Chapter XXXVIII: Part 38

TERMINATIONS.--If allowed to take its natural course, pulsating empyema almost always ends in death from exhaustion or syncope, or by discharging through the lungs or through the intercostal spaces. Formerly, it was oftener fatal than now, but it is still justly considered the gravest form of pleurisy. We have seen that exceptionally it is cured by becoming encysted. It may be cured by spontaneous openings into the lungs, and more rarely by fistulous orifices[121] through the walls of the chest. Is it possible for the disease to be cured by the absorption of the pus? The bearing of this inquiry upon the treatment cannot be over-estimated. If absorption can remove the pus, we may safely leave it in the pleural cavity. If the pus cannot be taken up by the absorbent vessels, we ought promptly to make use of radical measures and evacuate it. The literature on this point gives us few reliable cases. Spontaneous cure can rarely be produced by absorption. Douglass Powell[122] writes that "the spontaneous disappearance of such effusions is too uncommon to be expected, and the process of reabsorption is one too full of peril to be anticipated with anything but dread. It is indeed an attempt at such absorption that occasions the most characteristic hectic symptoms." Surgical intervention is the rule. The writers previous to the introduction of exploratory punctures speak of cases where purulent pleurisies were diagnosed and the effusions were absorbed. We have shown that the differential diagnosis between serous and purulent effusions is very uncertain when made from the general symptoms and physical signs. Even Trousseau, with all his skill and vast experience, made the mistake of diagnosis, and performed the operation of pleurotomy in a case of serous effusion, and his patient died. There are well-authenticated cases where, after thoracentesis, small quantities of pus left behind have been absorbed, especially in children. That purulent pleurisies have been effectively cured by the pus becoming encapsuled has been demonstrated by autopsies of persons dying from other causes. E. Moutard-Martin reports a case where, after withdrawing with an exploratory trocar a few drops of pus, and thereby establishing the diagnosis of purulent pleurisy, he was unavoidably prevented from opening the chest. Two months afterward he found the effusion had entirely disappeared. He states that this was the only case he had ever seen of a spontaneous cure without evacuation. Douglass Powell has seen one case which has satisfied him as to the possibility of a local empyema becoming absorbed. Wilson Fox reports another similar case. Chronic pleurisies in childhood are almost invariably suppurative, yet Barthez and Rilliet report 7 out of 13 recovered. It must be, and generally is, admitted that cure by pus undergoing retrogressive fatty degeneration, and then being absorbed, is possible, but it rarely occurs. Should the more fluid portion be absorbed, the inspissated pus remaining on the pleural surface may at some future time, upon softening, give rise to secondary tubercular or purulent collections. It is also true that cure is quite often effected by spontaneous evacuation through the lungs and through the walls of the chest. This is especially the case {548} in interlobular effusions and in cases sacculated by adhesions. Such cure is explained by the fact that adhesive inflammation, assisted by the elasticity of the lung on both sides, glues together the walls, isolates the fluid, and prevents air from entering, thus preventing the pus from putrefying.

[Footnote 121: In Andral's 8 cases of bronchial perforation there were only 3 deaths--a mortality less than by artificial opening previous to the application of Listerism.]

[Footnote 122: _Dis. of the Lungs and Pleura_, London, 1878.]

In cases of pulmonary perforations the probabilities of a favorable termination by absorption of gas, evacuation of fluid and the contents of the chest, are greater where air does not enter the cavity. The presence of air, especially if stagnant, in contact with the pus, makes a serious complication, causing putrefaction of the pus and consequent septicæmia, with all its dangers. The discharge of the purulent collection, through the parietes of the chest, after the manner of an ordinary abscess, is ordinarily made through the anterior part of the thorax, but it may take place in any part. At first this mode of evacuation, empyema necessitatis, is a great relief, but cures rarely result from it. Most frequently, owing to the imperfect evacuation through the tortuous canal and the entrance of air mingling with the pus, death supervenes unless the surgeon enlarges the orifice or produces a new one, and thoroughly empties the sac and persistently washes it out. From statistics collected by Wilson Fox, the mortality is not so great from spontaneous parietal openings as was formerly supposed. Of Andral's cases there were 2 deaths in 25. Goodhart had 11 cases, all of which recovered. Ewald lost 3 of his 6 cases. Cases of empyema necessitatis should be treated as artificial openings with every possible antiseptic precaution. The mortality would thus be decreased. The chances of cure by absorption are so small that when nature shows no tendency to either of the two spontaneous modes of cure, there is great danger of a fatal termination through hectic fever. The time for this result varies from a few weeks to months. When in empyema we have fistulous orifices they sometimes remain open for years. Near them are local points of depression, caused by external atmospheric pressure. When acute purulent pleurisy follows a low fever, such as typhoid or scarlet, a fatal termination may result in a short time; in other cases it is many months before the patient dies from exhaustion.

We cannot forbear to urge the importance of promptly and definitely settling the diagnosis by exploratory aspiratory punctures. Properly guarded, no evil can result, whereas a positive diagnosis enables us to act promptly with effective mechanical means of relief. It is undeniable that purulent effusions in the pleural cavity are very serious in their results, and are followed by death unless Nature or the surgeon evacuate them. Even when Nature does so, it is often imperfectly done, and the termination may be death unless we assist her to get entirely rid of the fluid.

