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.
Theory and observation show beyond a doubt that in all cases where
{560} there exists a decided intra-pleural tension pleurotomy of the
thorax modifies efficiently the circulatory and respiratory functions.
Instead of causing suffocation, it diminishes almost always, and that
instantly and remarkably, the dyspnoea. In 1868, Maisonneuve[175] made
the startling announcement, which he claimed was nevertheless rigidly
true, that of 100 patients who die after surgical operations, 95 are
poisoned by organic substances absorbed. He claimed that the liquids
exuded from the surface of wounds become corrupt when exposed to the
external air, and that subsequently they undergo morbific changes and
become formidable poisons. If, he said, we can prevent the dead liquids
from putrefying, the gravest operations could be performed without
danger. No one who studies the results of empyema in the past can
question that the greatest danger is from the blood-poisoning known as
septicæmia, caused by the absorption of the septic infection by the
lymphatics.[176] No matter what may be the nature of septicæmia, it is
sufficient that the vast surfaces of the pleura produce certain
prurient secretions, which, when absorbed and carried into the
circulation, cause hectic fever with its results. We claim that there
is less danger from putrid absorption when free incisions are made than
from those only large enough to introduce a drainage-tube. Rome[177]
collected 49 cases, but of these 10 contained fetid pus; 9 of the
number had been treated by one or many, even up to fifteen,
aspirations. He concludes that the surgical interventions, other than
pleurotomy, provoked in the purulent liquid of the pleura putrid
fermentations in one-fifth of the cases. The products of this
fermentation irritate actively the serous membrane, and cause an
abundant suppuration intractable in its nature, and there is imminent
danger of rapid exhaustion and hectic fever. One-third of Rome's cases
contained solid pieces which could not be removed in any other way than
by making free incisions. Although subserous cavities are not perfectly
analogous to phlegmonous abscesses, yet they closely resemble each
other. Histologically, the inflammatory process and its phases are the
same, but there is this difference--absorption of the deleterious
products is more active. Why allow a warm abscess to be transformed
into a cold abscess, which will open later spontaneously after having
caused grave disorders? We have seen how frequently large collections
of pus sooner or later open either through the lung or through the
chest-walls. If an opening has to be made, the more promptly the
better. In the first stage, especially in acute purulent pleurisy, the
slight neo-membranes and fibrinous deposits, barely solid, readily
undergo granular fatty degeneration, and are absorbed if relieved of
the pus. In this stage the two folds of the pleura are in their best
condition for becoming adherent to each other, and by obliteration of
the pleural cavity to end the disease. If acute empyema be treated
early and gently before the lung is compressed or injured, with free
opening and constant drainage, the patient being in a recumbent
position on face or side, the pleura needs no washings. The orifices
made spontaneously are frequently insufficient to completely empty and
to keep up the current of pus as it forms. In bronchial fistula, unless
the air is prevented from coming from the lung into the pleura by a
valvular opening, we have frequently to resort to pleurotomy. If in
empyema necessitatis the orifice partly closes or is not free enough,
we must not hesitate to enlarge it or make a counter-opening to enable
the matter to flow out. In tubercular pyo-pneumothorax, where the
purulent fluid has been the primary lesion and has perforated the lung,
the operation is not indicated. E. Moutard-Martin's treatise was
founded upon 17 subjects, 5 of whom died and 12 were cured. Of the 12
cured, 2 had bronchial fistula in pneumothorax without any sign of
tubercle; 5 had permanent fistulous openings and discharged {561}
occasionally a few drops of pus; 7 were cured without fistula.
Blake[178] reported 19 cases treated by permanent openings, with 15
"cured and much relieved." He operated by making incisions from one to
two inches long, parallel with the ribs, between the seventh and eighth
ribs, a little inside of the scapula. His practice was to keep the
orifice open. He used either a spiral wire covered with gutta-percha or
a gum-elastic catheter fastened to a shield and kept in position by
adhesive plasters. Martin Oxley[179] by pressing open the incision with
a pair of dressing forceps introduced a silver or india-rubber
tracheotomy-tube to keep the orifice open. He related several instances
where pieces of tubing fell into the cavity and remained there without
injury for months, and in one case as long as several years.
