but more usually it will be found necessary to remove a section of one or more
ribs in order that the pleural cavity may be thoroughly cleared of the products
of the inflammation.
Simple incision is usually performed in the fourth or fifth space or over
the point of maximum flatness; its anterior extremity should be well forward,
at least as far as the anterior axillary line and it should be continued backward
652 DISEASES OF THE RESPIRATORY SYSTEM.
for two or tliree inches. The skin, intercostal muscles and finally the pleura
are divided, the incision is widened as much as possible and the pus is allowed
to flow slowly out, in order that sudden relief of the intrathoracic pressure
may not interfere with the action of heart and lungs.
Following the evacuation of the pus the fingers should be introduced and
all slireds of fibrin, albuminous coagula, etc., removed. Most clinicians agree
that irrigation of the pus cavity is harmful rather than benefiicial. The pleura,
having been cleansed, drainage tubes of proper calibre and length (two, pref-
erably, whfch will provide against the interference with free drainage should
one become stopped) are inserted and the wound is dressed. The outer end-
of each tube should be transfixed with a safety-pin with a cord attached to
prevent its entrance into the pleural cavity. A small wad of gauze should
be about the tube between the pin and the chest wall lest traumatism take
place. A small quantity of iodoform powdered upon tubes and dressing will
assist in preventing putrefaction and will hasten the healing process. This
substance may also be sprinkled through the incision but care should be taken
to provide against any possibility of intoxication; 20 to 40 grains (1.33 to 2.66)
may be employed vnthout apprehension and later a smaller amount will
sufi&ce. The dressing should contain plenty of absorbent material, for the
discharge, at any rate at first, is considerable. Following the operation the
dressings should be changed daily — oftener if necessary — but as the healing
process progresses the intervals may be longer. The patient should be care-
fully watched and any rise in temperature usually signifies an interference
with free drainage and necessitates examination of the condition of the wound.
As the lung expands and the pus cavity proceeds toward healing the tubes
should be shortened from time to time until finally a drain of iodoform gauze
may be substituted. Before removing the tubes one should make certain
that no fistulous tracts or sinuses remain and that the pleiiral cavity is properly
The more radical operation of exsection of portions of one or more ribs,
by some authorities, is considered preferable to the intercostal incision. The
rib removed is usually the sixth, seventh or eighth and of this from a few
inches to its whole length are resected periosteally, removed, and the pleura is
incised and drained as in the operation by simple incision. At times it be-
comes necessary to remove parts of two or more ribs, and as a secondary
operation, in rare cases a thoracoplasty is indicated.
The operations described above are usually performed under general
anaesthesia but that of pleural incision may be, when desirable, done under
the influence of a local anaesthetic. It should be unnecessary to state that in
these as in all other operations the strictest aseptic precautions must be observed.
After operation the obliteration of the pleural cavity takes place in varying
lengths of time. It may close within a week or two or a discharging sinus
CHRONIC ADHESIVE PLEURISY. 653
may persist for months. The after-treatment consists of the employment of
all means suitable to maintain the strength of the patient, such as generous
diet, comprising among other articles plenty of milk and cream, the admin-
istration of codliver oil, iron and other tonics as indicated, and fresh air. Before
the patient can leave his room he should be dressed as if for out-of-doors
and the windows should be thrown open for several hours each day; when
able to walk he should be encouraged to seek the open air as much as
possible. Much benefit often accrues from a change of climate.
Respiratory exercises calculated to expand the lung, such as those described
under the treatment of serous pleurisy, should be ordered.
In cases which continue the discharge of purulent fluid from the pleura
for a protracted period the employment of inunctions with unguentum Cred6
may favorably influence the suppurative process.
CHRONIC ADHESIVE PLEURISY.
Synonym. Chronic Adhesive Pleuritis.
Definition. A chronic inflammatory condition of the pleural surfaces
characterized by the production of connective tissue adhesions.
.Etiology. Chronic adhesive pleurisy, usually, is a sequela of the adhe-
sions resulting from attacks of fibrinous, serous or piurulent pleurisy. It
may follow acute pneumonia or complicate tuberculous inflammations of the
lungs. In certain cases the lesion seems to be primary.
