190 The Pleura 



descends, and, with it, the apex of the heart. At the same time the 

 pericardium and heart are displaced towards the right, so that the 

 apex-beat is felt in the epigastrium. If the heart be pushed still further 

 to the right it has to glide up over the liver, and thus the apex-beat 

 may be found in the fifth space, or even higher. 



When the effusion is into the right pleura the apex-beat is neces- 

 sarily displaced towards the left. 



Pressure upon the venae cavae keeps them constantly full, but as 

 soon as some of the fluid is withdrawn from the chest by paracentesis 

 the superficial veins empty themselves, the aspect of the patient im- 

 proves, and respiration is eased. 



Sometimes the chest is found full of fluid without there having been a 

 pleurisy or any other disease to account for it; it is then probably caused 

 by the pressure of a malignant tumour upon the veins and lymphatics. 



When the fluid is purulent the disease is called empyema (ei/, 

 within ; nvov, pus), and the pleural abscess, for such it is, may discharge 

 itself by a bronchus, into the peritoneum, or through the chest-wall 

 about the fourth or fifth space, outside the nipple-line and below the 

 border of the pectoralis major a situation in which the chest-wall is 

 apparently weak ; or it may work its way to the sternum between the 

 planes of the intercostal muscles. 



Tapping: the chest is best done just in front of the angle of the 

 scapula when the arm is by the side through the middle of the fifth 

 space. If the contents be purulent, and the space narrow, it may sooner 

 or later be necessary to excise a piece of a rib, so as to ensure more 

 room for drainage, the periosteum being raised by a raspatory, and the 

 intercostal vessels being also turned out of the groove before the rib is 

 cut with the nippers. If the opening were made through a low space 

 and especially if on the right side there would be a risk of the 

 diaphragm rising so high as to block the tube. Indeed, it has even 

 happened that when an empyema has been incised too low down the 

 diaphragm has also been traversed, and that omentum has escaped 

 through the wound. 



When the pleura has been evacuated, the lung, if not permanently 

 crippled, and bound down by adhesions, expands again. If it fail to 

 recover, and a pleural fistula persist, the ribs may have to be divided 

 in front of their angle, so that the side of the chest may collapse and 

 the suppurating pleura may be obliterated. But if this be not done the 

 obliteration may ultimately be effected by the rising of the diaphragm, 

 by displacement of the heart and sound lung, by a falling in of the 

 chest, and by lateral curvature of the spine ; the ribs become crowded 

 together on that side, whilst they are expanded like a fan upon the 

 sound side, the shoulder on the crippled side being depressed. The 

 effacement of the former pleural space is effected by the formation of 

 new fibrous tissue which has been developed out of the granulations 

 sealing the space. 