Dabney[180] urges with force the importance of our having a continuous
discharge of pus as far preferable to its daily removal, "not only
because it seems less liable to become fetid, but because, as the two
surfaces of the pleura have to come together and heal by granulations,
the retention of pus would delay this process by keeping the costal and
pulmonary surfaces apart." Thorough drainage by two orifices or a wide
incision kept open by two tubes is more effective than a simple
drainage-tube. Antiseptic precautions are essential to ensure success
at every stage of the operation.
[Footnote 175: _London Prac._, 1868.]
[Footnote 176: Ranney, _Annals of Anat. and Surgery_, 1881.]
[Footnote 177: _Thèse de Paris_, 1882.]
[Footnote 178: _Boston City Hospital Reports_, 2d series.]
[Footnote 179: _Liverpool Medico-Chirurg. Journal_, January, 1882;
_N.Y. Medical Abstract_.]
[Footnote 180: _American Journal Med. Sciences_, Oct., 1882.]
Value of Injections and Washings.--The object of injections is to
enable us thoroughly to wash out the cavity and to promote adhesions
between the pleural surfaces. The chief danger being from septicæmia,
it is of the greatest importance that the pus should not be allowed to
remain in the cavity longer than can be avoided. The body-temperature,
taken twice daily, is one of the best means of ascertaining the extent
of the re-formation of pus. Stagnant pus, mingled with air, will
undergo fermentation and cause putridity; hence the great value of
incessant drainage through unobstructed tubes. When the pus is free
from unpleasant odor and runs freely, it is not necessary to use
washings or injections of any kind, for the cavity will purify itself.
Washings and injections have sometimes been found very injurious and
irritating, and sudden deaths have been attributed to them. If flocculi
form, washings of tepid water with a very small percentage of alcohol
or of salicylic acid (1 per cent.), used without force for fear of
rupturing some of the recently-formed capillaries, are useful. When
modifying injections are used, the patient ought to lie on the opposite
side. In this way all the diseased parts are reached by the fluid. An
ordinary syringe should not be used, but a Thudicum bottle or a
fountain syringe: either of these can be raised sufficiently high to
allow a gentle flow into the cavity. If the discharge becomes fetid,
injections of solution of permanganate of potash (1 or 2 grains to
ounce j) or of tinct. of iodine (1:4) in water ought to be used. The
author has never seen any results of poisoning from the use of carbolic
acid, but he has always used a feeble solution, 2 or 3 per cent. Dabney
had symptoms of carbolic-acid poisoning in one of his cases where he
used a 2 per cent. solution, notwithstanding the fact that he had taken
every precaution to ensure its prompt return. A. T. Cabot[181] mentions
a case of carbolic poisoning in a boy four years of age produced by a
feeble solution of one part to thirty of water used only to cleanse the
instruments, tubes, and hand of the operator. Kuster's[182] experiments
show that anæmia and septic and pyæmic fevers predispose the system to
carbolic-acid poisoning. He recommends an 8 per cent. solution of
chloride of zinc. Chlorate of potassium drachm j to pint j has been
used with benefit. The medical journals contain so many reports of the
serious, and even fatal, results from absorption of carbolic acid when
thrown into abscesses {562} that we are compelled to abandon it in
favor of other injections. B. W. Richardson long since showed the great
value of iodine as a disinfectant. It not only corrects the fetor of
decomposed pus, but at the same time lessens the secretion from the
walls. The first injections should be weak, gr. 4 or 5 of iodine and
iodide of potassium to a pint of water. Liq. iodinii com., ounce ss to
ounce iv, ought not to be used until the surfaces have become
accustomed to the action of iodine. Injections of medicated fluid ought
not to be used unless they are absolutely necessary, because in some
instances they have produced fainting attacks and epileptiform seizures
with alarming convulsions. These results have followed injections of
different fluids--borax, carbolic acid, iodine, permanganate of
potassium, and even warm water. Similar phenomena have followed the
injection of the bladder, the uterus, and even from passing a catheter.
