until he fainted, lying on his back, and the bleedings were repeated as soon as he began to feel pain, and whenever he felt a return of the pain he used to put his arm out of bed to have the vein reopened, for Jack Martin was a very gallant fellow. This is given as an extreme case, to be borne in mind under circumstances somewhat similar, particularly after injuries. In common cases of well-marked pleuritis from injury in strong and _healthy_ persons, it is now not unusual to abstract blood by those who rely on its efficiency, until the pain and difficulty of breathing are relieved, or fainting is about to take place. The patient should be raised in bed, the opening in the vein should be large, the flow of blood free. The quantity will vary from sixteen ounces to three times that amount in different people; but the important point is to repeat it as soon as the pain or difficulty in breathing returns. It rarely happens that one bleeding, to whatever extent it may be carried, will suffice to remove the symptoms; and recurrence should be had to this remedy as often as the pain and oppression require, and THE FORCE OF THE HEART will bear it, especially during the first two or three days. It will often be necessary to have recourse to it in smaller quantities for the next four or six days, and again in less quantity on any return of the inflammatory symptoms. Where the patient is likely to faint, he should be bled in the recumbent position; and as it is advisable to take away a sufficient quantity of blood, great care should be taken, by arresting its flow for a time, by giving stimulants, by admitting fresh air, and by sprinkling with cold water, to prevent syncope, which is sometimes dangerous in elderly persons, who may be subject to and who are not readily recovered from it. In the second stage of the complaint, profuse and repeated bleedings do not answer as well; they do not remove the evil which has occurred, although they may prevent its increase. Blood should then be drawn in such quantity only as will relieve the action of the heart, restless under its efforts to propel the blood through a hepatized lung. The quickness of pulse, the cough, the difficulty of breathing, must now be aided and relieved by other means; for although the pulse is not a certain indication, on which dependence can be placed in the early stage of this complaint, the breathing generally is; and as long as the respiration is oppressed, blood should be carefully abstracted, until it becomes manifest that the effect has been to quicken the pulse, while it materially diminishes its power, when it is forbidden.

307. A cupped and buffy state of the blood, together with a firm coagulum, is a satisfactory proof of the propriety of bleeding in the first stage of the disease; but after the effect of mercury on the system has been produced, it cannot be depended upon with the same degree of certainty. When the propriety of further venesection is doubtful, the greatest advantage may be obtained from the use of leeches and from cupping, particularly in cases of injury to the chest. Leeches may be applied by tens and twenties at a time; and when they have ceased to bleed into a warm bread and water or evaporating poultice, they may be replaced by as many more, until the pain and the oppression are removed. Cupping is always to be had recourse to when leeches cannot be obtained, and, when well done, it is frequently to be preferred; cupping to sixteen ounces will usually be found equivalent to forty or more leeches. Both these means often relieve to a greater extent, with less general depression, than a smaller quantity of blood taken from the arm, and are, therefore, at such times more advisable. When blood cannot be obtained from the veins, the arteries must furnish it; and both temporal arteries have been opened with the best effect in injuries of the chest, when blood could not be obtained from the arm, or from the external jugular vein.

308. The effects of bleeding were of old found to be different under different circumstances and in different climates. Asclepiades remarks that while phlebotomy was fatal at Rome and at Athens, it was beneficial in the Hellespont. Nevertheless, at a much later period, Baglivi says: “In Romano, phlebotomia est princeps remedium in plenritide.”

In the Crimea blood-letting has not been so favorably viewed, nor found so serviceable nor so necessary; although the abstraction of smaller quantities than those indicated above, and less frequently repeated, has been found eminently beneficial, the difference being dependent on climate and the impaired vigor of the sufferers.

The remedy first to be administered, and most to be depended upon in the first stage, is tartar emetic, which usually gives rise to vomiting, purging, and possibly to sweating; it should not be omitted because such effects are produced in the first instance. After a few, perhaps three or four doses, the vomiting usually ceases, the stomach tolerates its introduction, and its gradual increase from six to nine, twelve, twenty, or more grains in the twenty-four hours, is often borne not only with impunity, but with great advantage. Vomiting and purging are not desirable, as the effects of tartar emetic are more rapid and beneficial when they give rise to no particular evacuation beyond that of general perspiration. The most valuable remark of Laennec on its use is, “that by bleeding we almost always obtain a diminution of the fever, of the oppression, and of the bloody expectoration, so as to lead the patients and the attendants to believe that recovery is about to take place; after a few hours, however, the unfavorable symptoms return with fresh vigor; and the same scene is renewed often five or six times after as many venesections. On the other hand, I can state that I have never witnessed these renewed attacks under the use of tartar emetic.” He further says that the same favorable results do not occur from its use in pleurisy or in inflammation of serous membranes, as in pneumonia.

