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J. A. (Joel Asaph) Allen.

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in the disease, and is more often found when the effusion is puru-
lent than serous. It is naturally caused by the descent of the
diaphragm from the pressure of the fluid. The fact must, how-
ever, not be lost sight of that a very considerable effusion may
coexist with a normal situation of the diaphragm, t. 6., the stomach
note may be obtained at the sixth rib in the nipple line, and yet
a large effusion be present. What is true of the stomach
note is equally true of liver dulness, and hence of importance, as
otherwise injury to the viscera could easily occur during operation.
The practical significance of this sign, therefore, varies. When
present, it has a distinct diagnostic value. Its absence means
nothing.

Signs in the Other Lung, — These consist of crepitant rales,
cough, with more or less bloody sputum. They denote pronounced
intra-pleural pressure, and are, therefore, to be found in cases
where the effusion is very large. They, furthermore, indicate the
necessity for withdrawal of the effusion.

Cardiac Displacement Bruits, — This sign is present when the
heart is greatly displaced. It is usually a systolic murmur, devel-
oped over the base, and is supposed to be due to << straightening or
slight tension of the great vessels from pressure of the fluid."
(Powell.)

The signs which have just been enumerated are those of serous
pleurisy as well as of empyema, but they belong no more to the
one than other disease. Can we go further and find signs which



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PABMENTER : EMPYEMA. 327

Are indicatiye of the nature of the fluid, or, to narrow the inquiry,
indicatiye of pus in the thorax ? Before enumerating the symp-
toms and signs which are of some value in determining the nature of
the effusion, let me say that, in the earlier stages of empyema
there are none that are pathognomonic. In other words, serous
pleurisies may simulate, in every particular, an empyema of recent
duration. Therefore, when a patient presents symptoms which
are more or less adynamic, has rigors and chills which constantly
recur and are followed by fever, has a very frequent pulse (120-140)
with furred or dry tongue, anxious look and more or less rapid
emaciation, and hectic sweats, which occur whenever the patient
falls asleep, and has the physical signs which have been mentioned
«8 characteristic of effusion, we may strongly suspect an empyema;
but still, I repeat, each and every one of the symptoms and signs,
in their full degree of development, may be met with in a serous
pleurisy. In long-standing empyemata, however, there are a few
"signs which have an almost positive value.

Edema of the chest wall is one of these. Powell believes it to
be an absolute sign of pus.

An erysipelatous blush over part of the chest and pointing are
iilso sure signs of a purulent effusion, according to the same
authority.

Pectoriloquie Aphonique^ or BacelWs Sign. — While this sign
is of value, it is by no means pathognomonic. It is obtained
as follows : the unaided ear is applied over the region beneath the
scapula, and the patient made to whisper some rough word. This
is conducted distinctly to the ear in serous effusions, but not when
they are purulent, the difference being due to the fact that vibra-
tions are better conducted through a homogeneous medium, lil^e
serum, than through a fluid, like pus. This sign occurs, however,
too often in purulent effusions to regard it in any way an import-
ant one in differential diagnosis.

From what haa been said, it is clear that we have no pathog-
nomonic symptoms and signs of empyema at the time when we
heed them most, viz., early in the disease. There is but one way
in which to ascertain whether an effusion be serous or purulent,
and that is to use the exploring syringe. With this we can make
"a certa'in diagnosis ; without it we can not. While I believe that
the exploring needle should always be used, I do not think it
should precede a careful consideration of all the symptoms and signs
Which have been mentioned. To be sure, when done in an



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828 PABMENTBB '. EMPYEMA.

aseptic way, the puncture is without danger ; still, it is dreaded ta
some extent by the patient, but what is, in my opinion, more
important, its early use leads us to ignore the clinical history, and
causes us to disregard such evidences of the disease as demand
careful study and interpretation. In short, each case should be sa
well studied that the diagnostician has come to a conclusion i^ to
the probable nature of the effusion, and then uses his exploring
needle to confirm his suspicions.

Indications for Operation, — These are two. First, to save the
patient from impending death ; and, second, to cure the disease.