Pathology. The connective tissue growth, as a rule, begins in the cica-
tricial adhesions which previous pleuritic inflammations have left behind and
progresses until more or less of the surface of one or both lungs is firmly at-
tached to the chest wall. These adhesions are often so firm that the greatest
difficulty may be experienced in separating them. There may be displace-
ment of the heart, contraction of the wall of the thorax or spinal curvature
as a result of the contraction of this growth of connective tissue.
Symptoms. Early in the disease, before the adhesions have involved any
great amount of the pleural surface, there may be merely slight dyspnoea,
pain in the chest increased on inspiration, and cough. As the inflammation
progresses these symptoms become more marked, there is interference with
the heart action due to the adhesions and consequent displacement of the
organ, and the patient becomes weak and emaciated and an easy prey for any
Physical Signs. Over the adhesions the percussion note is dull, the voice
and breathing are harsh and intensified and there are sounds due to the
friction of the pleural surfaces.
Treatment. This consists in avoiding exposure to cold and dampness as
much as possible and when practicable, advising life in the open air in a
654 DISEASES OF THE RESPIRATORY SYSTEM.
climate where pulmonary affections are uncommon. Pulmonary gymnastics,
respiratory exercises and thoracic massage (see p. 635) will be found useful
in combating the interference "^-ith respiration. The patient's nutrition should
be kept up by means of a generous and easily-digestible diet containing plenty
of milk and cream, and the administrations of such tonics as codliver oil,
iron in appropriate form and the vegetable bitters. The heart weakness
may require the use of strychnine. For the pleuritic pain counter-irritant
liniments and ointments may be employed. An excellent liniment may be
made by triturating hydrated chloral, camphor and menthol in equal parts.
Inunctions of iodine-vasogen ointment with a view to possible absorption
of the adhesions may be prescribed.
In certain cases of contracted chest resulting from adhesions following
empyaema, relief may be sought at the hands of the surgeon.
Definition. An accumulation of serum within the pleural cavity.
-Etiology. This condition is a frequent accompaniment of anasarca due
to any cause, the most usual ones being nephritis or chronic endocarditis.
The effusion is a non-inflammatory one and therefore a transudate rather
than an exudate. It is the result of an interference with the proper circiila-
tion of the blood through the pleural membranes. The transudate is usually
bilateral but this is not always the case.
Symptoms and Physical Signs are identical with those of pleurisy with the
effusion of serum but there is likely to be less pain and there may be no febrile
Treatment will be considered under the treatment of the causative con-
n ' HYDROPNEUMOTHORAX; PYOPNEUMOTHORAX.
^^ Definition. A condition characterized by the presence of air and fluid,
which may be purulent, in the pleural cavity.
Etiology. Hydropneumothorax or pyopneumothorax is the result of a
perforation of the pleural cavity resulting from wound or disease of the chest
wall; the rupture of some pulmonary lesion such as an abscess, tuberculous
cavitv, infarct, gangrenous condition, etc.; the rupture through the diaphragm
into the pleural cavity of some inflammatory process due to malignant neo-
plasm of the oesophagus, stomach or intestine; the rupture of an empyaema
into the lung, or it may be caused by an empysema due to infection with some
gas generating micro-organism such as the bacillus cero genes capsulatus.
HYDROPKEUMOTHORAX; PYOPNEUMOTHORAX. 655
Symptoms. The patient suffers from the symptoms of the causative
lesion and at the time the rupture takes place complains of suddenly increased
pain and difficulty in breathing. There may be a sensation of something
giving way in the thorax. At times the symptoms of collapse, great prostra-
tion, rapid and feeble heart action and subnormal temperature, may be present.
In such cases death may rapidly supervene. In other patients the symptoms
of collapse become ameliorated but the ultimate prognosis, especially when
tuberculosis is present, is bad. There are gradual loss of flesh and strength
and dyspnoea, at times so severe that the patient insists upon sitting up in bed.
There is a febrile movement; when pus is present the typical irregular ciurve
of suppurative conditions is observed. The coiarse of the disease in these
latter cases markedly resembles that of empygema.