PROGNOSIS.--Formerly the prognosis in every case was of extreme gravity. The condition was looked upon as of necessity fatal. Surgeons despaired of a successful result in operating. Now, thanks to thorough drainage and Listerism, unless the case is an old chronic empyema, we are hopeful of cure and a favorable prognosis may be given. We may look for good results where the disease is early recognized and promptly treated. J. G. Blake[123] cured 16 in a total of 19 cases. Since 1869 he cured 9 out of 10 cases. Homer[124] saved 26 out of 52. Feidler[125] treated 112 patients, only 25 of whom died (all advanced tubercular cases); 21 were restored to good health; 66 (tubercular) were cured so far as return of effusion was concerned. Israel[126] had 10 recoveries out of 11 cases. A. T. Cabot[127] reports 11 recoveries out of 14 cases. Of the fatal cases, 2 died of phthisis; the third had existed four years.

[Footnote 123: _Med. and Surg. Rep. Boston City Hospital_, 2d Series.]

[Footnote 124: Quoted from _Med. Times_, Philada., Aug., 1883.]

[Footnote 125: _Ibid._]

[Footnote 126: Quoted from Dabney, _Amer. Journ. Med. Sciences_, Jan., 1883.]

[Footnote 127: _Bos. Med.-Surg. Journ._, Aug. 16, 1883.]

{549} When purulent pleurisy follows fibro-serous effusions, and when it occurs in vigorous children, the prognosis is more hopeful than when it is preceded by scarlet fever or occurs in subjects debilitated by diseases which have exhausted the recuperative forces of the body. Empyema of tubercular origin has necessarily a grave prognosis. In persons in advanced life the prognosis is very unfavorable. If hectic fever or septicæmia occur, the prospects of cure are comparatively slight. In cases of empyema necessitatis much depends upon the power of resistance of the patient, and upon whether the matter is discharged before it has produced caries of the ribs, sternum, or spine, or has prostrated the vital powers. If these sequelæ have been produced, the condition of the body is most unfavorable to the restoration of health. If the pus in pyothorax has been discharged through the bronchi, though it may give temporary relief, it is attended with great danger, and if the discharge continues it will gradually wear out the patient's strength.

TREATMENT.--The diagnosis being established, we at once realize the great responsibility of treating a disease of such gravity. In many other diseases of serious import we trust Nature to do her part toward cure; here, as we have shown, we find her unable to come to our assistance. One of the large serous cavities, connected as it is with the lungs, is not only disabled, but contains a deleterious fluid which cannot remain in a closed cavity without sooner or later affecting the processes of nutrition. We can do little by medical treatment save to sustain the organism by tonics and reparatory agents; we can give wine, quinine, arseniate of soda, and cod-liver oil; we can administer a sustaining diet and place the patient in the best hygienic and sanitary condition. We cannot conscientiously hold out to the patient a prospect of cure by medicines.

There is danger in resorting to the expectant plan of treatment. We lose valuable time, and finally we shall be forced to resort to surgical operations, which in fact constitute the modern treatment of purulent pleurisy. By them only are we able to promote the primary objects of our treatment, which are to get rid of the purulent matter and to stop the suppurative inflammation. We thus endeavor to obliterate the pleural cavity and promote the expansion of the lungs.

Surgical Treatment.--This has been the treatment which has been most effectively used from the time of Hippocrates to modern times. There has been, and still is, great diversity of opinion as to the best modes of withdrawing the pus contained in the pleural cavity, but it is settled that when the diagnosis is certain the fluid must be removed--if not by spontaneous openings, by artificial means. We must except to this rule cases of suppurative pleurisy of phthisical origin. Bowditch years ago stated that in this class of cases it was advisable not to make permanent openings into the chest. In these the suppuration does not stop, and the operation appears to hasten the fatal issue of the disease. Wilson Fox demonstrates from statistics that the mortality in phthisical cases is increased by operations.

There is no room for discussion as to the indications, as in cases of simple sero-fibrinous pleurisy. There is only one thing necessary to be ascertained--the certainty of pus in the cavity. This is shown by the pointing or by pus abstracted by exploratory puncture. The more promptly we act, the greater the prospect of cure. As Powell[128] emphatically says, "The prognosis is practically hopeless without surgical help. We must adopt some surgical measures or take upon ourselves responsibility for a large mortality." Bowditch, Trousseau, Hamilton Roe, Anstie, Parker, Marshall, and Moutard-Martin all concur as to the necessity of surgical interference. Clifford Allbutt[129] says: "If pus or septic material be present in the body, we must not {550} rest until it is removed. I therefore dislike and reprobate all tampering with an empyema."

[Footnote 128: _Loc. cit._]

[Footnote 129: _Brit. Med. Journ._, Dec., 1877.]

We propose to mention, as briefly as we can in justice to the subject, the several modes of operating, together with our conclusions and the results obtained by us and by others of much larger experience.

Modes of Operating.--These are numerous, but they may be divided into three classes: First, the simple immediate evacuation of the fluid by subcutaneous thoracentesis with the ordinary trocar or with an aspirator of some kind, without allowing the flow to be continuous: this is the closed method; secondly, the open method--the operation by incision with a bistoury, and the introduction of permanent canulæ or of drainage-tubes of metal, of hard rubber, or of soft tubing; thirdly, the more radical treatment by free incision (pleurotomy) with or without washings or injections by the aid of syphons. With all these modes of operating the strictest antiseptic precautions should be taken.

