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:
- 1845
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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![erate in quantity, recently formed, and unaccom- panied with organic disease of the lungs. On the other hand, the prospect of success diminishes considerably when the effusion is very external**, of long standing, and accompanied by symptoms of contained hectic. The copiousness of the effusion, however, though it generally diminishes the chances of re- covery, does not necessarily preclude the success of the operation. Baron Larrey operated success- fully in a case where the effusion amounted to fifteen pints; Dr. Hawthorne's patient lost twenty pints of pus during the first twenty-four hours; and in Dr. Archer's successful case, already quoted, eleven pints of fluid were drawn off at the first evacuation. The same remark is likewise appli- cable to the length of time during which the em- pyema has existed, arid to the symptoms of hectic with which it is accompanied, as there are several on record where the operation was success- fully performed under those unfavourable circum- stances. (Dictiormaire des Sciences Medicales, art. Empyt In the numerous class of cases where empyema is complicated with pneumothorax from the rup- ture of a tuberculous abscess in the lung, the chance of any permanent advantage from the operation must necessarily be very small, in con- sequence of the incurable nature of the original disease : in such cases, indeed, little else can be hoped for from the removal of the effusion than a temporary alleviation of suffering, or the prolonga- tion of existence for a few weeks or months at the utmost; such, at least, is the conclusion that we have formed, after having witnessed the pro- gress and fatal termination of eighteen cases of this nature, in five of which the operation was performed with no better success than that just described. (See P.vf.i'motiiojiax.) Laennec, however, is of opinion that we must not aban- don all hope of cure, even when there exists so serious a complication as this, provided there be no evidence of cavities in the opposite lung. (Op. cit.) The complication of pneumothorax does not seem to form so serious an objection to the opera- tion, when not coupled with the presence of tu- berculous abscesses in the lungs, as appears from its having been successfully performed in several cases where the sound of fluctuation, audible in the chest, sufficiently proved the coexistence of a gaseous and liquid effusion. Dr. Archer's remark- able case of this kind, published in the Transac- tions of the Association, has already been alluded to. A still more remarkable case of empyema with pneumothorax, terminating successfully by operation, is related by Dr. (jr. Hawthorne, in the Edinburgh Medical and Surgical Journal, No. 61. Neither docs the existence of a fistulous pas- sage through the lungs necessarily preclude the success of the operation, as is evident from those cases where it was performed after the empyema h nl hurst internally into the bronchi, and yet the communication thus formed through the lung did not appear in the least to impede the patient's ultimate recovery. I«e Dran relates a case on which he operated for empyema where the in- jection of a small quantity of mel rosarum and barley-water through the wound excited coughing, and part of it passed off by the mouth, mixed with pus; thus clearly proving the existence of a fistulous passage, through the lung, notwithstand- ing which the patient recovered completely. Seve- ral similar cases are quoted in the Dictionnairo des Sciences Medicales, from the writings of MM. Jaymes, Robin, and Bacqua. In these cases, how- ever, the empyema must in all probability have been circumscribed, and the lung retained by ad- hesions in contact with the walls of the chest around the circumference of the wound; or else the injection, instead of entering the lung, would have fallen to the bottom of the pleura. It is unnecessary here to enter into any minute description of the mode of performing the opera- tion, as this is described in all treatises on the subject and in all systems of surgery; but the reader is more particularly referred to the works of Le Dran, Richter, Sharp, C. Bell, Larrey, and Boyer, [Ferguson, and Liston,] where he will find all the necessary information. [For the removal of the fluid, Drs. Prichard and Babington have recently recommended instru- ments, which are described under Ascites, (page 188,)—and should any doubt exist as to the pre- sence of fluid, a grooved or exploring needle, as advised by Dr. Thomas Davies, (Lectures on Dis- eases of the Lungs, <^c, Lond. 1835,) may be passed into the chest, by which not only the pre- sence but the character of the effused fluid may be safely determined.] Authors make a distinction in the operation according as the matter points externally or not. The former they term the operation of necessity, from its site being necessarily fixed : and the lat- ter the operation of election, from the surgeon being at liberty to select at what part of the chest he makes his incision. In the empyema of necessity, as it is termed, when the matter points externally, the sooner an incision is made into the tumour the better, as there is no chance of the matter being removed by absorption, and the consequence of delaying the operation has too often been the formation of long sinuous passages through the parietes of the chest and abdomen, and caries of the ribs. In- deed this operation is much more generally suc- cessful than that performed at the place of election, which no doubt arises from the circumstance that those empyemas which point externally are almost invariably circumscribed, and confined to a small extent of the pleural sac. When no tumour appears, to fix the site of the operation, the place of election generally recom- mended by surgeons in this country is between the sixth and seventh true ribs, where the indigi- tations of the serratus major anticus muscle meet those of the obliquus externus. Laennec prefers the space between the fifth and sixth ribs. « Many reasons (he says) point out this snot as the best suited for the operation : for instance, we know that the upper lobe adheres to the ribs more fre- quently than any other part of the lungs, and that the lower lobe is frequently attached to the dia- phragm, while adhesions very seldom exist at the central part of the chest; and even should there chance to be any old adhesions in this point, they may be readily and certainly discovered by some](https://iiif.wellcomecollection.org/image/b21116775_0037.jp2/full/800%2C/0/default.jpg)