Physical Signs. Inspection and mensuration reveal one side of the chest
larger than the other. The intercostal spaces may be obliterated and the
respirator}^ movement of the thorax is slight. Upon palpation the vocal
fremitus is found to be much diminished or absent. The percussion note
above the fluid may be h}^er-resonant, tympanitic or more rarely dull; below
the fluid it is flat. Auscultation above the fluid reveals amphoric breathing
or a feeble or absent vesicular murmur; the voice is usually bronchial or ampho-
ric in quality. Below the level of the fluid voice and breathing are usually
absent. If the ear is placed upon the chest just below the scapula of the
aft'ected side and the patient is shaken the splashing sound known as succus-
sion will be heard, which is a pathognomonic sign of this condition. The
so-caUed metaUic-tinkle, the result of drops of fluid falling from the perfora-
tion into the fluid below, may be heard. With the ear at the back of the chest
the clink of a coin placed against the front of the chest and tapped by another
coin, may be heard. This sign is usually pathognomonic of hydropneumo-
thorax although it may be present over bronchiectases.
Treatmient. The patient shovild be confined to bed and fed upon a nourish-
ing fluid diet. The pain may be so severe as to require the hvpodermatic
administration of morphine. When less severe it may be controlled by coun-
ter-irritation (see p. 654). The heart weakness may be relieved by stimula-
tion by means of strychnine and alcohol. The dyspnoea may be lessened
by allowing the patient to sit up in bed and by inhalations of oxygen. Marked
dyspnoea and oppression may be relieved by tapping the chest above the level
of the fluid. A needle of large calibre to which a rubber tube is attached
should be used, but no aspirating apparatus. The pressure within the chest
will cause the expulsion of the air during inspiration, and to prevent its re-
entrance during expiration, the finger should be applied to the end of the
tube, or this should be placed under water contained in a bottle arranged for
the purpose. If the air continues to re-accumulate a drainage tube may be
permanently fixed in the chest waU.
656 DISEASES OF THE RESPIRATORY SYSTEM.
Aspiration of the fluid, if it is serous, may bring about improvement, but
when the fluid is purulent is likely to result in only temporary relief.
Operative procedures may be employed with the hope of obliterating the
Definition. An accumulation of blood within the pleiiral cavity.
.Etiology. Blood in the pleural cavity may result from the rupture of an
aneurysm, or from wounds of the blood-vessels of the neighboring parts. It
may be due to malignant neoplasms of the lung or pleura or it may take place
during the course of any of the hEemorrhagic diseases or very exceptionally
during pulmonary tuberculosis, particularly in children.
Symptoms and Physical Signs are those of hydrothorax.
The prognosis. This depends upon the cause but it is usually very unfa-
Treatment is that of the setiological factor combined with the aspiration
of the fluid.
NEOPLASMS OF THE PLEURA.
While new growths of the pleura are uncommon, this membrane may be
the seat of carcinomatous involvement. As a rule pleural carcinoma is secon-
^dary, having spread directly from a primary tumor of the lung, more rarely
it may be metastatic as a result of neoplasms of other parts of the body — notably
lung or breast.
Primary pleural sarcoma may occur and from it metastases may be depos-
ited in other organs and tissues.
Symptoms and Physical Signs. Those of either carcinoma or sarcoma
resemble the symptoms and physical signs of a chronic pleurisy and the
differential diagnosis may not be made before the appearance of the cachexia
typical of malignant disease, or of symptoms referable to the establishment
of metastatic growths in other parts. The pulmonary symptoms accompany-
ing pleural neoplasm are comparatively insignificant. Bloody effusion, if
present, is suggestive of new growth and examination of the effusion may in
rare cases reveal the presence of cells typical of carcinoma or sarcoma.
Treatment. This consists in the reUef of the distressing symptoms by
means of the aspiration of collections of fluid which interfere with lung and
heart action, stimulation — alcohol, strychnine, etc., as indicated — and the
maintenance of the patient's strength, in so far as is possible, by means of
nourishing food. If pain is a feature of the condition morphine may be given
DISEASE or THE MEDIASTINUM. 657
The use of the Rontgen ray, radium or any of the vaunted anti-cancer
sera may be undertaken but it is wise to inform the patient how Httle reliance
may be placed upon these forms of treatment.
Non-malignant tumors of the pleura such as lipomata and enchondromata
have been observed.
The pleura is also subject to hydatid or echinococcus disease. The occur-
rence of this condition is rare and usually the first noticed symptoms are
those due to the presence of pleuritic effusion. The fluid is usually serous,
more rarely purulent. The serous fluid of hydatid disease contains no albu-
min. The presence in the fluid of fragments of cysts and of hooklets is the
only incontrovertible evidence of this condition.