Thoracentesis.--For this operation we have a choice between the ordinary hydrocele trocar, the trocar protected by a soft valve at the orifice (Reybard's instrument), Jules Guérin's or Wyman's aspirating pumps, Dieulafoy's previous-vacuum aspirator with capillary needles, and numerous modifications by others of Dieulafoy's, including Potain's, and Reynard's modification of Potain's, or we can have recourse to Potain's, Southey's, or Williams's syphon. If we select the trocar (Reybard's), we prepare the instrument by cleansing it thoroughly and Listerizing it. Reynard[130] recommends a hypodermic of morphia previous to operation, to prevent the painful cough. The simplest method is to pass the aspirator needle through the flame of a spirit-lamp, and subsequently to plunge it in carbolic-acid solution. We spray with a carbolized solution the point of puncture, which should be at the sixth intercostal space, when possible, in the axillary line. Powell prefers a lower opening, in the seventh or eighth intercostal space and in the posterior axillary line. He wishes to completely empty the pleural cavity of pus and promote the obliteration of the abscess-sac by the descent of the lung as it re-expands, and by the return of the heart to its normal position: these processes converge toward the lower and postero-lateral position. We ordinarily prefer local anæsthesia by sprays of ether or rhigoline or by cocaine hypodermics to anæsthesia by inhalation. After drawing up the skin, so as to be able to close the orifice by the flap after the operation, we direct the trocar by the nail of the left index finger; we, with a quick movement, insert the trocar to the extent of three or four centimeters. By this quick insertion we do not run the risk of stopping the canula with the thick membranes. We allow the fluid to flow out slowly, but as completely as possible. In fibro-serous effusions we only draw off sufficient to remove intra-thoracic pressure, to avert the dangers caused by that pressure, and promote the process of absorption. In suppurative pleurisy, while we aim at relief from pressure, we wish to get rid of a fluid which is itself deleterious. Consequently, our object is to prevent absorption and to ward off the formation of fistulous outlets through the lungs or the parietes of the chest. Therefore we endeavor to completely evacuate the pus, and, as far as possible, to prevent its re-formation. While we desire to remove all the fluid if we can, we must not run any risk by doing so. If the cough annoys the patient, and the elasticity of the walls and the pressure from the displaced organs do not continue to force out the fluid, we had better stop the flow temporarily or renew the operation next day. We must desist if the cough becomes very persistent. We prefer Dieulafoy's aspirator or Potain's modification for the simple evacuation of the fluid, unless we wish to wash out the pleura; then we employ Potain's or Williams's (of Boston) syphon, because either can be applied {551} with greater effect. It is best not to take needles of too small a diameter, for the flocculi may easily choke them. We prefer No. 2 (1 millimeter) or No. 3 (1 millimeter and a half). By using the small-sized dome-trocar we avoid the possibility of injuring the lung. Care must be taken in removing the canula to withdraw the aspiratory force by turning the stopcock; otherwise we may draw the pus into the texture of the walls and establish fistulous openings. In using the common trocar fistulæ have frequently been made, causing a serious complication.

[Footnote 130: _Brit. Med. Journal_, Sept., 1881.]

Thoracentesis thus performed has often cured empyemas, especially in children. We find instances mentioned by Lacase, Duthiers, Dieulafoy, Lebert, Hamilton Roe, and others. It has been demonstrated that the operation is sometimes effective without resorting to injections and washings of the pleural cavity. Bouchet[131] reports a case in a child following typhoid fever, where he aspirated thirty-three times and cured the patient; another case, a child four years of age, after two operations; another child, seven years of age, after six aspirations. Guérin[132] reported several cases. M. Fouson[133] reported 19 cases of children treated by aspiration with success. The younger the child, the greater are the chances of success. He advised complete emptying of the cavity. Lewis Smith[134] prefers the use of an aspirator in operating upon children. He does not think it necessary to remove all the pus present. Cordet Gassicourt[135] reports cases of three infants, each of whom was cured by one aspiration. C. Gerhardt of Würtzburg[136] recommends in children complete evacuation of purulent fluid, through incisions and washings, avoiding entrance of air. Adolph Bajincke of Berlin[137] states that aspiration with antiseptic treatment is often successful in children. He advises, if after two or three aspirations the fever returns and the fluid increases, that free incisions be made, with injections of salicylic acid (3 per cent.), with antiseptic dressings. He recommends the removal of only a portion of the fluid. A. Jacobi[138] mentioned having in a single year 3 cases of empyema in young children, each of which required but a single aspiration; the quantity of pus in 1 case amounted to 300 or 400 grammes. The flexibility of the young ribs causes sufficient sinking in of the thorax to promote recovery. F. Richardson[139] advises two aspirations before incisions. R. W. Parker,[140] London, takes Richardson's view. He strongly advocates antiseptic precautions and injections of quinine (5 grs. to ounce j) and injection of filtered and carbolized air into the pleural cavity. Austin Flint[141] advises that aspiration should be used first, but if not successful, then incisions should be made at the base of the thorax and a tent introduced to keep the orifice open. Anstie[142] gives similar directions. According to Bowditch,[143] "whenever the pus is pure there is no immediate call for thoracotomy, for patients at times get well after simple aspirations. Youth and recent uncomplicated disease favor this. Heretofore, after three aspirations the author has resorted to thoracotomy." Dabney[144] says that aspiration occasionally gives good results, even in adults. S. C. Chew reported the case of an adult (twenty-five years of age) cured of empyema by one aspiration of sixteen ounces, and also a case of a child three years of age after three aspirations. Barnes[145] reports a case of a patient nineteen years of age who recovered after four aspirations of large quantities of pus. J. G. Blake[146] reports a case (boy ten years of age) where one aspiration of ten ounces accomplished a cure. He adds that in children repeated withdrawals of pus by aspiration are justifiable, but in adults after {552} one unsuccessful operation he advises permanent opening. Dupuytren[147] cured a case after seventy-three aspirations. The author has had 3 cases perfectly cured by aspiration: a child eleven months old, after three operations; a child of five years, after five operations; a boy sixteen years of age, after two operations.

[Footnote 131: _London Lancet_, 1860.]