The shock may have been too sudden or the injection too forcible or the
fluid too cold. A. L. Mason[183] suggests that it is probably owing to
sudden irritation of the lymphatics through the great splanchnic nerve,
with anæmia of the brain. Paralysis of the limbs after convulsions
makes the theory of embolic origin probable. These accidents must not
make us underrate the great value of frequent washings with injections
when rendered necessary by the approach of putrid infection. The number
of these washings should depend upon the urgency of the symptoms, and
antiseptic injections should not be employed unless we find evidences
of fetor, because of one great objection: they do not favor the
expansion of the lung.
[Footnote 181: _Loc. cit._]
[Footnote 182: Quoted by Dabney, _loc. cit._]
[Footnote 183: _Boston City Hospital Reports_, 2d Series.]
Cases of long-standing compression of the lung could hardly result in
complete re-expansion, but the general health will be recovered and the
chest, contracted by approximation of the pleural surfaces from the
walls being pressed in or ribs resected, will cease to secrete pus. If
fever persists, with diarrhoea, sweats, emaciation, and fetid
suppuration, it shows that the washings are not sufficient in number.
They can be repeated as often as every three or four hours, to be
decreased in frequency as the patient improves. Under frequent washings
Feyrot[184] reports favorable results in almost hopeless cases. Time is
very precious when these symptoms of exhaustion or septicæmia set in,
as it is of the utmost importance that we should endeavor to prevent
promptly the absorption of the putrid products, the inevitable effects
of which are to produce, before long, fatty and amyloid degeneration of
the principal viscera. The most effective way of using detergent fluids
is by syphons through two tubes perforated at their extremities and
fastened with shields. A Thudicum douche-bottle or a fountain syringe
can easily be used by patients themselves as often as is required. The
orifice and the tubes should be protected by thorough and rigid
antisepticism. As the case improves the cavity gradually gets smaller,
the two pleuræ become adherent, and the quantity of fluid lessens until
only a small amount flows out. Every eight or ten days we carefully
draw out the tubes by degrees, until we have only a little canal
beneath the walls. We can thus let the orifice heal slowly, for the sac
is obliterated and the patient cured.
[Footnote 184: _Thèse de Paris_, 1876.]
In the hands of Boyer, Delpech, Dupuytren, and Sir Astley Cooper the
bistoury gave bad results, but as now used, with all modern appliances
and antiseptic precautions, it affords infinite relief and many cures.
We claim that by early pleurotomy, with Listerism scrupulously used at
every stage of the operation, and if necessary with detergent washings,
the mortality from this extremely grave disease can be very materially
lessened.
Double Pleurisy.
Pleurisy may occur on both sides at the same time. Double pleurisies
are secondary, not primary, and result from rheumatism, or still more
frequently, {563} according to Louis, from tuberculosis. In 150 cases
of pleurisy quoted by him, there were no bilateral cases which were not
produced by rheumatism, gangrene, or tuberculosis. A double pleurisy in
a previously healthy person creates a strong suspicion of tubercular
origin. There is generally an interval of some days before the attack
of one side is followed by that of the other. When effusion takes place
the dyspnoea is very great. Death is imminent unless the fluid is
withdrawn by aspiration. Maintenon[185] states that the inflammation
may be so intense and the fever so high as to destroy life before the
effusion is thrown out. The physical signs are the same as in
unilateral cases. The effusion is never so great on one side as on the
other. The progress of disease is rapid, and the result is almost
always fatal.
[Footnote 185: _Thèse de Paris_, 1873.]
Diaphragmatic Pleurisy.
