CHAPTER XI.

TROMATOPNEA;

OR, THE PASSAGE OF AIR THROUGH THE EXTERNAL

APERTURE, AS A SIGN OF LUNG WOUND.

This occurs often with a loud gurgling sound, and the aperture of the wound appears to supersede entirely the natural passage. The effect is most startling upon the bystanders, and is generally considered a certain sign of the substance of the lung having been wounded, and a prelude to dissolution. Hippocrates says, “the patient dies if more air passes through the wound into the thorax, than enters by the trachea into the lungs.” Galen held a similar opinion. Whether these ancients formed their opinions from experiments or other sources, they had arrived at precisely the same results as Hewson, Van Swieten, and others of modern times. Dr. John Thompson, in his Observations made in the Military Hospitals in Belgium, page 80, observes :“ It is often difficult to say, in wounds of the chest, whether they penetrate into the sacs of the pleuræ : but all doubt with regard to this point is removed

the moment we observe air coming out of the wound upon coughing." This observation having been made by a man of standing, the perpetuation of erroneous opinions will not create surprise. A. F. Hecker, a great German authority, writes in vol. ii, page 779, to the same effect. In the Transactions of the Medico-Chirurgical Society of October 1841, page 564, a case of recovery from lungwound is narrated, and the proof given is, both blood and air escaped from the wound in the chest;" also, in the same Transactions for October 1842, page 615, there is given a case of stab-wound through both sides; venesection was practised, and recovery took place. The proof given of lung. wound is, “air was passing freely through the wound. .... No doubt could exist as to the lungs being wounded on both sides.” In the Medical Times of the 2nd November, 1850, page 469, Mr. George Shaw reports a case in which the wound penetrated the right chest between the fifth and sixth ribs. The air passed into and out of the wound with considerable noise every time he breathed. No depletion employed, and he recovered.

In the recent case of Thain the policeman, who was shot while guarding a prisoner (the preparation is in Guy's Hospital Museum), the report shows, that “ blood and air passed through the wound, and there was a little hæmoptysis." He died on the second day. The lung was found not wounded.”

Dr. Ballingall, in his Outlines of Military Surgery, page 306, says, “when air issues from a wound in expiration, there is ground for suspecting that the lungs are wounded.” The following Experiment, No. 2, leads to a different conclusion. The fol-. lowing case, No. 30, also shows that tromatopnæa was present when there was very little probability that the lung was wounded.

Experiment 2. A dog was placed under the influence of puff-ball. An opening was made into the right pleural cavity, between the third and fourth ribs. The external air passed freely inwards upon inspiration, and outwards upon expiration. No emphysema occurred. Heart's action continued long after respiration ceased. Dr. Richardson considered that the lung did collapse in this case, although slight respiratory murmur was heard over affected side. When the dog was examined, the lungs were found unwounded.

CASE 30. J. Meskell, aged 22, 3rd Buffs, wounded on the 8th of September. Ball struck on the upper third of the sternum, passed downwards, and appeared to have lodged somewhere about the lower dorsal vertebra in the left side. Air gurgled with a loud sound through the wound on expiration. Pulse 78; respiration 30. Considerable hæmoptysis. Emphysema around the wound.

11th. Emphysema has extended over all the left side.

WOU

12th. The air has ceased to gurgle through the wound.

15th. Copious hæmoptysis ; pulse 64; respiration natural. Febrile symptoms occasionally appeared, the pulse rising to 88, and the respiration to 44. The treatment was antimony, low diet, and rest.

On the 10th of October he was discharged to his regimental hospital.

I am indeed of opinion that, when the lung is really wounded, this tromatopnæa must cease; thus, when a small opening is made into the thoracic cavity without wounding the lung, air will pass freely out and in during respiration ; but if the opening be enlarged, and the lung be so wounded, that there is a direct communication formed with the opened pleural cavity, the entrance and exit of air will cease, from the simple physical fact that all opposition is removed, and no confined body of air is subjected to the alternate movements of the thorax. Tromatopnæa was present in two out of twelve fatal cases, and in one out of nine cases of recovery, recorded in the Director-General's Report. Out of nine fatal cases, noticed by the author, in which the lungs were wounded, it was present in two. Out of seven fatal cases, in which the lungs were not wounded, it was present in one.. Out of twelve cases of recovery, it was present in one. Among all the cases, strange to say, it was especially marked in Nos. 14 and 16; in the for

mer, the pericardium was wounded; in the latter, the anterior mediastinum was opened ; but in neither were the pleural cavities opened. Experiments Nos. 3, 6, 11, bear upon this point.

In concluding this portion of the treatise, I would desire to say that, although I would not place implicit reliance on any one of the heretofore accepted signs of lung-wound, if there were three or more of them present, I should consider their concurrence as strong presumptive proofs of lung-wound. To these add a weak pulse, a cold and clammy skin, and orthopnea with effusion of blood, now easily diagnosed by aid of percussion and the stethoscope, and the presence of the ecchymosis of blood in the loins (but which I never witnessed, although it is dwelt upon as certain evidence of effusion into the pleural cavity, by Valentin and others); with all these, or the majority, it may be considered as nearly certain that the substance of the lung has been wounded, and the danger imminent. Indeed, if it were not for the distinct statement made by Baron Larry, at page 240, as to the presence of this peculiar discoloration, “ce signe est l'un des plus pathognomoniques”, I should consider this as one of many matters of romance, unthinkingly handed down by one writer to another.