[Footnote 132: _De la Thoracentèse par asp. dans la Pleu. Pur._, 1871.]

[Footnote 133: _Thèse de Paris_, 1877.]

[Footnote 134: _Diseases of Children_.]

[Footnote 135: _Soc. de Thér._, 26 April, 1882.]

[Footnote 136: _Trans. Int. Med. Con._, vol. iv.]

[Footnote 137: _Ibid._]

[Footnote 138: _Ibid._]

[Footnote 139: _Ibid._]

[Footnote 140: _Ibid._]

[Footnote 141: _Clinical Medicine_.]

[Footnote 142: _Reynolds's Sys._, vol. ii.]

[Footnote 143: Unpublished MSS.]

[Footnote 144: _Amer. Journ. Med. Sci._, Oct., 1882.]

[Footnote 145: _Brit. Med. Journal_, Dec., 1877.]

[Footnote 146: _Med. and Surgical Reports Boston City Hospital_, 2d Ser., 1877.]

[Footnote 147: Altimont, _loc. cit._]

Such being the record, we are in duty bound to try simple aspirations before making use of the more radical modes of treatment. The character of the fluid as drawn off by the exploring-needle furnishes valuable indications. Should it be found laudable and inodorous, we had better aspirate once or twice before resorting to the free incision. It can do no injury, and we thus enable the lung to expand, diminish the size of the cavity, and prepare for the more radical operation. In children we ought to try this mode repeatedly unless we have symptoms of emaciation and hectic approaching; in adults only two or three times. The operation is simple, painless, without danger, and occasionally perfectly effective. If the fluid re-forms quickly--and it sometimes does with astonishing rapidity--or there are evidences of depression from fever, sweats, and diarrhoea, we must promptly have recourse to one of the effective surgical methods producing free drainage. It is undeniable that the treatment by thoracentesis is frequently unsuccessful, notwithstanding repeated operations.

In sero-fibrinous effusions the close method is the most successful, but in purulent effusion this is not ordinarily the case, and we are forced to employ the open method to produce free, continuous discharges, as the purulent fluid re-forms rapidly.

Open Methods.--Of these we have--(1) drainage through a single orifice by the introduction of a permanent canula or soft india-rubber tube; (2) drainage through two openings; (3) use of syphon; (4) pleurotomy; (5) drainage by resection of ribs. Each of these modes has its advocates. They have all been frequently used with varying results. Each has its advantages and disadvantages.

The first point to be noted about these modes of operation is, that we cannot prevent the introduction of a greater or less amount of air to replace the fluid, and therefore it is of primary importance that we should always render the air aseptic. The incision must be made after thoroughly cleansing the point to be opened. The bistoury, the canula, the dressings, the receptacles of the pus, the sponges, and everything connected with the operation, should be purified to prevent the possibility of the contamination of the pleural cavity and its contents. At each subsequent dressing all these precautions should be renewed. Antiseptic gauze of six or eight layers in thickness, with finely-combed oakum or salicylated cotton, ought to be placed over and around the orifice for an area of twelve inches. In this way what little air enters after the operation may be rendered thoroughly aseptic.

Lister[148] recommends that the coverings of gauze should be in eight folds if the drainage be excessive--that these be charged with a disinfectant composed of one part of carbolic acid to four parts of resin and pure paraffin. The dressings, he directs, should be kept in place by elastic bandages. This treatment stops suppuration promptly, and converts the discharge into one of a serous nature. His views have been amply confirmed. A. T. Cabot[149] recommends that the dressings be covered with a piece of mackintosh large enough to project in every direction. In his cases he found it acted as a valvular fold, forcing the air and pus out and preventing air from entering.

[Footnote 148: "Lectures on Clin. Surgery, etc.," _London Lancet_, Dec., 1879.]

[Footnote 149: _Loc. cit._]

Drainage by Canula through a Single Orifice.--The patient, having had about three hours previously a good substantial meal of easily-digested food, is placed in a semi-recumbent position, leaning over toward the healthy side. {553} Before selecting the point of puncture, the side ought to be first washed with soap and water, so as thoroughly to remove all dirt and epithelium débris, and then bathed in a 1:20 solution of carbolic acid. As there is to be but one opening through which the fluid is to pass, it is desirable to have it low down. The eighth intercostal space, somewhat behind the posterior axillary line, is ordinarily the best point for the puncture. Lower than that we may encounter the diaphragm, and, as we must use a trocar of considerable size, we may inflict serious injury. As we desire to completely empty the pleural cavity, a higher point would not be as effective. After having satisfied ourselves of the presence of fluid at the point selected by the physical exploration, we ought always to insert, as a crucial test, a new exploratory hypodermic needle which has been rendered aseptic. Ordinarily, it is not necessary or expedient to resort to etherization, unless in case of a child, for local anæsthesia by cocaine hypodermically, by rhigoline or the ether spray, or by the application of a small piece of ice covered with salt (as suggested by Powell), will render the incision painless. It is needless to add that a weakened heart, a sluggish capillary circulation causing a cyanotic appearance, and marked dyspnoea contraindicate the employment of etherization. We prefer cutting through the integument with a bistoury, and then inserting the trocar, which must be pushed with a thrust through to the pleura. All of the pus should be allowed to escape, unless cough, oppression, or threatening syncope should be noticed, in which case it is better to insert the tube and arrest the flow by a cork. The outward flow should be rendered slow by covering the orifice with the dressings and allowing the fluid to soak into them. The tube should only be long enough to go well through the parietes into the pleural sac; otherwise it acts as an irritant, and interferes with the adhesion of the two pleural surfaces, which is necessary for the obliteration of the pus-secreting cavity and the expansion of the lung. The tube should be kept in position by a hard-rubber shield attachment, with bandages previously soaked in disinfectants applied around the body, and several layers of carbolized gauze. The firm canulæ, metallic or hard rubber, straight or curved, as proposed by Woillez and Dieulafoy, are now generally abandoned. These admit air either by the sides of the opening or through their canals, and they sometimes produce, at their extremities, local ulceration through the lung or even through the diaphragm, and cause peritonitis. Their only advantage consists in the facilities they offer for washing out the cavity. With canulæ made of soft india-rubber there is no danger of injuring the lung, etc. They are not painful to the patient, and they can be protected by valvular strips of gold-beater's skin or some soft substance at their orifices. Through these india-rubber tubes we can inject all fluids and washes, except those containing iodine. It has been proved by Dujardin-Beaumetz[150] that iodine hardens india-rubber, renders it extremely brittle, and destroys its elasticity in a short time, even after a contact of forty-eight hours. In a case of Bucquoy's[151] the tube underwent such alterations that it could only be extracted by a long and painful operation. If these tubes are in use when iodized fluid is to be injected, they must be temporarily removed, and a metallic one, with arrangements for a double current, substituted during the process of washing. If the canulæ are to be kept in permanently, they must be of large size, so as to allow free flow outward of fluid.

