SURGERY. 735 
jury extends beyond the pleura costalis. But this symptom 
can only be expected when the wound is straight and freely 
pervious. 
“ To discover whether the wound has injured the lungs, 
or not (says Mr. Hennen), is a point which has given to the 
older surgeons great room for the employment of their inge¬ 
nuity in devising possible cases, and has occasioned no 
small waste of time and wax-tapers in ascertaining the exit of 
air through the passage. A practical surgeon will require 
but little investigation: bloody expectoration immediately 
on receiving the wound, and the terrible symptoms of dysp¬ 
noea, sense of stricture and suffocation, insupportable anxiety 
and faintness, which succeed, soon enough discover the 
fact.” The immediate danger is either from debility from 
hemorrhage, or suffocation from the blood flowing into the 
air cells and cavity of the thorax. Emphysema may also 
cause more or less suffering and danger. The symptoms 
here enumerated, whether single or in combination, may be 
deemed the primary effects of wounds of the lungs. Violent 
inflammatory affections of these organs and of the pleura 
occur; or long and tedious suppurations and exfoliations 
of bones, which, though not so rapidly fatal, are often as 
certainly so as the others. Diseases also may follow, which, 
although we cannot strictly call them pulmonary con¬ 
sumption, agree with it in many poiuts, particularly in 
cough, emaciation, debility, and hectic, 
The commonest effect of penetrating wounds of the thorax 
is the disease called emphysema. This is a swelling, arising 
from a diffusion of air in the cells of the cellular substance. 
It may occur in wounds which j ust enter the cavity of the 
chest; in others that extend more deeply, so as to wound 
the lungs; and also in cases in which these organs are 
wounded by the spiculee of a broken rib, or clavicle, while 
there is no outward wound whatever. We find, that em¬ 
physema is a more common consequence of fractured ribs, 
and narrow stabs, than of large penetrating wounds; be¬ 
cause, in the latter cases, the air readily passes outward, 
through the opening. 
When the chest becomes expauded, in the act of inspira¬ 
tion, some of the air, which enters through the trachea into 
the wounded lung, instead of distending this organ, now 
passes through the breach in it, so as to get into the space 
between the pleura pulmonalis and pleura costalis. 
When the thorax is next diminished in the act of expira¬ 
tion, the effused air is compressed against the wounded lung; 
but none of it can enter this viscus again; accordingly, 
fresh air accumulates in the space between the pleurae at 
every inspiration, while none can escape during expiration. 
This case may produce suffocation from the pressure of the 
collected air on the diaphragm, mediastinum, and opposite 
lung. 
However, as emphysema commonly follows narrow stabs, 
or fractures of the ribs, attended with injury of the lungs, 
the pleura costalis and intercostal muscles are at the same 
time wounded or lacerated, so that part of the air also usually 
gets through the above wounded membrane and muscles, 
into the cellular substance on the outside of the chest, and 
thence is sometimes diffused, through the same substance, 
over the whole body, so as sometimes to inflate it in an ex¬ 
traordinary degree. 
So unlimited is the diffusion of air in some cases, that the 
cellular substance beneath the conjunctiva of the eye has been 
known to be prodigiously inflated. 
From what has been stated, it is evident, that, in cases 
of emphysema, the danger does not depend so much on the 
extent of the external swelling, as on the degree of compres¬ 
sion produced on the mediastinum, diaphragm, and the lung 
of the opposite side, combined with inflammation and ex¬ 
travasation of fluid in the chest. 
In all cases of penetrating wounds of the chest, and espe¬ 
cially in injuries of the lungs, the free use of the lancet is the 
only thing which can be depended upon in the early part of 
the treatment. By it, internal haemorrhage is restrained; 
and by it, the dangers of the subsequent inflammation of 
the thoracic viscera are to be averted. The records of sur¬ 
gery furnish abundant proof of the necessity of such prac¬ 
tice. 
In every penetrating wound of the chest, therefore, and 
more particularly when the lungs are injured, the first bleed¬ 
ing should be copious. If the patient should faint, we 
ought not to administer cordials, but allow him to revive 
gradually. We should avail ourselves of this opportunity to 
extract, without pain, all foreign bodies within reach, whe¬ 
ther cloth, ball, iron, wood, or splinters of bone. Should 
there be reason for believing that any of these extraneous 
substances are lodged, and that by an enlargement of the 
wound, they might be extracted, the practice ought to be 
immediately adopted. The next object is to dress the 
wound itself. If it is a gunshot, a light mild dressing will 
be sufficient; but if incised, the lips of it should be closed at 
once. The patient is now to be left to repose, and he will 
often lie for some hours in a state of comparative ease, till 
the vessels again pour forth their contents, induce fresh spit¬ 
ting of bloody froth, and a repetition of all the symptoms 
of approaching suffocation. In this circumstance, the lancet 
must be used again without hesitation; for, as Mr. Hennen 
justly remarks, though in the after-treatment of a wound of 
the nature here described, considerable benefit may be de¬ 
rived from medicine, until the danger of immediate death 
from hemorrhage is over, “ we must not think of employing 
any thing, except depletion by the lancet; it, and it only, 
can save the life of the wounded man.” 
If air does not diffuse itself before the third or fourth day 
from the accident, there is not much chance of its doing so 
afterwards, because the extravasation of coagulating lymph 
around the wound soon shuts up the cavities of the cellular 
membrane. 
It is sometimes requisite to open the chest either to eva¬ 
cuate air or water: an operation called paracentesis thorasis 
The most eligible place, is between the sixth and seventh 
true ribs, just at that point, where the indigitations of the 
serratus major anticus terminate. By placing the patient on 
his abdomen, this opening may be rendered very depend¬ 
ing. 
An incision, about two inches long, must be made through 
the integuments. These are first to be drawn to one side, if 
it be intended to close the wound immediately afterwards. 
The intercostal muscles are next to be cautiously divided, 
and a small puncture carefully made in the pleura costalis, 
as soon as it is exposed. The intercostal muscles must be 
divided closely to the upper edge of the lower rib, in order 
to avoid any chance of wounding the intercostal artery, 
which runs in a groove along the lower edge of the upper 
rib. 
Water is sometimes found in the pericardium when there 
is none in any other cavity of the thorax, but it is generally 
accompanied with hydrothorax. The symptoms of this dis¬ 
ease are nearly similar to those of hydrothorax; and we 
find that Dessault and other very eminent surgeons have not 
been able to distinguish them. Dr. Baillie says, “ that the 
feeling of oppression is more accurately confined to the 
situation of the heart; and the heart is more disturbed in 
its functions in dropsy of the pericardium than in hydro¬ 
thorax.” It is also said, that a firm undulatory motion can 
be felt at every stroke of the heart. 
If the existence of this complaint is ascertained, and if 
the quantity of water is suspected to be great, it may be 
perhaps advisable to discharge it, as practised by Dessault 
and others, by making an opening between the sixth and 
seventh ribs of the left side, opposite to the apex of the 
heart. 
The ribs are not often broken ; the upper escape on ac¬ 
count of their guarded situation beneath the clavicle and 
shoulder; the lower because their great mobility makes them 
el ude the effect of external violence. These inj uries are rarely 
attended with any material displacement; the intercostal 
muscles tending to hinder a permanent separation of the 
fragments. The injury is most commonly situated near the 
greatest 
