1200 THE ORGANS OF VOICE AND RESPIRATION 



tion of a tube, and pulmonary collapse has arrested bleeding. In other cases it is necessary to 

 resect portions of several ribs, and stop bleeding by ligatures or suture ligatures. J. Chalmers 

 Da Costa reports a case in which a furious secondary hemorrhage followed a gunshot wound. 

 He resected several ribs, packed the pleural cavity about the lung with sterile gauze, to obtain 

 a base for support, and then arrested the bleeding by packing iodoform gauze against the firmly 

 supported lung. This patient recovered. 



Incision of the lung (pneumotomy) is performed for pulmonary abscess (either tuberculous or 

 pyogenic), pulmonary gangrene, hydatid cysts, and bronchiectasis. In pulmonary abscess, 

 locate the area by physical signs and the arrays, resect a portion of a rib over it, and note if the 

 pleura is adherent. If it is adherent, continue the operation. If it is not adherent, insert stitches 

 of catgut through the two layers of pleura and the superficial part of the lung, so as to encircle 

 a considerable area, and then wait several days for adhesions to form. Adhesions protect the 

 pleura from infection, and, by keeping air from the pleural sac, prevent pneumothorax. When 

 ready to continue the operation, locate the abscess with an aspirating needle and syringe, open 

 it with a cautery at a dull red heat, and drain by means of a tube. 



Pneumotomy is very unsatisfactory in tuberculous cavities and bronchiectasis. In tubercu- 

 losis, excision of the diseased area (pneumectomy) has been employed, but it is not to be advised. 



Operations upon the lungs can be most safely performed with the patient in a Sauerbruch 

 chamber. The danger of collapse of the lung is thus eliminated. 



The routine methods of physical examinations inspection, palpation, percussion, and aus- 

 cultation are nowhere more important than they are in the diagnosis of diseases of the lungs. 

 It is essential, too, that in every case the two sides of the thorax should be compared with each 

 other, and that the wide variations that may be met with under normal conditions in different 

 persons and at different ages should be kept in mind when the thorax is being examined. 



On inspection the thorax will be seen to be enlarged and barrel-shaped in emphysema, in 

 which the volume of the lungs is increased by dilatation of their alveoli, or in an acute attack of 

 asthma, or when a large pleural effusion or mediastinal tumor is present. The thoracic wall will 

 be flattened or sunken, on the other hand, over an area of lung that has collapsed or become 

 fibrosed, as often happens in chronic pulmonary tuberculosis. The respiratory movements of 

 the thoracic wall will be lessened, or even absent, over a part or the whole of the affected side in 

 such acute disorders as pleurisy, pneumonia, or pleural effusion, or in more chronic disease where 

 the underlying lung is fibrosed, or is crushed to one side by a mediastinal tumor; and by the use 

 of the x-rays a corresponding loss of movement or displacement of the Diaphragm on the affected 

 side can often be observed. Binder normal conditions the intercostal spaces are a little depressed; 

 but they may be obliterated or even bulging on that side when a large effusion or newgrowth 

 fills up one of the pleural cavities. 



On palpation, the hand can be used to verify the eye's impressions as to the degree of move- 

 ment on respiration of any part of the thoracic wall. The facility with which the vibrations 

 produced by the voice are conducted from the larynx by the underlying lung to the hand (in the 

 form of vocal fremitus) can also be tested. The vocal fremitus is commonly much increased 

 over the consolidated area in pneumonia or in fibrosis of the lung, and much diminished over a 

 pleural effusion when the lung is pushed up by the fluid toward the top of the pleural cavity. 

 It is also diminished, but to a less extent, in emphysema, and in bronchitis when the bronchi 

 are blocked by secretion. In bronchitis the bubbling of the secretion in the tubes can often be 

 felt by a hand placed on the thoracic wall as the patient breathes ; and in chronic pleurisy the 

 friction of the two roughened pleural surfaces against each other can sometimes be felt in the 

 same way. 



On percussion, the normal resonance of the pulmonary tissue is found to be increased in em- 

 physema, and in pneumothorax this hyperresonance may be still further increased. The 

 resonance is lessened in any condition causing collapse or solidification of the lung tissue, or 

 when its place is taken by fluid (pleural effusion) or some solid growth (mediastinal tumor). 

 Thus, dulness on percussion at the bases of the lungs is common in the hypostatic congestion of 

 the bases seen in heart failure; dulness at the right base is often due to compression of the lung 

 by enlargement of the liver; some dulness at the apex of a lung is frequently met with in tuber- 

 culosis of that part, before the disease has progressed very far. Complete dulness over one side 

 of the thorax, back and front alike, except at the apex, is common when a large pleural effusion 

 has taken the lung's place. Von Koranyi, Grocco, and others, have drawn attention to a tri- 

 angular patch of dulness along the vertebral column (the paravertebral triangle of dulness) on 

 the unaffected side in pleural effusion; this triangle of dulness is said to be absent in other con- 

 ditions causing loss of pulmonary resonance on percussion, and is due to shifting over of the 

 contents of the posterior mediastinum toward the sound side. The apex of this triangle is in 

 the middle line at the upper level of the fluid effusion; its base, some two to four inches in length, 

 runs horizontally outward from the middle line at the level where the pulmonary resonance 

 normally comes to an end. 



On auscultation of the lungs, both in health and disease, the variety of sounds to be heard is 

 very great. It is impossible to give adequate consideration to them here, and for further infor- 

 mation reference should be made to the text-books dealing with the subject. 



