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
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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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    puerile : this phenomenon is therefore of consi- derable importance, as it announces the ineffi- ciency of the opposite lung. 10. D/splace/nent of the heart.—The science of morbid anatomy furnishes numerous examples of the strongest membranes yielding to the appli- cation of constant and gradually increased pres- sure ; in empyema, and likewise in pneumotho- rax, the mediastinum yields to the distending force of the accumulated fluid, and allows the heart to De displaced by its pressure. When the left side is the seat of the effusion, the heart is thrust from its natural situation, either down into the epigas- trium, where it may be seen and felt pulsating, or over to the right of the sternum, where its pul- sation is sometimes so strong as to attract the at- tention of the patient. When the effusion is in the right side, the change in the heart's position is not in general so remarkable; but by careful examination with the stethoscope, it will generally be found to pulsate considerably to the left of its natural situation. In two cases, one of which we have already alluded to as having been lately ope- rated on for empyema, the apex of the heart was distinctly felt striking against the stethoscope be- tween the fourth and fifth ribs in the left axilla. As, then, displacement of the heart is constantly produced by effusion into either sac of the pleura, and seldom if ever arises from any other cause, it may be considered as the most constant and least equivocal of all the signs of effusion, and, when joined with other symptoms and physical signs of empyema, may be regarded as quite pa- thognomonic. 11. Depression of the diaphragm.—The dia- phragm in like manner yields to the pressure of the incumbent fluid, and descends into the abdo- men, thrusting the abdominal viscera before it. When the right side of the diaphragm is depress- ed, the liver is protruded beyond the margin of the ribs, and has even been felt so low as the iliac fossa, (S/o//, Ratio Medendi.) Such cases have repeatedly been mistaken for enlargement of the liver. Of this a remarkable instance has been recorded by Roux, in a memoir r.ppended to the third volume of Desault's works, where, in a case pronounced by one of the most eminent medical men in Paris to be an incurable enlargement of the liver, the true nature of the disease was dis- covered by Bichat, who performed the operation of paracentesis thoracis, and thereby saved the patient's life. 12. Abdominal pressure.—Another test of the existence of pleuritic effusion imagined by Bichat, and described by Roux in the memoir just quoted, is the effect of pressure on that side of the abdo- men where the effusion is suspected to exist. According to those celebrated anatomists, pressure exerted on that side of the abdomen correspond- ing to the empyema, thrusts the diaphragm and the fluid which rests on it up into the thorax, and thus, by increasing the pressure of the effusion on the lung, produces an insupportable sense of suffocation. In those cases where we have em- ployed this test, the result was the very opposite of that above stated ; for while no uneasiness was produced bv pressing up the diaphragm into that side where the effusion exiitcd, any attempt to stop the free motion of the diaphragm at the other side, where alone respiration was still carrried on, was most distressing to the patient. The same observation-has likewise been made by M. Cho- mel, (Dictionnaire de Medecine, Art. Pleurisie.^ 13. Cough and Expedorufioyi. — The cough in empyema is generally short and single, and when there is no accompanying bronchitis, is often wanting altogether. If there be any expec- toration it is generally catarrhal, unless when a communication is established between the bronchi and the fluid effused in the pleura; in which case the quantity of matter expectorated is sometimes so great as to threaten suffocation. This, however, can only occur when a large communication is suddenly formed, and opens directly into one of the principal bronchi; but in those cases where the rupture is small and communicates only with the lesser bronchi, the evacuation of the fluid must go on slowly and by small quantities at a time. In such cases it is often difficult to deter- mine the source of the expectoration : some wri- ters describe it as possessing a peculiar fetor which is quite characteristic. Laennec compares the smell to that of gangrene. (Page 447.) Profes- sor Nespoli to the smell of assafoetida, ma assai piu di questa penetrante e acido. (Discorso, &c. Firenze, 1825.) Some have compared this odour to garlic, some to that of phosphoretted hydrogen, and others to other ill smells. (Dr. Forbes's Note to Laennec, p. 447.) But as thes^ fetid smells have all been observed in the expectoration of gangrene, and even of simple bronchitis, too much importance should not be attached to this sign; more particularly as in many cases of fistulous communication between the pleura and bronchi no such fetor has been observed. When, however, this appearance of the expectoration is accompa- nied with a marked improvement of other symp- toms, and with a diminution in the diameter of the dilated side, we may conclude that a commu- nication with the bronchi has been formed ; and this diagnosis will be still farther confirmed if the signs of pneumothorax supervene in consequence of the atmospheric air entering through the com- munication. 14. Fever. — The febrile symptoms which accompany this disease vary considerably, accord- ing to the f'onslitution of the individual and the progress of the effusion ,• tnus. while acute empye- ma is usually accompanied with rapid pulse, burn- ing heat of skin, and other symptoms of the highest degree of febrile excitement, the more chronic forms of the disease often present no other symptom of fever than a slight acceleration of the pulse towards evening, or after taking food ; and the patients sometimes even enjoy a state of perfect apyrexia. It has been remarked by Broussais, and the observation has been confirmed by Andral. ^hat the hectic of empyema is never accompanied with profuse night-sweats, unless when tubercles are developed in the lungs or in the false membranen of the pleura. Another peculiarity in the hectic of empyema, according to Broussais, is, that the pulse generally returns to its natural frequency after rest, particularly after a night's rest; whereas, in the hectic of phthisis, the pulse seldom or never comes down to its natural standard. The same author likewise states that in the hectic of