309. Mercury is a remedy of the greatest importance in serous inflammations, such as pleuritis, although of less value than tartar emetic in the first stage of pneumonia, than which it would appear to be more efficient in the later period of the stages of hepatization and infiltration, though some physicians place entire confidence on its efficacy in all. It is of most value when combined with opium. Some suppose that the opium merely prevents the irregular action of the mercury; others, in some papers printed in the journals for 1801, state that opium has a distinct curative effect, being capable, when given in large doses, of subduing inflammation, and more particularly of allaying pain, relieving the cough and irritation, and of procuring sleep; in which opinion I fully concur. Opium is highly advantageous in irritable and nervous persons, and will frequently relieve the nervous pain, the pleurodynia which remains after pleuritis, when nothing else succeeds. Calomel in large doses is usually preferred to all other forms, but a difference of opinion has occurred as to what is a large dose; whether two, three, four, six, ten, or twelve grains are large doses, and whether they shall be given every one, two, three, four, or six hours. It has been attempted to solve this question by supposing that in highly inflammatory cases in healthy persons, from three to six, and even to twelve grains, may be given twice or three times a day, with better effect than smaller ones more frequently repeated; but this has not been made manifest.

In cases less inflammatory or complicated with gastric derangement, the disease assuming more of a general than of a local character, the excretions being vitiated, the skin dry and hot, and the tongue loaded, from gr. iss to gr. iij of calomel, combined with three grains of Dover’s powder, may be advantageously given every second or third hour, the great object being to affect the gums as quickly as possible. This is not effected in some cases by any of the quantities given until after a considerable lapse of time, while in others it is accomplished by less than half a dozen grains of the remedy. It has not been ascertained that twenty-four or forty grains given in two or four doses in twenty-four hours will affect the mouth more rapidly than three grains every two hours for the same time, neither is it less liable to cause irritation; while the third or half a grain of opium given every two hours seems to keep up the effect of that remedy with great advantage. It does not materially signify which method is adopted in strong and healthy persons, although the smaller doses are most satisfactory to all parties when the patient is weak and irritable, while the large and less frequent doses often excite great apprehension. It is argued that calomel in large doses never causes the dysentery nor the severe ptyalism produced by smaller doses; that it acts more quickly, and that after giving twenty grains, and repeating it in six hours, any other medicines may be given without interfering with it, although the strictest attention must be paid to diet, generally confining it to very small sups of warm whey. Very serious derangements do, however, follow the exhibition of the large as well as of the small doses, inasmuch as it is impossible to know beforehand what quantity will cause a severe salivation or diarrhœa, which it may be difficult to arrest.

310. It may be concluded that, of the two heroic internal remedies, tartar emetic and calomel, recommended for the cure of inflammation of the chest, tartar emetic is the more appropriate for inflammation of the lungs or pneumonia, provided it be not accompanied by symptoms of gastric inflammation; in which case its use should be superseded by leeches to the epigastrium, and saline aperients, lest the irritation, vomiting, and purging should increase the evil. But care must be taken that one inflammation shall not be allowed to increase, while attention is principally paid to the other, and symptoms of irritation, the _gastro-enterite_ of the French physicians, are not to be mistaken for gastritis. Mercury, in the form of calomel, is more to be depended upon in inflammation of the pleura, over which, as well as over inflammation of serous membranes in other parts of the body, it exercises a remarkable influence.

311. Blisters are never useful during the continuance of acute inflammation of the chest, although their use is indicated when the patient is much exhausted, the pulse weak, and the breathing continues difficult; or in cases in which the disease proceeds slowly, or is becoming chronic, when they often do much good. The same may be said of dry cupping, mustard poultices, and other cutaneous rubefacients, such as the ol. terebinth. used hot, which often do much good in the commencement and termination of slight attacks, or of their supervention on chronic disease, or after injuries.

In the acute stages simple drinks only should be allowed. As soon as the inflammatory action has subsided, the lightest farinaceous nourishment, gradually augmented by the addition of broths, jellies, eggs, fish, and lastly of animal food, should be substituted. The temperature of the room ought to be moderate and equal.

Inflammation of the lungs frequently terminates by the deposition of a white or lateritious sediment in the urine, which is considered a critical evacuation, not however to be relied upon, unless accompanied by a remission of the important symptoms. A moderate diarrhœa and a profuse perspiration are also signs of a favorable crisis.