[Footnote 150: Quoted by Dieulafoy, _Pneum. Asp._, English ed.]

[Footnote 151: _Ibid._]

After the operation the patient should always remain in bed in an easy, comfortable position, with the orifice covered by the dressings. His diet should be of an easily-digested and nutritious character. His temperature, pulse, and the condition of his secretions should be carefully watched. Ordinarily, it is not well to reopen the discharge-tube for three days. The same antiseptic precautions should be used then as at the operation, {554} and a fresh tube inserted. The pus secreted ought, if the case be one of recent origin, to be small in quantity and without odor. After a few days it is best to allow the fluid to flow out on the dressings as it forms, which is done by turning the patient well over on his side. An occasional cough assists the discharge. Should the odor become putrid or gangrenous, or hectic symptoms show that the secretion is profuse and has no free exit, it becomes necessary at once to use washings and injections of simple warm water or warm water feebly alcoholized--1:45 or 1:80--or feebly iodized solutions. The greatest care should be taken with these washings that very gentle force be employed. (See Pleurotomy.) This mode of operating is most effective in recent cases, for it gives the best opportunity to the lung to expand. It is the easiest to perform, and, subsequently, the least troublesome. If it be found ineffective, an additional orifice can be made and a fenestrated tube inserted, or the orifice can be enlarged by a free incision. There have been many successful cases of this mode of operating, but, as the author has sometimes found, it is difficult to establish free drainage, which is most important for the success of the treatment. The result of his experience has been that, in chronic cases especially, the two-opening drainage or free incision without tubes (pleurotomy) has finally to be employed. Powell recommends, after removing intra-thoracic pressure by aspiration or syphon, in a day or two to completely evacuate the fluid under the antiseptic spray and insert a tube for a few days only; then to allow the wound to heal, and await results, trusting nature to secrete a fibro-serous fluid which can be easily absorbed.

Drainage by two openings, as first effectively employed by Chassaignac, is made by the introduction, through a large covered canula, of a tube of india-rubber, perforated with holes, drawn out at another orifice. The tube has its two extremities on the outside, and one posterior, in the eighth or ninth intercostal space, and the other in front, in the seventh intercostal space, after the withdrawal of the canula. The anterior orifice is first made, and a long curved probe with a bulb at the end is passed through backward and downward until it strikes the posterior lowest intercostal space. The operator cuts down on the probe, which points outward. To this end the fenestrated drainage-tube is securely fastened, and is then drawn out through the first orifice. Both ends are retained out of their orifices, by a shield firmly fixed on the tube, for at least an inch. The pus flows out little by little, but continuously, through one or other orifice, according to the position of the patient. This is the most effective method to prevent accumulation. Unfortunately, false membranes and flocculi sometimes stop up the orifices in its walls, the pus does not flow out as it is formed, and there are all the evils of air and fluid mixed and retained in the serous cavity. It is, however, generally admitted that by this system of drainage a number of cases have been cured; but it is not often employed as a primary operation, as we wish to avoid, if possible, the irritation which may result from the presence of so much tubing in the chest. Moreover, it is not the best operation if there is any hope of the lung expanding again. In old chronic cases we cannot hope for more than very limited expansion.

Gross[152] speaks of drainage-tubes as harsh and dangerous. Flint, Sr.,[153] prefers free incisions, with introduction of tents, to drainage-tubes. Dabney[154] considers continuous drainage in some form vastly preferable in the majority of cases. Israel[155] had 10 cases recover out of 11 treated by thorough and continuous drainage. Cheadle believes that a large collection will certainly require a free opening in the end, and the sooner the pus is let out the better.

[Footnote 152: _System of Surgery_, vol. ii.]

[Footnote 153: _Clin. Med._]

[Footnote 154: _Amer. Journ. Med. Sci._, Oct., 1882.]

[Footnote 155: Quoted by Dabney.]

Chassaignac's method of drainage will answer well unless, as frequently {555} happens, the purulent pleurisies contain large fibrinous masses, hydatid pouches, or pieces of sphacelous débris.

