THORAX. ther down than we can with fafety have accefs to from the friction of the clothes, and receiving the fophagus, the incifion is to be enlarged as any milk which may fail from the breaft. much as poffible, that the forceps may be able to CHAP. XX. OF PARACENTESIS OF THE reach and extract it. When the operation is performed, the wound will be difficult to heal, as the fides of it will be frequently separated by the action of deglutition. On this account as great a degree of abftinence as poffible is to be advifed; and nothing but nourishing liquids, in small quantities, are to be allowed. The patient fhould be prevented from moving his neck; and the wound is to be healed as foon as poffible by the fame methods which are used with wounds in other parts of the body. On the other hand, if the operation has been done for the purpose of conveying nourishment into the ftomach, when the patient was diftreffed by a tumor either in the cefophagus itself, or in fome of the neighbouring parts, it will be neceffary to keep the wound open during the continuance of the tumor, or the life of the patient. CHAP. XIX. OF SORE NIPPLES. 516. WOMEN are more generally affected with fore nipples in fuckling their fift child than at any period afterwards. This may in fome meafure be owing to the fmalinefs of the nipples; but very often it arifes from their being unaccustomed to the irritation of fucking. In fome cafes, the nipples are fo flat, and fo much funk in the breaft, as to render it difficult for the child to lay hold of them. Affiftance can fometimes be given, by the mother preffing back the prominent part of the breaft, fo as to make the nipple project between two of her fingers. If this prove infufficient, the nipple may be made to project by applying to it a tout child feverai months od: but when this cannot be done, breaft glasses, fuch as Pl. CCCXXVI. fig. 68. may answer the purpofe. By applying thefe to the nipple, and fucking out the air, the child will commonly be enabled to lay hold of it. 518. WHEN either the action of the heart or of the lungs is impeded by fluids collected in the cavity of the pleura, a discharge of thef: fluids by a perforation is the only chance the patient has for relief. The fluids which collect in the pleura are, feram, blood, air, or pus. A collection of water or ferum is frequently found in the thorax, combined with dropiy in other parts of the body; but the affection is often local, and it is then chiefly that advantage is to be derived from an operation. B. fides, in the two great cavities of the thorax, collections of water are frequently met with in the pericardium, and are faid to be fometimes difcovered between the layers of the anterior mediaftinum. The difeafe is marked by the following fymptoms: There is a sense of weight or oppreflion in the thorax, and difficulty of breathing; the patient has frequently a more uneafy fenfation in one fide than in the other; has fudden startings during fleep, with a sense of suffocation; is troubled with a frequent dry cough; the pulfe is small and irregular; the skin dry, and the urine fanty. 519. With thefe symptoms there are commonly other marks of dropfy; and the patient fometimes, upon any fudden motion, is fenfible of an undulation within the cheft; and when the quantity of water is confiderable, the undulation will even be heard by the bystanders, if the body be fmartly agitated. For this purpose the patient's body should be uncovered while under examination; and the furgeon fhould place his hand upon the breaft near the fternum; then an affiftant ought to raife the patient fuddenly from an horizontal to an erect posture, or to ftand behind the patient and make fudden jerks; when, if water be prefent, the undulation will be felt; but it is neceflary to guard againft being deceived by the noife fometimes made by the contents of the ftomach. 520. When the water is collected in one fide only, if the difcafe be of long ftanding for the most part that fide is more prominent than the other. If the water be in the pericardium, the fymptoms are nearly the fame as those above enumerated, with this difference, that the pain is generally felt behind, and to the left fide of the fternum; and the ftroke of the heart is as if buried in water, while an undulatory motion has been faid to be felt oppofite to the anterior extremities of the third, fourth, and fifth ribs. 517. The nipples are liable to excoriations, cracks, or chops; which, tho' not attended with a formidable appearance, are often more diftref fing than large ulcers. Mild, aftringent, and drying applications are most to be depended upon in fuch applications; as port wine, brandy diluted, or lime water; all to be applied warm. After bathing the parts with any of thefe, the