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]