Syphons, as used in purulent pleurisies, have some very decided advantages. Potain's ingenious instrument, based upon the syphon principle, enables us alternately to empty the pleural cavity into a basin of water, and, by reversing the instrument, to inject the water into the pleural cavity, thus washing out as often as necessary and with ease the purulent collection and cleansing the cavity. Potain's syphon is composed of an india-rubber tube 30 centimeters in length, to be introduced and remain in the pleural cavity. This tube is introduced through the canula, after the withdrawal of the trocar, to the depth of at least 20 centimeters, in order that its extremity should reach the posterior wall, the tube having been previously filled with water. The outer extremity is put into a basin containing water. The part of the tube at the outside of the orifice is closed by a serre-fine just beyond the shield, as is also the extremity in the water. Another tube is connected with the chest portion. This can be used for introducing water to wash out the pleura. The syphon of Potain has very decided advantages over the metallic and hard-rubber drainage-tubes. It prevents the introduction of air and enables us completely to empty the cavity; it permits us to wash out the cavity as frequently as is necessary without fatigue to the patient, without pain, and without change of position, and thus prevents attacks of coughing. All this is done slowly, and the flow can be arrested at any moment by means of the stopcocks. Where repeated washings are required the patient himself can perform them with ease. With the other modes the washings are practised with difficulty. The improved syphon by F. H. Williams of Boston is simple in construction, of small size, and inexpensive. Revilloid of Geneva (1882) reports 10 cases thus treated, of which 6 were cured. Bénard[156] reports 8 cases treated by syphon, of which 4 were cured. Goodhart's[157] statistics are not favorable to the use of the syphon. Of his 28 cases thus treated, 10 died; in only 6 did the syphon method alone effect the cure. Powell[158] objects to the syphon method, because by it the chest cannot be drained unless the lung expands completely or air is freely allowed to enter the pleura. These conditions are impossible in such cases with a single opening and a single tube. Moutard-Martin, while speaking of the advantages of Potain's syphon, admits that in chronic cases where there are pieces of false membrane and flocculi floating in the fluid the tube may be clogged up, just as occurs in the metallic tubes and the drainage-tubes. The patient may thus die by retention of pus and by putrid absorption, unless pleurotomy is employed. It must be borne in mind that the syphon is a weak aspirating instrument. It ought to be 10 meters long to possess an aspirating force equal to that of a pneumatic pump (water being taken as the standard), and its long arm should measure from 7 to 8 meters, in order that its aspiratory force should equal that of a good pneumatic aspirator. Thus we see how weak is the aspirating power of a syphon which only measures the space which separates the bed of the patient from the floor. The ordinary aspirator can be easily changed into a syphon. The descending arm of the tube must be emptied by a stroke of the piston; the current is then established and the stream becomes continuous (Dieulafoy[159]).

[Footnote 156: _Thèse de Paris_, 1871.]

[Footnote 157: _Guy's Hospital Reports_, 1877.]

[Footnote 158: _Loc. cit._]

[Footnote 159: _Trea. Pneum. Aspiration_, Eng. trans., 1873.]

While all prominent modern authorities admit the value in some cases of double metallic tubes, of those of hard rubber, of drainage-tubes, and of syphons, with thorough and complete antiseptic treatment, yet observation has taught us that there are many disadvantages and uncertainties. The drainage-tube may give rise to considerable irritation and prevent the closing of the sac--a very important aid to the cure. If the flow is retarded, the {556} fluid may decompose. Therefore it is well to remove the tube frequently, to wash, cleanse, and renew it. The admission of air and stopping up of tubes, the feeble force employed, the putrid pseudo-membranes, and sometimes sphacelous débris, cause, in many instances, fatal results. It frequently happens that at first, when trying the simple aspirations, we find a whitish laudable pus which subsequently becomes thick and fetid. We use drainage-tubes and Williams's syphon, with strict adhesions to Listerism, and yet there may ensue continuous fever, emaciation, sweats, drawn face, and general oedema. We resort to detergent washes, with salicylate of sodium, of tincture of iodine, very diluted, yet the patients get worse and the tubes become obstructed. There is not sufficient free flow of the contents of the chest.