nipple thould be covered with unguentum nutritum, or Goulard's cerate; the firft of which is confidered as beft. Even foft ponatum often rubbed upon the part, and covered with a soft l'nen rag, will give confiderable relief. But the nipple should be perfectly cleared of these applications, before the child is laid to the breaft, by port wine, or equal 521. In the treatment of this disease, little ad-" parts of brandy and vinegar. If attention be paid vantage can be derived from internal remedies. to thefe remedies, they will have the defired ef- Squills, cream of tartar,, mercury, and digitalis, fect; but there is ftill another which has often are upon fome occafions attended with advangiven great relief, viz. the application of a thin tage; but the only method from which we can fkin to the nipple, as the neck and part of the expect any degree of fuccefs is the removing of body of a fwine's bladder with an aperture in it; the water by an operation, which fhould be perwhich, being properly moistened and fixed to the formed as foon as there is reafon to expect that breaft, will completely protect it in the time of danger may arife from delaying it longer. The fucking. As long as the nipples remain any operation is done in the fame way as fhall be afway affected, small cups of glass or tin are useful terwards deferibed in the case of empyema. For retaining the dreffings, defending the nipples 522. Blood collected in the thorax is always extravafated through fome wound or rupture of moft conftantly left to their fate. Within these the velles of the lungs or thorax. The breath- few years, however, fome cafes have occurred ing becomes oppreffed, the motion of the heart where the patients have been completely relieved and arteries feebie and irregular, and all these by an operation being performed. This is done in 1ymptoms are more ditreffing than collections of the fame way as in the evacuation or other fluids. other fluids. As it frequently happens in cafes of this kind, that fome of the veffels of the lungs are injured, part of the blood is thrown up ty coughing; which, when confiderable, gives a temporary relief to the lungs and heart; and while this is the cafe, no operation is neceflary; but whenever the action of these parts becomes much impeded by a great accumulation of blood, a perforation ought to be made to discharge it. When the extravafated blood is too firmly coagulated to pass off by a perforation, the wound ought to be made confiderabiy larger; and if this be infufficient, injections of warm water ought to be thrown in, and allowed to remain for fome time, to promote the diffolution of the mafs, which is afterwards to be evacuated. If the extravafation has been occationed by a wound in the lower part of the thorax, a new perforation will be unneceffary; an enlargement of the wound will be quite fufficient. But if it be feated in the upper part of the cavity, a perforation in the middle and lateral part of the thorax ought to be made, that the blood may be freely difcharged. In cafe of a rib teing fractured, or a vessel ruptured, the incifion ought to be made as near as poffible to the part affected, to allow the blood to escape, and loofe pieces of bones to be removed. 523. The discharge of air into the cavity of the thorax produces fymptoms little lefs alarming than those proceeding from the effufion of blood. In general they are, oppreffion in breathing: a tightness of the breaft, attended with pain; inability to breathe in the recumbent pofture; a fluthing and fwelling of the face; a feebie, and at laft an irregular pulfe: The extremities become cold, and cold sweats break out on the forehead. With these fymptoms there is frequently a fwel ling over the external parts of the body, by air getting from the ruptured lungs into the common cellular substance; and all these complaints jucreafing, the patient, if not quickly relieved, foon dies; fometimes in a few hours, with marks of fuffocation. 524. The air may be produced in the cavity of the thorax by wounds in the lungs, by mortification generating air in any of the thoracic vifcera, by erofion of ulcers, by laceration in confequence of fracture in any of the bones of the thorax. We diftinguish this from other collections by the fud. den oppreffion in breathing, by the flushing of the face, by no blood being thrown up, and by the emphysematous fwelling of the cheft and other parts, which has a crackiing noise upon being preffed. The treatment of this complaint confifts in making small punctures in the affected part of the skin, fo as to allow the air to efcape from the cellular fubftance; and if the air fhail have fpread to diftant parts of the body, it will escape most readily by fuch openings. But if this give no relief to