The serous lining of the upper surface of the diaphragm may be involved
in an ordinary pleurisy, or inflammation may be limited to it without
involving either the pulmonary or the parietal membrane. In this latter
case we have modifications of the characteristic symptoms and physical
signs. Functional disturbances and special symptoms enable us to
diagnose it. There is a febrile movement with occasional delirium, and
some of the prominent symptoms, but without the physical signs to
indicate the exact locality. The pain is intense, and dyspnoea exists
even to the extent of orthopnoea and respiratory anguish, the
respiration jerky and convulsive. The pain comes on suddenly in one of
the hypochondriac regions, extending up to the attachments of the
diaphragm to the costal surfaces. The pain is intense, and increased by
full inspirations, by physical efforts, by vomiting, and even by the
eructations of wind. The position of the patient attracts attention: as
he sits with the trunk inclined forward, he has an anxious and
distressed expression of countenance, sometimes accompanied by nausea
and vomiting with singultus. Pressure elicits a characteristic
tenderness; if applied under the false ribs, it causes suffering. The
phrenic nerve is painful on pressure practised over the accessible
points of its course, between the two inferior bands of the
sterno-cleido-mastoid at the base of the neck. There are also painful
irradiations in the cervical plexus above the clavicle and in the
scapular region. Pressure over a circumscribed spot of the epigastric
region causes a sharp agony of pain. This point is at the intersection
of two lines--one, the external border of the sternum; the other, at
the osseous portion of the second rib. Guéneau de Mussey[186] has named
this the diaphragmatic bottom. This pain extends sometimes to the
vertebra and upward to the first intercostal space. Auscultation and
percussion at the base of the lung give us some results: impaired
expansion of the lung at the base and dulness on percussion; the
diaphragm is in a great degree immobile, owing partly to the pressure
upon it, and partly to a paresis from inflammation of its upper serous
covering (Stokes[187]). When the inflammation is on the right side, we
may find an icteroid tint, with vomiting, delirium, etc., with the
liver pushed below its normal position in the abdomen. The inflammation
of the pleural covering of the diaphragm may be caused by
sero-hepatitis extending through the diaphragm (Copeland[188]).
[Footnote 186: _Archiv. de Méd._, 1879, vol. ii.]
[Footnote 187: _Dis. of Chest_, 1837.]
[Footnote 188: _Dict. Med._, vol. iii., edited by Lee.]
If the effusion is confined to the space between the lung and
diaphragm, the diagnosis is obscure. There may indeed be cases where we
have but few of the symptoms already mentioned. If the fluid is not
confined to this portion, but flows into the pleural cavity, it gives
great relief, and the result is favorable. Diaphragmatic pleurisy may,
however, end in death, either by its discharge into the peritoneal
cavity or by constitutional disturbances.
{564} Interlobular and Mediastinal Pleurisies.
The effusion is sometimes confined by adhesions between two lobes. The
mediastinal variety is situated between the pleural boundary of the
mediastinum and the adjacent portion of the pulmonary serous membrane.
It is but rarely met with, and may be diagnosed by local symptoms. The
flatness on percussion in the interlobular variety is very
circumscribed. Both forms cause local pains, but in the mediastinal
variety the pain is very deep and perceptible at the middle of the
sternum, and is increased by the respiratory movements. In both
varieties there is more or less fever. If either variety exist on the
left side, the condition of the pericardium must be carefully examined,
as pericarditis may be confounded with it. These limited collections of
fluid may burst into a bronchus and be expectorated.
Multilocular Areolar Pleurisies.
Multilocular encysted collections of fluid in the pleural cavity are
due to the partitions made by pseudo-membranes which divide the pleura
into subcavities. These occur generally in subjects who have had
previously dry or adhesive pleurisies. They are more serious than
ordinary pleurisies. We meet with them in aspirating, when, after
draining off the fluid from the base of the pleural cavity, we find the
lung expanding, but above that point there is absence of respiratory
murmur and of other physical signs indicating the presence of fluid.
Reybard[189] divides multilocular pleurisy into three varieties, with
varying symptoms and physical signs, according to whether it exists at
the upper, middle, or lower portion, right or left side. Owing to the
thickness and distribution of neo-membranes, it is frequently difficult
to localize the points of collections of fluid. Aspiration is the most
accurate means of ascertaining the exact point and extension of the
effusion.
[Footnote 189: _Bullétin Acad. Méd._, 1879.]
Rheumatic Pleurisy.