Pleurotomy.--We naturally shrink from freely opening the chest. It is right to try the simpler methods--aspiration, tubes to remain in the chest, drainage, use of syphons--but we are forced in many cases of chronic empyema to use pleurotomy, the thoracotomy of Bowditch, the operation of l'empyème of the ancients. It consists of a wide opening into the thorax between two ribs, permitting the escape of the effused liquids. If the orifice is large enough, we can remove from the cavity of the pleura not only the pus, but the large fibrous masses, gangrenous débris, hydatids, and putrefying material which produce septicæmia and death. The literature of this subject shows that bad results have ensued from this operation, and again and again it has been abandoned, but now that we can, by means of large openings, freely wash out the cavities, and can apply injections of antiseptic and alterative medicines to the suppurating surfaces, many lives are saved. Hippocrates' dogma as to the danger of free and rapid evacuation of pus had often a dangerous influence in preventing a thorough emptying of the sac. The object of this radical operation must be kept in view--to evacuate the pus by a free current, to permit the discharge of plastic products and organic débris, and to allow easy and frequent washings with healing and purifying injections. By these means we arrest suppuration, obliterate the sac, and allow the lung to expand. For this purpose wide orifices should be boldly made. They should be made where the chest bulges most, but not always at the most dependent portion. Ordinarily, the eighth intercostal space, somewhat behind the posterior axillary line, has been the one selected, because it has been supposed that thereby the cavity could be most effectually drained. The author has usually punctured higher, in the seventh intercostal space on the left and in the sixth on the right side, for the fifth and sixth ribs being more fixed, there is less danger of subsequent approximation. We cannot always determine the exact position of the diaphragm. The lung may be bound down by old adhesions to the diaphragm, and thus the latter may be injured by too low an incision; we can, moreover, better adapt the position of the patient to enable the matter to flow out from a higher orifice. Cases have occurred where the liver has been perforated on the right side by low punctures. In health the uppermost point of the diaphragm may be as high as the fifth space on the left side or the fourth space on the right. The cure does not depend upon the exact position of the puncture, because we expect to insert a mouth-tube to keep the orifice open, and probably resort to washings. It is not by its weight only that we expect the fluid to escape; incessant movements of the thorax assist in forcing the fluid through the tubes. Marshall[160] urges the fifth space on the right side, and as near the weak point of the chest under the nipple as possible. On the left the pericardium must be carefully avoided. He advises that the operation should never be lower than the sixth or seventh intercostal interval. Douglass Powell prefers a lower puncture, in the seventh or eighth space in the posterior {557} axillary line. In the punctures lower down the tube as it ascends rubs upon the diaphragm and protracts the healing, and the orifice closes too early. The emptying of the sac and the washings can be thoroughly attended to higher in the chest. The weak point selected by nature for empyema necessitatis ought always to be examined to see if there be any thinning of the wall, for if that be the case, the puncture should be made there. The incision should be made on a plane somewhat below that of the aponeurotic and muscular portions of the chest, to prevent the liquids from infiltrating into the subcutaneous cellular tissue. If we ascertain first by exploratory puncture that there is pus lower down, it is safe to operate at that point. The exterior orifice should be wider and larger than the interior, and not parallel with it, in order to avoid the gaseous infiltration in the tissues by the respiratory movements. Care must be taken that the bistoury should pass close to the upper border of the inferior rib, to avoid the intercostal artery. In making the incision--about 6 centimeters in length--should the artery be cut, it can easily be remedied by torsion. We raise the skin, and thus make a flap over the orifice. The bistoury should not be introduced with one cut through the soft textures, as recommended by Woillez, but layer by layer should be cut through. This secures avoiding the intercostal artery, and gives a larger exterior than interior cut, thus preventing danger of liquid infiltration. We can be guided by the index finger, and feel the textures as we cut down upon them. Under a continuous spray to thoroughly purify the air that may enter, a free opening should be made large enough to allow the finger to be introduced. As air enters the fluid contents escape through the orifice, protected by antiseptic dressings of gauze, oakum, and salicylated cotton. At first it is well to remove the dressings containing the pus twice daily; later, once daily will be sufficient. The orifice must be kept patent by a short, wide tube with a fine wire around it. We can thus, by changing the position of the patient, get rid of the contents of the chest cavity. If there should be fetidity, it is desirable to use washes of warm water first, and afterward of feebly-alcoholized water--a solution of salicylate of soda, chlorinated soda, or permanganate of soda. Cabot[161] had most success in the use of sol. chlorinated soda, one part to twelve or fifteen of water, for purposes of injection. The average time that the tubes remained in, with his cases, was only twenty-four days. His favorable results he imputed to the mechanical action of the india-rubber covering over the antiseptic dressings.

[Footnote 160: _Loc. cit._]

[Footnote 161: _Loc. cit._]

Resection of Ribs.--The ancient operation of resection of ribs, dating back to Celsus, is strongly advocated by Pietavy, Thomas of Birmingham, Lane, and other modern writers as affording the best means of thoroughly evacuating the pleural cavity of its purulent contents and of keeping up constant drainage. John Marshall[162] reports 4 cases where he resected the ribs to make permanent openings. In all of these cases the walls became gradually firm and new bone was formed. He concluded that the removal of a portion of one rib was not sufficient, but that a large space through four ribs is the proper size for the opening, that the sixth rib is the essential one to deal with, and that from one and a half to two inches of bone should be taken away. In one case he performed a subcutaneous division of costal cartilage with a view to weakening the thoracic walls and allowing them to fold in. A number of cases are reported of resection of ribs, with varying success, by Ewald,[163] Taylor, House,[164] and Thomas.[165] Taylor[166] advises the removal of the periosteum to prevent the rapid re-formation of bone. If after the puncture the rigidity of the ribs seems to keep up the discharge, and the lung does not expand to meet the rib, a resection of a considerable portion of two or three ribs may be {558} made for relief. If, again, in the progress of the case the adjoining ribs have fallen in and have approximated, and thus become a source of pain in retaining a permanent drainage-tube, a portion of rib may be resected. The principal object of resection of ribs is to favor their falling in, for a sufficient orifice can thus be made between the ribs for the discharge. The upper two-thirds of the breadth of a rib may be trephined in order to give more room for exploration, evacuation, ablution, and prolonged drainage. This is the operation of Esthander,[167] who thus treated successfully 5 of his 6 cases operated upon. Fenger of Chicago[168] operated in this manner on fourth, fifth, and sixth ribs.

[Footnote 162: _London Lancet_, March, 1882.]

[Footnote 163: "Med. Soc. Berlin," _Lon. Med. Rec._, 1876.]

[Footnote 164: _London Med. Record_, Aug., 1876.]

[Footnote 165: _Trans. Clin. Soc._, vol. xiii.]

[Footnote 166: _Brit. Med. Journ._, Feb., 1881.]

[Footnote 167: "Resection du Côltes de Emp.," _Revue Mens. de Méd. et Surg._, 1879, vol. B.]

[Footnote 168: _Med. News, Philada._, Sept., 1882.]

