CHAPTER XXI. PNEUMOTHORAX. СНАР. THERE are three modes of death after this lesion. 1. The shock to the system causing rapid collapse. 2. The supervention of effusion into the pleura, with Three the accompanying irritative fever and subse- death. quent exhaustion. 3. The new lesion not having proved immediately fatal, the case becomes chronic, and the patient sinks in the ordinary course of the tubercular disease, the termination not being directly due to the pneumothorax. 1. The shock proves fatal. This result I have witnessed within twenty-four hours, and within one week after the accident. Whoever has seen the effects shortly after its occurrence, cannot fail to be struck with the general depression of the nervous and circulating systems. The patient is conscious of an alarming alteration. He is pale, gasps for breath, and is intolerably restless. The respiratory efforts are immense, but the relief from the deepest inhalation is trifling. There is a consciousness of diminished space for breath, and many sufferers have exclaimed that the air does not enter. An acute local pain aggravates the distress. Position frequently changed fails to relieve, and if the opposite lung be unsound (as often happens), there is a constant struggle to retain a posture on either side, very painful to wit Y modes of Shock fatal. CHAP. ness. Orthopnoea supervenes. The pulse is at once greatly reduced in volume, and increased in frequency. The systemic circulation cannot fail to be embarrassed, from two causes. 1. The volume of blood in the pulmonary circulation is diminished by one half (if the collapse of the lung be complete), and the balance between the right and left cavities of the heart is interfered with. As a question of quantity alone, this altered distribution of the circulation must be a trial to the system, and venous engorgement be the immediate result. 2. The diminished aerification of the blood, from deprivation of nearly half of the respiratory space formerly available. The great nervous centres are supplied with impure blood, and all ultimate capillary changes, whether for secretion or for decarbonisation, are imperfectly performed. The respiratory process, which is spread over all the tissues, resulting in molecular, heat-producing changes, the oxydising of effete material, and the removal of carbonaceous impurity, is disordered, and the patient is reduced somewhat to the condition of an animal with communication between the right and left cavities of the heart. The intense nervous exhaustion, dyspnoea, pallor, loss of animal heat, thready and rapid pulse, indicating feeble ventricular contraction, form a group of symptoms which often results in speedy death, and the prognosis required immediately after the occurrence of perforation of the lung, being formed with regard to these altered physiological relations, cannot be other than a grave anticipation of the worst result. Should the shock prove fatal in from twelve to twenty-four hours, there is no pause in the increase and progress of these symptoms; but it not uncommonly happens that a week or more may elapse before the system seems to have realised the injury to its chief vital functions. The fatal result is not, however, less attributable to the primary effects of the accident, than if death had occurred within a few hours; and I have had occasion to remark that so long as the patient is kept perfectly quiet, and no demands are made on the nervous or circulating powers, life may be continued, although at a low par, and valuable time be gained for the economy to readjust its requirements to the alterations which have taken place in the respiratory system. The following case well exemplifies this. CHAP. XXI. Limited thorax, death in 10 days. T. C. æt. 18, had been for some months under my care, Case. and had a cavity in the apex of the left lung, evidenced by cavity, the usual signs. Her general health was very slightly im- pneumopaired, the fever which had attended the softening and excavation stages having subsided some months previously, and the opposite lung affording no abnormal sounds. She was in pretty good flesh, had a moderate, daily expectoration, and her appetite was excellent. She was able to attend to her business as barmaid in a hotel. One morning, while dressing, and in the act of combing her back hair, she was seized with sudden pain in the left shoulder, with faintness and dyspnoea. On arriving, I detected the occurrence of pneumothorax. The left side was loudly resonant on percussion, vesicular respiration absent, metallic sounds accompanied the inspiration, and amphoric blowing was heard just below the spine of the scapula. Perfect rest and stimulants restored her, and she was comparatively comfortable on the next day, and improved daily for a week. When calling to pay my usual visit on the tenth evening, on passing by the bar of the hotel, I was surprised to see her sitting in a small room inside it, and enclosed by glass partitions in the usual fashion. On entering, I found her eating bread and cheese, and drinking ale, and several persons were smoking, so that the atmosphere was, even to me, intolerable. I at once suggested her removal to her bedroom, and she was carried up in a chair as she had come down. She was in good spirits, but said that she had felt a strong desire to have her supper again in the old place.' She was put to bed, and did not seem to be much exhausted, but she was found dead in bed at 2 A.M. that night. No post-mortem was allowed, but there can be no doubt that she died of collapse, just as might CHAP. Prognosis to include a tempo have occurred within the first day, and that the exertions made had demanded more from the system than its impaired nervous, respiratory, and circulating powers could meet. In all cases of pneumothorax, therefore, the prognosis is to include the likelihood of death occurring rary rally. within the first week, even although the other lung be sound, and the general health previously but slightly impaired in proportion to the local mischief which has given rise to the lesion in question. It is not out of place here to recur to the observation previously made -that acute attacks occurring in the course of chronic disease are not tolerated in proportion to the strength and robust condition of the patient, but are frequently seen to be best borne by a system which has been already reduced (of course within certain limits); the respiratory requirements being small, and the necessity for aerification of a large quantity of blood being lessened by previous emaciation. This is especially true of pneumothorax, the most prolonged cases of which lesion I have had occasion to witness in individuals who had been emaciated in the ordinary course of phthisis. The persistent vitality of many of our chronic cases of consumption manifested throughout the various secondary complications is here exhibited occasionally in an extraordinary degree, and that which would kill a more robust is tolerated for months by a weakened, and often almost exhausted patient. The opinion offered to friends immediately after the occurrence of pneumothorax arising from a tubercular perforation of the lung is therefore to include the chance of the case becoming chronic, and the possibility of a rally, even from very unfavourable symptoms. Effusion into pleura. 2. The supervention of effusion into the pleura. Should the immediate shock not prove fatal, there is XXI. most commonly a pause in the progression of all the CHAP. symptoms. And unless the contents of a cavity have been emptied by a large opening into the pleura, the pleuritis is slow to develop itself. The medical attendant should be prepared for this state of things, and neither build too much on this temporary lull, nor reckon on the certainty of a great increase in the local mischief within a short period. He is to regard his patient as in the utmost hazard of an acute pleurisybut to suspend his judgment, as to the result, till effusion takes place. Is the secondary effusion an inevitable result? We may safely say that it is not. The actual physical condition consists in a collapsed lung, more or less bound down by adhesions, and a pleural cavity partly filled with air. Should the purulent matter from the tubercular cavity not be present in the pleura, there is nothing to forbid a partial recovery from the accident which has taken place. That air can be absorbed from the pleura is proved beyond a doubt by the result of operations for empyema, which, performed in the usual manner, invariably permit its entrance through the trocar. ope A boy under my care in the Hospital for Consump- Case. tion, who had a copious effusion into the left pleura, Empyema, was operated on by Mr. Fergusson, and air was per- ration, air mitted to enter freely into the cavity of the pleura. recovery." About three pints of serum were drawn off, and he recovered after some weeks, the lung returning nearly to the base of the chest, but being evidently bound down by adhesions which prevented its complete expansion. I do not advocate this mode of operating, as air must be regarded as an extraneous body hindering the desired descent of the lung quite as much as serum. The valvular syphon of Dr. Russell seems preferable to the ordinary trocar. The physical conditions required to produce an emptying of the contents of the cavity into the pleura are |