312. Inflammation of the chest has been hitherto considered as accompanied by inflammatory fever as an essential character, but this is by no means always the case. In large cities, and among troops after hard service, in which they have been subjected to much privation, and in certain epidemics, the accompanying fever often partakes of a low or typhoid character, and becomes infinitely more dangerous. This modification of disease I have known from my earliest years, in different climates, in all of which it proved most fatal. It is a disease formed of a local inflammation accompanied by general symptoms of a low asthenic type of fever, combined with those of marked derangement of the stomach, intestines, or liver, as shown by a dry black, or red black, or brown tongue, offensive breath, diarrhœa, vomiting of a dark-colored or greenish fluid, watery or sanious expectoration, great thirst, headache, a feeble and quick pulse, low delirium, and great prostration of strength. It was marked, on the banks of the Guadiana, by the discharge of lumbrici by the mouth and by the anus. This disease has always appeared to arise from peculiar circumstances, and to disappear when they ceased to exist; such as great privations and exposure to cold and fatigue, the use of ardent spirits without sufficient food, bad air, or other depressing causes. It is sometimes epidemic. The fever is typhoid, the local inflammation latent, and the symptoms of it masked. It may be complicated with inflammation of the stomach and intestines; it may occur in cases of erysipelas, or after wounds or injuries attended with large secretions of purulent matter, or with other complaints. While the symptoms of low fever are general and well marked, those of the latent affection of the lung are not so prominent or even observable. The patient complains but little, and sometimes not at all, of his chest, until attention is drawn to it by a slight cough, and difficulty of respiration, attended by a character of countenance which usually indicates embarrassment in the functions of the lung. It may be brought on by a common non-penetrating injury of the chest.

In typhoid pneumonia, general bleeding, if admissible, is to be had recourse to with extreme caution, even in young and robust persons. Local depletion is oftentimes useful, and perhaps ought to be alone relied upon. The great dependence is on calomel and opium, and after such local depletion as may be thought advisable, counter-irritation by blistering, and the administration of stimulants, such as camphor, ammonia, and wine, in small and repeated quantities. Mild aperients only should be employed, and anodyne injections are frequently useful. While auscultation has thrown a clear and steady light on the nature of the mischief which is going on, it has added little or nothing dissimilar to the practice pursued some forty years ago. The nature of the hepatization or solidification which takes place in the lung in typhoid pneumonia has given rise to some difference of opinion among morbid anatomists, who incline to believe, from the rapidity with which it takes place, and with which it is sometimes removed, that it depends more on passive congestion, and on a typhoid alteration of the state of the blood, than on an altered action in the vessels of the part. This opinion does not seem to be fully supported by dissection, unless it be generally admitted that gray hepatization, and the third stage of disease of the lungs in pneumonia, mean simple congestion.

When the patient survives the imminence of danger in which he is placed by the attack of the disease, and the expectoration becomes copious, with great emaciation, quick pulse, and hectic fever, a slight infusion of senega or of cinchona with ammonia, with a mild and well-regulated diet, and change of air and climate, answer best in aiding recovery.

A typhoid pleuritis is presumed to exist, as a distinct disease from typhoid pneumonia, although the analogy between them is admitted to be close; like it the disease is latent and more frequently pointed out by the sinking of the powers of life than by any new suffering. The signs of effusion may be discovered on auscultation, and the treatment is essentially similar; blistering and counter-irritants being perhaps more useful, if time be granted for their application.

313. Empyema, _from_ εν, _in_, _and_ πυον, _pus_,--a name given to all collections of fluids in, and to the operation for evacuating them from, the cavity of the chest. Empyema is not a special disease, but the result of another; commonly of acute or chronic pleurisy, or of injuries of the chest, which give rise to inflammation, ending in suppuration. When it occurs from the effusion of a serous fluid, constituting a local dropsy, it is usually the result of disease of the heart, or of the great vessels, and is accompanied or preceded by symptoms indicating the existence of those complaints, in which case it is not likely to be benefited by any operation. The disease is then denominated hydrothorax. The serous fluid is generally transparent, although more or less tinged with blood, when thrown out in persons who die within a few days after receiving a wound of the chest. It may, and does occasionally, contain in these cases a large quantity of blood; but an early effusion of blood is not uncommon in very acute cases of pleuritis. It is usually more or less turbid when the result of ordinary inflammation, although the presence of albuminous or purulent matter is not constant. Whether colorless, transparent, turbid, or purulent, it remains free from fetor, unless gangrene has occurred internally, or some communication with the atmosphere has taken place by an external opening.