the oppreffed breathing, paracentefis ought to be performed. In former times, patients labouring under fuch fymptoms were al 525. Pus, or purulent matter is more frequently collected in the thorax than any other fluid: it is much more freqently formed, however, than confined there. This difeafe is called Empyema. As the matter is ufually fpit up as fait as it is generated, in the diffections of those who have died of this species of consumption, much extravafated pus is rarely found in the cavity of the thorax, though a great portion of the lungs be deftroyed. Cafes not unfrequently occur, however, which require the operation; and these may be diftinguished by the following 'ymptoms: The patient at first generaliy compla ns of a fixed pain in fome part of the thorax, attended with heat, quick pulfe, and other symptoms of inflammation; refpiration becomes oppreffed; he is unable to lie on the found fide; or, if both fides be affected, can only lie on his back; has a conftant tickling cough, clammy fweats, frequent rigors or fhiverings. If thefe fymptoms be attended with an enlargement of the affected fide, or with a foft oedematous fulness there, and along with thefe if there be a fenfible undulation of a fluid, it may be concluded that a collection of matter is formed. The matter is commonly firft formed in the fubftance of the lungs, and is afterwards difcharged in the cavity of the pleura, though in many inftances large quantities of purulent matter have been found to originate from an inflamed state of the pleura. 526. The operation ought to be performed as foon as there is evidence of the collection being the caufe of the oppreffed breathing, and that there are no figie of this being relieved by expectoration. The operation ought to be done upon the part where the collection is fuppofed to be fituated; and this may be known by the feat of the previous pain, and perhaps by the matter being diftinguished between two of the ribs. If no matter flow, it is probably feated in the substance of the lungs; but even in this cafe, fuch an opening may be useful, by taking off the support, and giving the abfcefs an opportunity of burfting. If the undulation of the fluid be general, the operation is to be performed in the following manner: The patient is to he laid in an horizontal pofture, with the affected fide inclining a little over a table. An incifion is then to be made with a fcalpel through the fkin and cellular fubftance, between the 6th and 7th ribs, and half way between the fpine and fternum, from one to two inches in length, and in the direction of the ribs. The mufcies are then to be cut through, keeping as near as poffible to the upper edge of the inferior rib to avoid wounding the intercostal veffeis and nerves. As there is no occafion for the bottom of the wound being of the fame length with the external incifion, it may be gradually contracted, so as at last to be only about the half. The pleura being now exposed, is to be divided by light fcratches, taking the affiftance of a furrowed probe to prevent the lungs from being injured, 29992 in in cafe they fhall be found adhering to the ribs. If the contrary takes place, the fluid will rush out immediately upon a fmall opening being made into the cavity of the thorax; but if an adhesion appear, and if it be slight, which may be known by the introduction of a blunt probe, as much of it may probably be feparated as to allow the fluid to escape. In case it be confiderable, the incifion is either to be continued a little nearer to the fternum, or an attempt made in fome other part. Af. ter the fluid is obferved to flow, it will be proper to introduce a filver canula, (Pl. CCCXXVI. fig. 69.) at the opening; by which means it will run more readily off, or can be more easily stopped in cafe the patient become faint. If the quantity of fluid be not confiderable, it may generally be drawn off at once; but if it be great, partial evacuations ought to be made at different intervais, as circumstances may direct. 527. The canula therefore should be fo formed, that by means of a strap put round the body of the patient, it can be readily fecured. Its mouth is to be shut by means of a cork. A pledget of emollient ointment is to be laid over the wound; and the whole being fixed by a napkin and fcapulary bandage, the patient should be laid to reft. The remainder may be drawn off, probably in a day or two, or as foon as it is fuppofed the patient can bear it. After the fluid is carried off, the canula is to be withdrawn and the wound healed; or in cafe the operator be afraid of bad effects being produced upon the lungs by ir ritation from the canuia, tho' of this there will be little danger, as the lungs will generally be out of its reach, the skin may be