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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![remains of respiration over their site, and the place of the operation may then be varied accordingly : besides, we know that the thickest false mem- branes exist at the junction of the diaphragm with the walls of the chest, and that at the right side an enlarged liver frequently reaches as high as the sixth or even as the fifth rib; in which case, when the operation is performed in the usual situation, the instrument, instead of entering the chest, would transfix the diaphragm and penetrate the abdomen; there are several cases on record of the operation having been frustrated by this accident. Laennec informs us that in a case of pleuro-pneumothorax, after making an incision through the integuments between the fifth and sixth ribs, he thrust the trochar, as he thought, into the thorax, and was much surprised to find that no fluid followed its introduction; but on dissection he discovered that the instrument had entered the cavity of the abdomen, after transfix- ing the diaphragm, which had been thrust up into the cliest by an enlargement of the liver, and had contracted a firm adhesion to the seventh rib. (Op. cit.) A similar accident happened to La Motte, (Traite complet de Chirurgie, vol. ii. obs. 77, p. 292 ;) and Solingen saw the diaphragm wounded by the introduction of a canula after the operation, which was performed between the first and second of the false ribs. (HandgriflTe der Wundarzney, Th. ii. Kap. i. p. 175.) The only object of operating so low down is to make the opening at the most dependent part of the chest for the more complete evacuation of the effusion ; but this ol)ject may be sufficiently attained by operating between the fifth and sixth ribs, which may in fact be made the most dependent point of the chest, by causing the patient to lie, as he gene- rally feels disposed to do, on the diseased side. The danger of wounding the intercostal artery may be avoided by making the incision close to the superior edge of the lower rib. [See on this subject Stokes on the Chest, Amer. edit. p. 483, Philad. 1844. Recently the writer directed the operation to be performed in a case of chronic pleurisy. The operator, in accordance with the recommendations of Dr. Ferguson, (^A System of Practical Surgery, Amer. edit. p. 530, Philad. 1843,) selected the seventh rib, a little in front of the angle, for the place of puncture, but no fluid escaped. On repeating the operation immedi- ately above the fifth rib, half way between the spine and the sternum of the right side, he was completely successful.] Wlien the incision is carried through the pa- rietes of the chest and the false membranes with which they may be coated, a rush of fluid is im- mediately expelled by the pressure of the parietes, and continues to flow in an uninterrupted stream until the surface of the fluid falls to the level of the wound, after which it issues in a scries of in- terrupted jets corresponding to the motions of the diaphragm ; for as this muscle descends in inspi- ration, the fluid which lies on its surface sinks along with it, and the atmospheric air rushes in to fill up the space created by its descent: again, as the diaphragm rises in expiration, the incum- •lent fluid is elevated to the level of the orifice, and issues in a jet from the wound ; this alternate sucking in of air and expulsion of fluid continues until the quantity of matter is dinunished so as no longer to rise to the level of the wound during expiration, after which each movement of the dia- phragm is followed by the alternate introduction and expulsion of air, so long as the wound is al- lowed to remain open. Many reasons, however, render it inexpedient to continue the operation to this period. The sudden removal of .so large a quantity of fluid frequently produces such a sho:k to the nervous system as throws the patient into an alarming state of collapse ; the withdrawing so great a degree of pressure from the heart and large blood-vessels and from the opposite lung must likewise derange materially the functions of these important organs, and consequently oppose the success of the operation ; and another inju- rious consequence of protracting the operation until all the fluid has been evacuated is, that the parietes of the chest are unable to accommodate themselves to the space which is thus left unoc- cupied, and which must consequently be filled with atmospheric air. For these reasons it is advisable to close the wound before the fluid begins to issue in an in- terrupted stream, and to repeat the evacuation at longer or shorter intervals, according to the extent of the ef!usion and the urgency of the symptoms. In general, the removal of twenty ounces of fluid at a time will be found sufficient to relieve the breathing, (as this effect is produced, at least in the first instance, by diminishing the pressure on the opposite lung, and not by restoring the func- tions of the organ at the diseased side,) and an interval of forty-eight hours may be allowed to elapse before the wound is again opened. When, however, the effusion is verj' extensive, and the breathing not sufficiently relieved b)' the removal of the quantity above specified, the fluid may be allowed to flow for some time longer, or the evacu- ation may be repeated at shorter intervals. When the principal part of the effusion has been remov- ed in this way, a large poultice may be apphed over the wound, and the remainder of the fluid allowed to escape as fast as it is secreted. By this method of gradually removing the effu- sion, we diminish the shock to the nervous sys- tem, reheve the thoracic viscera gradually from the pressure of the accumulated fluid, and prevent the introduction of air into the thorax, until the parietes have had time to accommodate themselves to the diminished volume of their contents, and by their mutual approximation diminish, to the utmost, the space left by the evacuation of the effusion. The following measurements taken from a pa- tient of twelve years old, who lately underwent this operation, will serve to illustrate the diminu- tion which takes place in the capacity of the dis- eased side by the falling in of its osseous parietes: Circumference Circumference of the dheaaed of the «iound 9th day alter the ojicration .'.■.■.■.■. ]3 9 \\ \ Thus, in the space of nine days, the circumference of the diseased side diminished nearly three inches. This contraction of the osseous parielcf, aided by](https://iiif.wellcomecollection.org/image/b21116817_0040.jp2/full/800%2C/0/default.jpg)