While the fluid remains transparent, the appearance of the pleura is little changed, but when it has become turbid in any great degree, or flocculent, or purulent, the pleura has lost its natural appearance. In its simplest character, when the fluid is puriform, particularly if the inflammation have not been very active, it is covered with a layer of whitish inorganic sediment, which can be scraped off by the scalpel. This is sometimes quite red, as if loaded with blood which had been deposited upon it. Whenever pleuritic symptoms continue beyond the ordinary period of about three weeks, or, after a temporary abatement, are followed by those of effusion, which are not in turn removed, the occurrence of empyema may be suspected.

Empyema may form from a pulmonic abscess bursting, or a gangrenous spot being detached and falling into the cavity of the pleura. An abscess in the liver or other parts may also communicate with the pleura, and abscesses formed from injury or otherwise in the wall of the chest may also give rise to it. It is usually, however, caused by acute inflammation, by penetrating injuries, or by the introduction of foreign substances. It should, however, be borne in mind that when it occurs from wounds, the external opening must have healed, or the complaint would be simply a wound in the chest, with a discharge from the cavity of the side affected. A true surgical case of empyema, following an injury of the chest, in which the wound has healed, is not to be ascertained but by the same means as in a case arising entirely from internal causes, unless the protrusion of the cicatrix should indicate the presence of matter behind it.

314. The symptoms by which the termination of inflammation in effusion may be known: are dyspnœa, or difficulty of breathing, which is greater when the effusion has taken place rapidly, less when it has been gradual; subsidence of pain; inability to lie on the unaffected or sound side, which subsides, or is entirely removed, after the operation has been performed and the fluid evacuated, although it should be replaced by air in consequence of the lung being unable to resume its natural position. When the effused fluid has filled one side of the chest, that side is evidently enlarged, and this can be distinctly seen when the dilatation does not exceed half an inch, measuring by a tape from the spinous process of a vertebra behind to the center of the sternum. The ribs are nearly, if not quite, immovable, and partially raised, offering a strong contrast to the active motion of the ribs on the other side. The intercostal spaces in these persons may be more or less filled up, rendering the whole surface smooth and soft. In some very severe cases the external parts become edematous, so that the ribs cannot be felt, and this sign, although not always present, is certainly pathognomonic when it takes place at a late period of the disease. When the effusion is into the left side of the chest, the heart is frequently pushed over with the mediastinum to the right side, and its pulsation can be seen and felt to the right side of the sternum; or it may descend with the diaphragm into the epigastrium--changes which are not so extensive or remarkable when the effusion is into the right side, as the liver materially impedes the descent of the diaphragm, and the heart is already in the left side, in which it is sometimes raised rather than depressed. It is said that if the hand be placed over the affected side, while the patient speaks with a tolerably loud voice, and a strong vibration is felt in the part, the case is not one of empyema; but this is as uncertain a sign and as little to be depended upon as the dullness on percussion which sometimes takes place under the sternum in empyema. The cough and expectoration offer nothing peculiar, unless a communication exist between the lung and the cavity of the chest, when the expectoration in general becomes very fetid and disagreeable. The febrile symptoms depend on the activity of the previous disease, and the rapidity with which the effusion has taken place.

Night-sweats, it has been supposed, never accompany the hectic fever of empyema, unless there be tubercles in the lungs or pleura--a remark which cannot be depended upon.

315. Two symptoms have been insisted upon by older authors as distinctive of effusion in the chest, which more modern ones are disposed to doubt, particularly in the early stages of the disease. One is an edematous swelling of the back, the other a protrusion of the intercostal spaces. A third may be added when the effused fluid is blood, which is that the edematous swelling becomes ecchymosed, or red, or bruised looking, from the effusion of blood into the cellular membrane beneath the skin, over the whole space occupied by the blood within. That the first two symptoms do assuredly indicate the presence of pus, cannot be doubted; and that the third is a sign that the effused fluid is blood, has not been disproved; but it must be borne in mind that they are late, not early symptoms, and the operation should not be delayed until they are present, if other signs should appear to demand its performance. Valentin was the first to notice the ecchymosis of the side and back when the chest was full of blood, a sign which Larrey particularly insists upon, but which certainly does not appear so early as to be distinctive, when other symptoms exist which almost render it certain. The swelling does not arise from transudation of matter through the pleura, but from irritation transmitted through it, as in any other deep-seated abscess. Dilatation of the chest is usually an early symptom, although a considerable effusion may exist without it, or with but a slight elevation of the intercostal spaces. When the complaint is distinct, these spaces are elevated to a level with the ribs, so that the surface becomes perfectly smooth and equal; a farther protrusion is a very rare occurrence. Effusion indeed of serous fluid to a considerable extent, so as to displace the heart, may take place without the intercostal spaces being elevated, which is only believed to occur when the intercostal muscles have become paralyzed. When the matter has been evacuated, the muscles recover their tone, and the intercostal spaces reappear.