so drawn back before the first incifion is made as afterwards to ferve the purpose of a valve. And for some days after the operation, the incifion in the integuments may be brought opposite to that in the pleura, to allow the matter to run off, or to produce a radical cure by exciting a certain degree of inflammation over the lungs and infide of the thorax, 528. After the matter is evacuated, the wound ought to be kept open a confiderable time for the purpofe of difcharging the matter as faft as it is collected. If the wound be apt to heal up too foon, which will be known by the fymptoms of oppreffion being renewed, it will be proper to keep the paffage open by tents, or to introduce a bougie or filver canula a few hours occafionally, to the fource of the matter be dried up; which, However, seldom happens for a confiderable time, and frequently never. By attending to this circumftance, the patient may enjoy good heaith; whereas, by the neglect of it, a repetition of the firft operation wou'd foon be necessary. CHAP. XXI. OF PARACENTESIS OF THE AB DOMEN, OR TAPPING. 529. THIS operation is an opening made in to the abdomen, to empty any quantity of extravafated water collected in that species of dropfy called the afcites. 530. A uid in the cavity of the abdomen is ditcovered by the fweling which it produces; by a fenfe of tightnefs in the part affected; by la. borious and difficult breathing, efpecially when in a horizontal pture; but particularly by a fense of fluctuation communicated to the fingers placed on one fide of the abdomen, while the fwelling is forcibly ftruck on the oppofite fide. There is befides much thirft, a dry skin, scantine's of urine, &c. Whatever may be the influence of diuretics and other evacuations in the cure of general dropfical affections, they are rarely serviceable in local diseases of this kind, and even the operation of tapping seldom cures the diftemper; but it commonly gives the patient ease for the time, and is attended with very little pain. 531. Upon the fuppofition that nothing forbids the extraction of the water, the method of operating is this: Having placed the patient in an horizontal fituation, as beft fuited to prevent fainting, and to allow the water to run freely off, the part to be perforated ought to be marked with ink; and the most approved part for the operation seems to be at a point lying at nearly an equal diftance between the umbilicus and the centre of the fpine of the os ilium, this being moft out of the way of any of the vifcera, and fufficiently depending to allow the water to escape; and as the fpleen is lefs frequently enlarged than the liver, the left fide is generally preferred. Various means have been used for applying an equai profure in this operation. Some apply preffure by the hands of affitants; others ufe a broad piece of flannel, or other cloth, flit a certain way from each end; then the ends are drawn by affiftants till fufficient preffure is made. Broad beits are used by fome practitioners; but one of the beft contrivances for this purpose is the bandage invented by the late Dr Monro; Pl. CCCXXVI. fig. 70. Till ve, ry lately, a puncture was first made with a lancet, then a trocar of a round form fig. 71. with a triangular point, was conftantly ufed: but the entrance of this inftrument being always attended with difficulty and pain, a flat trocar is now very frequently employed: and that invented by Mr Andree (fig. 72.) feems the beft which has yet appeared. The bandage being now applied and drawn a little tight, the part to be punctured is to project a little over the edge of the bed. The operator fixes the head of the trocar in the palm, while the fore finger directs the point of the inftrument. He is then to push it forwards tiil he is fatisfied, by the want of resistance, that the end of the canula has reached the cavity of the abdomen. The perforator is now to be withdrawn, and the water allowed to flow as long as any of it can be taken off, the bandage being from time to time pulled to favour the difcharge. But if the patient become faint, a ftop for a few minutes should be put to the discharge every now and then, by placing the point of the finger upon the mouth of the canula. If any of the vifcera happen to stop the flow of the water before the fwelling is much diminished, a blunt probe is to be introduced, but bent at the end, left it flip into the cavity of the abdomen. When the ferum is thick and gelatinous, it may fometimes be ne. cessary to introduce a larger trocar than the one firft employed. When the water does not flow, because it is collected into cifts, the canula is to be withdrawn, and the wound covered with a pledget of fimple ointment. The operation may then be renewed immediately, or on the follow |