The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases, materia medica and therapeutics, medical jurisprudence, etc., etc (Volume 2).
- Date:
- 1849-59
Licence: Public Domain Mark
Credit: The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases, materia medica and therapeutics, medical jurisprudence, etc., etc (Volume 2). Source: Wellcome Collection.
Provider: This material has been provided by the National Library of Medicine (U.S.), through the Medical Heritage Library. The original may be consulted at the National Library of Medicine (U.S.)
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![tack, constituting the primitive hemorrhagic pleu- nsy of M. Laeiinec, but is more frequently ob- served to occur at a more advanced stage of pleu- risy, particularly at the time when vessels begin to be formed in (he false membranes, or when a fresh attack of inflammation supervenes in them. Much importance was attached by the old writers to the decomposition of these eftusions and their tendency to putrescency ; but the best pathologists are now agreed that they never acquire an offen- sive odour, or exhibit any sign of decomposition unless when the parietes which enclose them be- come gangrenous, or when a communication has been established between the fluid and the exter- nal atmosphere. {Andral d.nA Broussuis, Op. cit.) The quantity of these effusions is sometimes so very great as to compress the lung into the small- est possible compass, and exhaust it of its air more effectually than could be done after death by means of an air-pump ; at the same time the pa- jietes of the chest which are in any degree sus- ceptilile of motion are distended to the utmost; the ribs are elevated, and their lower margins everted, so as to increase their capacity as much as possible ; the intercostal spaces are protruded ; the diaphragm is forced down into the abdomen, and the abdominal viscera are consequently dis- placed, especially the liver, which, in cases of ex- tensive empyema of the right side, has been known to descend into the iliac fossa. {Stoll, Ratio Me- dendi.) The medustinum, in like manner, yields to the distending force of the effused fluid, com- presses the opposite lung, and allows the heart to be thrust completely out of its natural situation. We shall presently see that this displacement of the heart is one of the most constant and least fallible symptoms of empyema. Without this great enlargement of the affected side, it would be physically impossible that one sac of the pleura could accommodate such an enormous quantity of fluid as has occasionally been found there. A patient of Dr. Croker, of Dublin, was lately operated on for empyema by Mr. Crampton, when the almost incredible quantity of fourteen imperial pints of pus was drawn off from the left pleura. In Dr. Archer's case of successful paracentesis of the thorax, recorded in the second volume of the Transactions of the Dublin Association, eleven pints of an inodorous fluid were drawn off, and in a few weeks after the patient was quite convales- cent. Many other instances might be quoted of effusions equally great, or even still more exten- sive. When the effusion is removed, it seldom hap- pens that the pleura is exposed to view, as its sur- face is almost invariably covered with a coating of adventitious matter, which gives the interior of the chest much more the appearance of the walls of a large abscess than of a cavity lined with se- rous membrane. When, as in cases of latent pleurisy, the pleura is covered with a layer of the inorganic sediment, which is deposited when the effusion is wholly puriform, the layer of matter may be scraped ofl' with the handle of the scalpel, and then the membrane underneath presents an opaque blueish appearance, as if caused by the maceration to which it had been so long submit- ted. A few red dots or strite, as if laid on with a pencil, are ftenerally dispersed over its surface; the membrane itself is seldom if ever really thickened, its apparent thickening being in al- most every instance caused by a coaling of ad- ventitious membrane, which had been exuded during the earlier stages of inflammation. When the chronic pleurisy succeeds to an acute attack, this apparent thickening of the pleura is a very constant appearance : sometimes the adventitious membrane forms a delicate transparent pellicle, which appears perfectly incorporated with the subjacent membrane, but may, however, be dis- sected from it in one or more layers; sometimes the pleura is closely studded with minute trans- parent or opaque granulations of a flattened form, but most frequently the adventitious coating is of an opaque whitish colour, and varies in consist- ence from curd or soft cheese to fibro-carlilage, to which substances it often bears a very strong re- semblance ; and as it is generally composed of se- veral strata laid one over the other, it sometimes forms a dense solid layer many lines or even inches in thickness. When a coating of this de- scription is developed on the pulmonary pleura, it forms such an unyielding envelope round the lung in its compressed, contracted state, as must eftect- ually prevent its expansion when the ])ressure of the fluid is removed ; and as the lung in this con- dition cannot dilate itself promptly enough to keep pace with the progress of absorption, when the disease terminates favourably, the parietes of the chest must necessarily fall in to occupy the space left by the removal of the fluid : in this way is produced the contraction of the chest which so constantly follows the removal of a chronic effu- sion from the pleura either by absorption or eva- cuation. The adventitious membranes which line the pleura are liable to a variety of morbid altera- tions ; they are evidently susceptible of inflam- mation, and likewise of ulceration ; for in many cases they have been observed eroded, as it were, with small circular pits, sometimes shallow and sometimes penetrating through the whole thick- ness of the false membrane : occasionally these penetrating pits communicate with each other by sinuses, or by a more extensive separation of the false membrane from the subjacent pleura, but at other times the ulceration penetrates through the pleura itself. When this happens on the costal pleura, it sometimes gives rise to the formation of external tumours, which either burst externally and discharge the matter of the empyema, or else form one or more sinuous passages by which the pus is infiltrated into the subcutaneous and inter- muscular cellular tissue ; but when it takes place in the pulmonary pleura, a communication is eventually formed with a bronchial tube, through which (according to the jiositicm of the body at the time) part of the fluid escapes, or air enters. Several cases illustrative of these morbid appear- ances are recorded in Dr. Duncan's interesting essay on empyema and pneumothorax, in the 28th volume of the Edinburgh Mciiical Journal. The pleura and its adventitious coating of false membranes is likewise subject to gangrene, and the detachment of the gangrenous eschars some- times serves, as in the case of simple erosion jusi noticed, to form an outlet by which the niatter cV the empyema is evacuated.](https://iiif.wellcomecollection.org/image/b21116817_0025.jp2/full/800%2C/0/default.jpg)