Jacobi[169] says that resections ought not to be practised upon children. W. A. Lane,[170] from the observation of 5 cases of empyema in children, strongly recommends that a portion of rib or ribs be removed at first, and the cavity thoroughly drained from the beginning. It assists, he argues, the cure by promoting the falling in of the ribs, the expansion of the lungs, and the ascent of the diaphragm. In children the difficulty in securing free drainage is that the spaces between the ribs are small, and after the cavity is opened they become much more contracted; soft tubes thus become compressed, and hard tubes cause much local irritation. Resection of ribs enables the operator to keep the orifice open and have perfect drainage. The opening should be large enough to allow the introduction of the finger and of an india-rubber tube of sufficient diameter to give free passage to the contents of the chest, without the tube being displaced by movement of the ribs. In only one of Lane's cases was trouble caused by rapid increase of bone. He operated as low as the ninth intercostal space in the axillary line, taking care always, by the hypodermic syringe, to ascertain that there was pus at that point. He divided the periosteum longitudinally, and removed with cutting forceps about three-quarters of an inch of rib. After he had thoroughly cleared out the cavity he introduced a short india-rubber tube, so that its inner end should not project into the cavity. Wire sutures were passed deeply through the intercostal tissues and tube, and, to render the position of the tube more secure, soft pins were fixed through the wall of the tube, and attached to them were pieces of elastic surrounding the chest.

[Footnote 169: _N.Y. Med. Record_, Jan., 1881.]

[Footnote 170: _Guy's Hospital Reports_, vol. xli., 1882.]

If necessary in order to have uninterrupted free drainage, children as well as adults should have their ribs resected. The important point in operating is to secure free exit to the fluid and purification of the cavity by the necessary washings by the open method. Pleurotomy by resection of ribs is almost universally acknowledged to be the most effective treatment, for it promotes most rapidly the agglutination of the pleural surfaces and the expansion of the lung.[171]

[Footnote 171: Lawson Tait strongly advocates this same method of treatment in peritonitis. He has performed laparotomy successfully in 20 cases, using washings and drainage-tubes (_Bost. Med. and Surg. Journal_, Aug. 16, 1883).]

Good drainage is the essential consideration after the operation. We must prevent putrefaction or fetid decomposition in the pleural contents. So long as pus is retained within the sac, it does not putrefy, but putrefaction follows contact with the putrefactive agencies which abound in ordinary air, as shown by Pasteur and Tyndal. These are solid particles floating in the atmosphere. Although air must be admitted, it should be rendered aseptic. The drainage-tube, which should be just long enough to go thoroughly into the cavity, by itself is in many cases insufficient. The upper part of the cavity may retain on its surface pus and flocculi which may prove dangerous. By the syphon we can fill the cavity slowly with medicated tepid water without shock and {559} without risk of tearing away the neo-membranes. Woillez[172] advises that pleurotomy should be promptly used whenever pus is found. Béhier advocates the same treatment. E. Moutard-Martin,[173] whose authority is high from his great experience and conservatism, advises us always to commence the treatment with thoracentesis by aspiration. He says, if the fever persists and the general condition grows worse, he does not hesitate to resort to pleurotomy. The author's more limited experience coincides with his. I. Marshall[174] states as his opinion that purulent pleurisies require the immediate or early adoption of the open method. In fibro-serous pleurisy we wish to restore the physiological condition of the pleura, whereas in purulent cases the object is to obliterate the sac by adhesions throughout the surfaces, just as abscesses are cured. It is necessary that the costal and pulmonary pleura and that of the diaphragm should be brought closely in contact. This is produced simultaneously by the dilatation of the lung and the diminution in every way of the pleural cavity. The dilatation is produced by the disappearance of the intra-pleural pressure and the pressure in the opposite direction from the bronchial surfaces. This last depends upon the condition of the lung and of the visceral pleura. If the lung has been long compressed, it is almost carnified and reduced to a state of foetal atelectasis. It rarely happens that the bands which bind the lung down do not in time undergo granular fatty degeneration and disappear. This enables the lung to expand, if not to its original size, yet sufficiently to occupy the cavity, reduced in size by the approach of the walls. The heart, which previous to the operation was thrown more or less out of its normal position, comes back from the empty side, and often passes the position that it normally occupied. The lung follows the heart. The whole mediastinum finds itself altered in its position and in its contents. The depressed diaphragm rises promptly to its old position in the pleural cavity. The liver, spleen, and the rib-wall undergo striking modifications. We do not expect the lung to dilate to its full extent, as after aspirations in simple pleurisies. The lung, indeed, is already impaired in its movement. We admit air in order to secure treatment to these surfaces. When air is admitted into the normal chest, the lung is retracted to about one-half its size. In serous effusions we fear free admissions of air, because it assists in compressing the lungs, and may contain germs which promote suppuration. We must bear in mind that we may have double pleurisy from the pus producing pleural necrosis at the point of contact of the pleural sacs about the middle of the sternum opposite the middle of the third rib. Elsewhere there is no such danger, for the pleural surfaces remain a long distance from each other.

[Footnote 172: _Bul. Soc. Méd. des Hôp._, 26 April, 1872.]

[Footnote 173: _Pleurisie purulente_, 1872.]

[Footnote 174: _Loc. cit._]

Why should we postpone pleurotomy, with or without resection of ribs, until we have used the drainage-tube, canula, etc.? The impression is that this operation is attended with danger, whereas ordinarily, with care, such is not the case. In pleurotomy there is not the same danger of serious accidents as in thoracentesis, especially as performed by canulas and trocars. Pleurotomy never causes acute oedema of the lung. The forcible unfolding of the lung, with rush of blood to vessels that have been almost emptied by compression, does not occur under these circumstances. After the large openings of the chest the causes of the forced expansion of the lung do not exist. The diminution of the pressure on the mediastinum, the re-establishment of the thoracic aspiration, and consequently the more free access of venous blood into the right heart, favorably influence the general circulation. The pulse increases in force, the cyanosis is dissipated, frequently within a few hours, and the anasarca disappears in a few days.