Diseases of the chest and the principles of physical diagnosis . osition. An additionalfactor in producing injury of the diaphragm in cases of effusion is theweight of fluid which has often been present for months. In the case ^ Records of the Pathological Dept., University of Penna. 2 Fifth Annual Report, Phipps Institute, 1908. 3 International Clinics, vol. ii, Twenty-sixth Series, 1916. DISEASES OF THE DIAPHRAGM 643 of a large and um-ecognized empyema it is no unusual thing at the autopsytable to find that the leaflet on the affected side is turned inside out,the convexity being toward the
Diseases of the chest and the principles of physical diagnosis . osition. An additionalfactor in producing injury of the diaphragm in cases of effusion is theweight of fluid which has often been present for months. In the case ^ Records of the Pathological Dept., University of Penna. 2 Fifth Annual Report, Phipps Institute, 1908. 3 International Clinics, vol. ii, Twenty-sixth Series, 1916. DISEASES OF THE DIAPHRAGM 643 of a large and um-ecognized empyema it is no unusual thing at the autopsytable to find that the leaflet on the affected side is turned inside out,the convexity being toward the abdomen (see Figs. 345 and 346, also ). This is due, in part, to loss of function and elasticity, the result ofinflammatory changes, and, in part, to the weight of the fluid. Associated with changes in the structure of the diaphragm are adhe-sions. In some instances, as in the case of dry pleurisy, the adhesionsprobably occur first and the chronic inflammatory changes in the muscleoccur secondarily. In the case of effusions it is probable that the loss of. Fig. 370.—Obliteration of complementary pleural space and adhesion of diaphragmto chest wall on right side, following a pleural effusion. {Roentgenogram by Dr. H. ) function is primarily due to changes in the diaphragm itself and thatlater adhesions form which serve to anchor the diaphragm in its abnormalposition, so that even if the muscle does recover, the adhesions prevent theleaflet from asssuming its normal position and function. The portionsmost likely to be affected are the spaces between the pericardium and thediaphragm and the phrenocostal sulcus. The latter forming the mostdependent portion of the pleural space, may retain a small amount offluid and sediment which tend to favor adhesions even when the aspira-tion has been most complete (Figs. 370 and 371). As a result of adhesions 644 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM at these points, the affected leaflet becomes more or less fi
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