The treatment consists in aspiration to relieve the symptoms of compres-
sion of the lung. Surgical intervention is unsatisfactory.
DISEASE OF THE MEDIASTINUM.
Under this heading are classed the pathological conditions which may
affect the contents of the mediastinal space, excepting affections of the heart,
aorta, trachea and oesophagus.
Various types of tumors may develop in the mediastinum; of these the
most important are:
I. Carcinoma and Sarcoma. These may be either primary or secondary,
the sarcomata being more often primary than the carcinomata. The former
begin in the remnant of the thymus gland, in the lymphoid structures which
are numerous in this situation or are secondary to sarcomatous growths of
neighboring tissues; the mediastinal glands may also furnish a starting point
for primary carcinomata. Secondary carcinomata develop as a result of
primary growths in the breast, lungs, stomach, pleura or more remote struc-
tures; they are seldom of large size.
Symptoms. Small growths may not give any evidence of their presence;
when symptoms are manifest they are those of pressure. Dyspnoea is early
and constant, it may be due either to pressure upon the trachea, heart and
great vessels, or upon the recurrent laryngeal nerves. In the latter instance
hoarseness, loss of voice and the peculiar brassy cough ^ which is so character-
istic of thoracic aneurysm, are also present. Pressure upon the thoraci:
vessels results in distention of the veins of the upper part of the body with
accompanying coldness, cyanosis and oedema of the hands and sometimes
clubbing of the fingers. The distended veins may be tortuous and even almost
varicose in appearance. There may be inequality of the radial pulses due to
pressm-e upon the arteries. Pressure upon the sympathetic nerves causes
pupillary inequality. (Esophageal compression results in dysphagia. Pleu-
ritic and pericardial effusions may be present. In marked instances of the
658 DISEASES OF THE RESPIRATORY SYSTEM.
affection, the growth may be so large as to nearly fill the thoracic cavity, the
lungs and heart being pushed far out of their normal situations.
Tumors in the middle and posterior mediastina sometimes cause a cough,
paroxysmal and whooping in character, from pressure upon the vagus nerve;
with this cough there may be muco-piirulent or blood-streaked sputum; dys-
phagia is sometimes marked but may be absent. Pressure upon the pneumo-
gastric is also said to cause cardiac palpitation, arrhythmia and attacks of
faintness. Compression of the azygos veins may result in oedema of the
upper aodomen and the transudation of serum into the pleurae.
Growths which are secondary to tumors of the lungs or pleurae are less
apt to cause marked pressiire symptoms but there is more frequently fluid in
the pleural cavities and the cervical lymph glands may be enlarged. There
is usually more or less cachexia, especially when there is associated involve-
ment of the pleiira or lung.
Physical Signs. Growths in the anterior mediastinum may cause a bulging
or even an erosion of the sternum. Upon palpation the vocal fremitus is
sometimes exaggerated, sometimes diminished. Pulsation may be noted but
is not of the expansile type which characterizes aneurysm. If the lesion is
situated high in the mediastinal space it may be felt above the manubrium,
if its situation is low it may be palpable in the xiphoid notch. The percussion
note over the tumor is dull, the area of diilness corresponding in some degree
in size and shape to that of the growth; it is usually somewhat irregular in
extent. Auscultation over the dull area may reveal nothing, but at times the
breath sounds and those of the heart are distinctly audible; a ventriculo-
systolic murmur may be present due to pressure upon the vessels at the base
of the heart.
Tumors of the middle and posterior portions of the mediastinum are evi-
denced by few physical signs other than dulness upon percussion and modi-
fication of the respiratory signs.
The diagnosis. Thoracic aneiu-ysm resembles in many particulars the
condition under consideration but in mediastinal disease the course of the
affection is much more rapid and the symptoms of venous obstruction are
much more pronounced; the cachexia is more marked and the tumor seldom
possesses an expansile pulsation. Erosion of bone with its accompanying
pain is more common in the case of aneurysm, the tracheal tug is often present
and the characteristic diastolic shock may usually be both felt and heard; in
tumor this is said to be never present. Mediastinal growths are more common
in those of advanced years, except in the case of sarcoma, which may develop
in youth, and may be associated with tumors of other parts; laryngoscopic
examination may give evidence of tracheal narrowing.
