GEN. I. of matter in the chest. one patient I found three pints of pure pus in the pericardium without any ulcer either on that membrane or SPEC. IV. on the heart. In another the cavity of the pleura of the Empyema. Apostema right side was distended with a pus that smelt more like Lodgement whey than a putrid fluid, and the lungs were compressed into a very small compass: but there was no appearance of ulcer or erosion either on these organs or on the pleura; but only under the pus was a thin crust of coagulable lymph." We have already observed upon this secretion of imperfect pus, and it is not necessary to explain it any farther. case related Dr. Darwin relates a singular case of empyema, in Singular which the pus seems in like manner to have been pro- by Darwin. duced without ulceration, though he ascribes it indirectly to an abscess in the lungs. "A servant man, after à violent peripneumony, was seized with symptoms of empyema, and it was determined, after some time, to perform the operation; this was explained to him; and the usual means were employed by his friends to encourage him, by advising him not to be afraid'. By which good advice he conceived so much fear that he ran away early next morning, and returned in about a week quite well." This should indicate that something may at times be accomplished by internal medicines, though no plan has hitherto succeeded that has been devised by professional skill. Hence indicines may at times be ternal me useful. Other in stances of Nor is the present the only case on record in which the contained fluid has disappeared by metastasis. It metastasis. has passed off by the intestinal canal *, by the bladder†, and by the vagina ‡, in the form of pus; and is said in one instance to have vanished on the eruption of a scabies §. It has also been frequently carried off by an opening formed by nature, and the patient has recovered his usual health. This opening has commonly been be • Kelner, Diss. de Empyemate. Helm. 1670. Marchetti, Obs. 82. 89. + Buchner, Diss. sistens solutionem Empyematis per mictionem purulentam. Hal. 1762. N. Act. Nat. Cur. Vol. I. Obs. 5. Schlichting, Phil. Trans. Vol. XLII. p. 70. Hautesierk, Recueil, 11. p. 239. GEN. I. Lodgement of matter in tween the ribs, most usually between the third and fourth, SPEC. IV. but in one instance we find the abscess pointing and Apostema Empyema. bursting under the scapula. Morgagni has recorded singular case of a double empyema, a lodgement of pus being formed on both sides +. And Balme a still more extraordinary case, in which the pus entered the cellular membrane and spread over almost the whole trunk 1. the chest. Double em pyema. Ramifying over the entire trunk. Advice of When the fluid is discharged by paracentesis, Hippocrates urges repeatedly upon the surgeon to evacuate Hippocrates it only by degrees §; and Borelli gives a case in which in perforating where the patient seems to have sunk and been lost under a the opening sudden evacuation alone ||. There has also been no small discussion concerning the part of the thorax to which the scalpel may be most advantageously applied. David, in his prize dissertation, advises near the sternum¶; Mr. Sharp between the sixth and seventh rib**: Mr. Bell wherever the pain or fluctuation may direct ++. should take place. Warner's success and mode of practice. the whole of Mr. Warner, whose success made it many years ago a favourite operation in our own country, seems to have been of Mr. Bell's opinion, and varied the point of opening according to the nature of the case. And so little danger did he apprehend from the use of the Evacuated scalpel on any occasion, that he not only evacuated in all instances the whole of the matter at once, but in one or two instances operated, where there was neither a polarized pain, nor fluctuation, nor visible discolouration, nor any external sign whatever, to direct him to one part rather than to another, or even to determine the real nature of the disease; otherwise than from the specific symptoms laid down in the preceding definition ‡‡. the contain ed pus at once. Usual mode of treatment. In Mr. Warner's cases about twenty ounces of pus formed the average of discharge at the time of the per • Hurten, Diss. de Empyemate. Argent. 1679. Journ. de Medicine, Tom. LXVI. p. 244. § Περὶ Νουσῶν. ΙΙ. p. 476. ). 42. ** Critical Enquiry, &c. Chap. vi. Περὶ τῶν ἔθνος Παθῶν, p. 536. 1. 15. Mem. pour le Prix de l'Academie, 1. + Surgery, Vol. 11. 390. ‡‡ See Original Cases and Dissections, &c., by John Forbes, M.D. p. 257. 