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._]