Penetrating Gunshot-Wound of the Abdomen: Excision of the Bullet from the Erector Spinae Muscle: Recovery
Authors: G. Buchanan
Journal: BMJ (1883)

sion, occupying half one pleural cavity, has existed three or four weeks, and shows no signs of progressive absorption.PERFORMANCE OF PARACENTESIS.-Site of puncture.Low down.Reasons.Dr. Bowditch's rule.Find inferior limit of sound lung behind, and tap two inches higher than this on side of effusion, in a line perpendicular from the inferior angle of the scapula.Position of patient, supported by assistants so as to be easily lowered into a horizontal position.Precautions in withdrawing fluid.Not too quickly, nor completely.Warn patient as to deep inspiration.In- dications for stopping: if the stream flag, if there be any sucking noise, or much cough.EMPYEtA.-Frequency in children, e.g., of 44 and 16 consecutive cases of pleurisy, 27 and 14 were empyemata (Dr.Barlow).*Pro- gnosis good in children, save in those of very tender years.Formation occasionally very rapid: e.g., pus present on 4th, 5th, and 7th day.Importance.Pus frequently localised or encysted, e.g., not uncommon in middle third of thorax, limited above by adhesions, and below by fixing of lower lobe of lung to chest-wall; at this spot loud bronchial breathing, resonance, etc. Diaphragm to empyema.Pain intense.Physical signs comparatively slight.Disease often re- ferred to other parts, e.g., stomach and liver.Pus always to be withdrawn.Risks of leaving-a.External perforation; usual site, in the 15th space in the inframammary line, according to Mr. Mar- shall.tHis explanation that this is a relatively unprotected part of the chest-wall and pleura, the pus here being only covered in by the internal intercostal, the intercostal fascia, and the weakest parts of the pectoralis major, and the external oblique.External perfora- tions may lead to caries, amyloid disease, etc. b.Lung-perforation.Gangrene.Sloughing, hectic, etc. c.Tuberculosis.An empyema, even if caseating and inspissated, may be infective.View of Niemeyer, degenerating particles taken up from any caseous relic may be distributed by the blood and set up tubercle, by depositing local'foci of irritation.d.Risk of lardaceous disease.Spontaneous absorption of empyema.Very occasional, and risking tubercoulosis.DIAGoOSIS or EMPYEXA.-(Tide supra.)TREATMENT OF EMPYEMA.-A.Simipe punctue by needle of kypoderusie syringe or aspirator.May be used, and repeated, under a few conditions.a.If patient be very timid.b.Where collections are very small or multiple.e.Where pus is sweet, the patient healthy, the illness of short duration, and when refilling does not take place quickly.In the above cases, repeated puncture may be successful in empyema, sometimes; but, as a rule, it affords relief, not cure.Patients thus treated should be watched for some time.Puncture may coax pus to surface (Goodhart).tDisadvantages of puncture.'Plugging.Loss of time.Risks.Mode of using aspi- rator.Previous incision in an adult, or where much fat or cedema is present.Puncture through thickened pleura must be quick and certain.Site of puncture.Depends on the amount of pus. 1.If slight or multiple.2. If large, where subsequent drainage will be easiest, in eighth or ninth interspace behind, in line of scapula.Amount to be drawn off, about eight to sixteen ounees in a child, and twelve to twenty-four in an adult (Marshall).§ Rules for stopping, constricting pain, urgent dyspncea or cough, syncope_ Aspiration to be gentle and limited, rather than violent and com plete; the latter risking fresh effusion and suppuration, haemor- rhage, and injury of lung.Importance of all subsequent avoidance of chills.-B.Subaqueous drainage.Mode of using.(Apparatus shown.)Advantages. 1. Simple. 2. Tube well tolerated, and (if secured) follows movements of chest.3. Drainage can be made gradual, and adapted to expansion of lung.4. Readily converted into a siphon for washing out chest.This last of doubtful advantage.If pus be fcetid, make a free opening; if pus remain sweet, washing out is meddlesome (vde infra).Disadvantages. 1. Tube, necessarily small, is easily blocked.2. Ulceration usually soon takes place by side of tube, and air enters.Risk.Favourable cases.In children, where the collection is not great, nor of long standing, the lung thus expanding as the fluid runs out.-o.Inoi- sion.Free drainage.Admits of washing out of pleural cavity, if required.Disadvantages.