8vo. Lond. 1824. GEN. I. Apostema of matter in foration *: the patients usually found instant relief; the pain, cough, and quickness of pulse diminishing, and the breathing becoming easier. He dressed the wound with Empyema. a sponge-tent till there was no longer any discharge, and Lodgement afterwards superficially; and in about six weeks the the chest. patients were discharged cured. In this case it is perhaps more necessary to keep the wound open than in any other operation, since, till the ulcerated surface of the interior is completely healed, the secreted pus is apt to accumulate, and the operation must be renewed. Tents of all kinds are very properly exploded in most cases in the present day; but Mr. Bell has judiciously observed that in the paracentesis the old fashioned practice ought still to prevail +. In some instances the Cure by operation might perhaps best be performed by a seton. seton. Desault on one occasion passed a seton completely through the chest; and M. Fournier tells us that, upon the strength of his authority, he pursued the same plan upon a soldier who had received a shot from a musket fired close against his breast, which passed directly through both lobes of the lungs from the left to the right side, and carried with it pieces of the wadding as well as of his own clothes. These were all discharged by the seton, and in twenty-seven days the wounds were cicatrized 1. case by Hawthorn. Dr. G. Hawthorn has given an instance of this dis- Singular ease that for its severity and danger, and particularly for its successful issue, is well worth recording §. The patient was thirty years of age, and the disease had been brought on by exposure to damp night-air in a state of intoxication. He suffered greatly from quickness of pulse, incessant cough, oppression, and dread of suffocation. A distinct fluctuation was perceived in about three weeks from the attack; shortly after which he was * See Phil. Trans. Vol. XLVII. XLVIII. LI. as also his works in their collected form. + Surgery Vol. 11. Ch. xxi. Sec. IV. Dict. de Sciences Médicales, Art. Cas. Rares. § Edin. Med. and Surg. Journ. No. LXI. p. 513. GEN. I SPEC. IV. Apostema Empyema. Lodgement of matter in the chest. Matter discharged of various ap pearances and qualities. a little relieved by a discharge of purulent matter effused opera Riedlin operated with success twice on the same person *. The matter when discharged or examined on dissection has been found, as may be easily supposed, of very different consistences; sometimes pure pus, sometimes cheesy, and sometimes gelatinous. And the mischief to the interior of the chest has in some cases been very great. Several of the ribs have been found carious +; the lung on the affected side totally eroded; and in one case the pericardium destroyed as well as the lung §. GEN. I. SPEC. V. Comprehensive use of the term by Celsus here copied. SPECIES V. APOSTEMA VOMICA. Momica. DERANGED FUNCTION OF A THORACIC OR ABDOMINAL THE specific term is a derivative from the Latin vomo, • Lin. Med. Ann. v. Obs. 30. + Heuermann, Vermichta Bemenkungen, 11. p. 217. § Goekel, Gallicinium Medico-pract. GEN. I. SPEC. V. Apostema Avenbrug sively so; and hence, on the present occasion, it is used in the comprehensive sense in which it is employed by Celsus, who applies it to a bursting of pus from the liver, Vomica. or any other large internal organ, as well as the lungs *. Sauvages follows Celsus in this interpretation, but distinguishes the vomica from the aposteme by making the discharge from the latter consist of pure pus, and that from the former of a mixt matter, being at first a sort of adipose mucus (mucus quidam adiposus) which at length becomes purulent. Avenbrugger, to whom we are indebt- How emed for the Inventum novum, or method of ascertaining ployed by diseases of the chest by percussion, takes nearly the ger. same range, or rather carries it to a still wider extent so as to include other depositions than that of genuine pus, and hence divides vomicæ into purulent and ichorous, meaning by the latter term the reddish yellow fluid occasionally found in a sac from the destruction of a hepatized or scirrhous lung or other organ t. Boer- Employed haave and Cullen confine vomica to the lungs, and this in a more in a more restrained sense than most writers; for they sense by limit it to what has been called, though with no great accuracy, occult vomica, "vomica clausæ ". Linnéus and Vogel on the contrary, while they confine the term to differently the lungs, explain it by open vomica "vomicæ apertæ", and Vogel. in which the pus is thrown forth profusely and suddenly. One termination of the hepatic aposteme may be regard- May be ed as a variety of this species, for, as we have observed, the hepatic it sometimes issues in a discharge of pus by the mouth aposteme. or rectum. Wherever it occurs, it appears to consist in Vomica a conglobate gland, first enlarged by a strumous con- originates in a conglogestion, and afterwards slowly and often imperfectly bate gland. suppurating. Vomicæ vary in size, from the diameter of Varies in a millet seed to that of an orange. The smallest rarely contain any fluid, and sometimes not even a cavity; but they are often highly irritable, and maintain a very considerable degree of hectic fever. When ulceration has * De Medicin. Lib. iv. Cap. viii. + Inventum Novum ex percussione thoracis humani, ut signo, abstrusos interni pectoris morbos detegendi. Vien. 8vo. 1761. restrained and Cullen. Boerhaave And still by Linnéus related to size. |