The frequently associated pleuritic effusion may complicate the difficulties
of the diagnosis of mediastinal disease as far as physical signs are concerned.
DISEASE OF THE MEDIASTINUM. 659
but examination of the fluid withdrawn by the exploring needle is often very
helpful. The effusion is likely to be blood tinged or somewhat milky, due to
the presence of fat. Large endothelial cells in the fluid are said to be charac-
teristic of malignant tumors involving the pleural membrane. Aspiration of
the fluid of simple pleurisy relieves the respiratory embarrassment but when
a growth in the mediastinum exists this symptom persists.
The diagnosis of the type of the tumor may sometimes be made. Sarcoma
is more likely to affect young subjects and is usually more rapid in its course
than carcinoma. The latter may be associated with growths in the breast.
2. Non-malignant tumors of the mediastinum such as fibromata, dermoid
and hydatid cysts, teratomata, Hpomata and gummata, have been observed.
3. Abscess of the mediastinum is not especially rare; it is most common
in the male sex and its most frequent cause is traumatism; the condition may
also follow the infectious diseases, erysipelas or tuberculosis. In the latter
instance the course of the affection is apt to be chronic. The abscess is most
often situated in the anterior mediastinum, is evidenced by a throbbing pain
and, if of large size, by dyspnoea. In acute instances there is an irregular
temperature sometimes associated with rigors and sweats. The abscess may
rupture through the diaphragm, the thoracic waU or into the trachea, bronchial
tubes or oesophagus.
The condition may be suspected in the presence of abscess of the lung,
empyaema, or if, after a history of injury or caries of the dorsal vertebrae, ribs
or sternum, pressure symptoms with septic temperature develop. The phys-
ical signs are often indefinite; a fluctuating tumor may be palpable at the
suprasternal notch or behind the ensiform cartilage. The employment of the
aspirator in doubtful instances is justifiable.
In chronic abscesses the pus may undergo cheesy degeneration, and be-
coming inspissated, cause no evil result.
4. Sitnple lymphadenitis of the mediastinal glands occurs as a result of
all inflammatory conditions of the bronchi and lungs. The glands are most
abundant in the posterior mediastinum and their involvement is characterized
by hypersemia, infiltration, swelling and oedema. The physical signs of the
condition consist of dulness, often very difficult to detect, between the upper
portions of the scapulae. In marked instances there may be dulness over the
Tuberculous affections of the mediastinal glands may be primary or follow
the simple type of lymphadenitis.
5. Indurative Mediastino-pericarditis. This condition occurs in several
forms. It may be characterized by pericardial adhesions and marked increase
in the fibrous tissues of the mediastinum; in a second type the pericardium is
adherent to the neighboring structures but the mediastinal inflammation is
slight; in still another variety the pericardium may be unaffected.
66o DISEASES OF THE RESPIRATORY SYSTEM.
The condition is uncommon but is most frequently observed in young
adults; it may be associated with a chronic diffuse peritonitis. The symptoms
are those of pericardial adhesions with cardiac h}'pertrophy and dilatation;
dyspnoea, cyanosis and general oedema are usual. Physical examination may
reveal the presence of coarse, dry rales over the right border of the heart.
These signs may be more easily detected if the patient's arms are raised.
6. Mediastinal Emphysema. In traumatism, fatal whooping cough and
diphtheria and after tracheotomy, air may force entrance to the mediastinum.
The ocfcurrence of the condition is said to be favored in the latter instance by
the respirator}^ obstruction, the forced eff'ort at inspiration and the operative
division of the deep cervical fascia which, in the proper performance of tra-
cheotomy, should not be separated from the trachea. The emphysema may
involve the subcutaneous tissue. Air in the mediastinum also may be observed
in pneumothorax and rupture of the lung.
The treatment of mediastinal disease is chiefly symptomatic although
operative interference in a few instances has succeeded in removing tumors
in this situation. Recovery is said to take place in 40 percent, of the cases
of mediastinal abscess, but this figure should be raised since the statistics
are those of the pre-antiseptic period. The treatment of abscess consists in
free incision and drainage.
Favorable results have been reported to have followed the employment
of the Rontgen ray in non-operable malignant growths, but while this form