In all cases of empyema in which the lung is so bound down by adhesions that it cannot be expanded by the continued process of respiration, a cure can only be accomplished by an alteration of the form of the affected side of the chest, by which its cavity is diminished, and often nearly obliterated. This is an effort of nature. The pleura changes its character, becomes so thick as materially to diminish the cavity, the diaphragm ascends, the heart leans to that side in many instances, the spine curves, the ribs thicken and become flatter, and close in upon each other, abolishing the intercostal spaces.

_Treatment._--As long as the febrile symptoms consequent on the inflammation continue to any extent, medicines will be of but little avail, and counter-irritants should be avoided. When they have subsided, purgatives and diaphoretics may be tried, in combination with tonics and a light but good nourishing diet. Blisters applied frequently upon a large surface often do good. When these means fail, the operation must be resorted to.

316. It has not been satisfactorily decided whether the operation for empyema was first performed on Phalereus, Jason, or Prometheus; it is therefore said of all three that, being expected to die of an abscess in the lungs declared to be incurable, they went into battle for the purpose of getting killed; but being only run through the body, they all recovered, in consequence of the escape of the purulent matter through the holes thus made. The operation was performed by Hippocrates and his successors, by the knife, by caustic, and by the hot iron. Ambrose Paré was the first who recommended a trocar and canula, and many instances of success in all ways are recorded. The modern methods are by the trocar and canula, and by incision. Whenever auscultation, percussion, or succussion give reason to believe that a fluid is collected, which medicine has not been nor is able to remove, the simple operation by the trocar and canula should be performed. If fluid should pass through the small canula generally used by way of exploration, a larger one may be introduced in its place if thought advisable. In ordinary cases, the little wound should be closed immediately after the evacuation of the fluid; it usually heals without difficulty, and the operation may be repeated if necessary. Care should be taken that the point of the instrument is perfectly sharp, or it may separate the thickened false membrane from the inside wall of the chest, and, by pushing it before it, prevent the fluid from passing through the canula when the trocar is withdrawn.

317. The place of election, in England, for a _puncture_, in ordinary cases, is usually between the fifth and sixth ribs, counting from above, and between the sixth and seventh from below, and at one-third the distance from the spinous processes of the vertebræ, or two-thirds from the middle of the sternum. If there should be any protrusion of the intercostal spaces, it may be a rib or two lower down. The point of the instrument should be introduced a little nearer the lower than the upper rib, and pressed on until all resistance has been overcome. It is entered nearer the lower rib to avoid the intercostal artery, and yet not touching the rib lest it should induce a too forcible contraction of the intercostal muscles, by which the operator might be inconvenienced.

If the person should be very fat, or the puffing of the integuments considerable, it may not be easy to feel the ribs, in which case even recourse should not be had to incision. When the arm is placed by the side, and bent forward at a right angle so that the hand rests on the ensiform cartilage, the inferior angle of the scapula will correspond in general, but not always, with the interval between the seventh and eighth ribs at the back part. The attachment, however, of the last of the true ribs, the seventh, to the xyphoid cartilage, can always be ascertained in front, and an error of importance cannot well take place, as the object in making a puncture by measurement is to avoid the diaphragm. Freteau, of Nantes, says that he performed the operation on the left side between the tenth and eleventh ribs, and on the right side between the ninth and tenth in more than thirty dead bodies, and always opened into the cavity of the chest, commencing the incision close to the edge of the latissimus dorsi muscle, or about three inches and a half from the spine--an operation which in this place should be done by incision, and not by the trocar. When there is reason to believe that there is an extraneous body to be extracted, such as a ball, the place of election is of importance, as it is desirable it should be a little above the diaphragm in order to facilitate its extraction; for although, by carefully shifting the position of the patient, a ball or a piece of bone may be brought to rest against the opening, it will not be easily taken hold of unless it lie upon the diaphragm, a point which will be hereafter further elucidated. When an external swelling indicates the presence of matter, and there is reason to believe it communicates with the inside of the chest, the opening should be made into the tumor, and is then called the “operation by necessity,” which is not an uncommon occurrence after gunshot wounds. It is not, however, always done in the most convenient place, and should then be repeated lower down, which will also be sometimes necessary in consequence of the matter collected in this way being cut off by adhesions from the general cavity.

When the operation by incision alone was performed, the success was certainly not great. In modern practice (after the operation by puncture) it has been much greater, which may be attributed to the operation having been had recourse to at an earlier period, or about the end of the third week. After wounds penetrating the chest which do not admit the effused fluid to flow out, it should be done much earlier.