Contra-indications for Operation. — Cases in which there ia.
coexisting and advanced phthisis, and certain hopeless cases of
putrid or gangrenous empyema, are, so far as I can recall, the
only ones in which a radical operation is contra-indicated. Not
infrequently we see cases in which death seems imminent either
from suffocation or cerebral anemia. It is easy to understand how
suffocation can occur from the pressure of the fluid upon the lung
of the opposite side, seriously limiting its expansion and that of
the whole thorax as well, and causing congestion of the sound
lung, which becomes less and less able to perform its function^
until finally asphyxia occurs. It is not so clear how cerebral
anemia is caused. Trousseau ascribed the cause to the dragging
of the heart from its position, which, in turn, caused a sharp twist
in the aorta. As. a result of this condition, some sudden move,
ment on the part of the patient could easily cause either an abrupt
and complete interruption of the circulation, or rapid clotting and
thrombus formation in the vascular system, and thus suddenly
deprive the brain of blood. Bartels, on the other hand, would
give a different explanation. He does not believe that the elastic
aorta, imbedded as it is in connective tissue, -can thus easily suffer
torsion. According to this author, sudden death from cerebral
anemia occurs only in cases where the effusion is upon the left
side. When the heart is pressed out of its place, and to the right
side, the aorta, as it comes through its opening in the diaphragm,
suffers a sharp <<kink," so to speak, this condition being aided by
the fact that the aorta is quite firmly fixed in this situation. The
kinking may amount to very nearly a right angle. If the inferior
vena cava has a similar << kink," and the patient makes softie sud^
den movement, or has a severe coughing fit with coincident spas-
modic contraction of the diaphragm, then the heart, already some^
what empty of blood from the rapidly increasing exudate (especi*



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PABMSNTER '. SMPYBMA. 3 2d

ally in serous pleurisy), becomes suddenly so deficient in blood
that the blood pressure is not sufficient to furnish the brain with
arterial blood, and, according to the duration of this condition, the
patient either faints or dies. Whichever explanation we may
accept, one thing is certain : there is danger in delay, and especially
in left-sided effusions with symptoms of congestion, as Trousseau
has wisely observed. In fact, the indications for operation, where
conditions like those juist named exist, are as clear and imperative
as the ligature of a bleeding vessel. Before, however, considering
the operative treatment of empyema, a word or two about the medi-
cal or expectant plan of treatment. Experience has taught us, over
and over again, that drugs will not remove pus from the pleural
cavity. The best, therefore, that we can hope for is that Nature
may come to the rescue, and the pus be discharged either through
some point in the thoracic wall or through a bronchus. This
happens only in most exceptional instances, and cannot, therefore,
be depended upon to free the patient from so dangerous a malady
as empyema becomes when allowed to go on indefinitely. Further-
more, even when natural discharge of pus does occur, caseous
masses remain, which are highly infective, and which can and do
cause general tuberculosis.

When shall we operate ? We have already seen that delay
brings certain dangers, such as suffocation and cerebral anemia. Then^
furthermore, we must remember that pus is a dangerous foreign
body in itself, and that the longer it remains in the pleural cavity
the more thickened the pleura becomes, and the more unable is the
lung to expand. In addition to these unfavorable conditions can
be added that of changes in the thorax wall (bones and cartilages)^
which may render final and complete closure of the cavity impos-
sible.

Methods of Operation. — Few surgeons of experience, I imagine,
now rely upon aspiration for the cure of empyema. Now and then
a case occurs where one or two aspirations are sufficient to remove
pus, which does not reaccumulate, and speedy cure ensues. Such
results are extremely rare. Aspiration only succeeds, as a rule,
where the empyema occurs in childhood and is due to the pneumo-
coccus. Withdrawal of the pus, wholly or in part, is usually fol-
lowed by increase of temperature, due, probably, to absorption of
the pus, which absorption is stimulated by the relief of pressure,
as is so commonly seen in serous pleurisy. Very soon the pleural
cavity becomes again filled with pus, and the condition of the patient



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330 PABMBNTBB : BMPTBKA.

either unimproved or worse than before. As this is the usual
history of cases in which aspiration is employed, it naturally does
not commend itself to us as a safe and thorough method of treat-
ment.

Buelau's Method. — This is a modification of the aspiration
method of treatment. The pleural cavity is punctured with a
large trocar, in the canula of which is introduced a long rubber
tube. This runs down into a vessel of sublimate solution situated
upon the floor. The end of the tube is weighted with a piece of
lead, to keep it in the antiseptic solution. The object is to cause
a negative pressure in the pleural cavity, by which the aspiration
of the pus outward is favored. This treatment has received the
favorable recommendation of Curschmann, Immerman, and Schede,
the latter going so far as to say that the method would be ideal
were it not for the ease with which the tube becomes displaced,
especially in children and restless patients. On the other hand, it
is claimed, and most judiciously, that this method is not applicable
to putrid pleurisies or those due to the streptococcus, in which irri-
gation is so very commonly required. One distinct advantage it
may have, as Duplay and Reclus have pointed out, and that is in
cases of double empyema, where, from the fact that no air enters
the pleural cavity, it would be a safer procedure than open incision,
which, by admitting air with its attendant collapse of the lungs,
would cause fatal asphyxia. It must, however, be confessed that
Biilau's method, like simple aspiration, cannot completely empty
the pleural cavity. The often huge caseous masses remain, and,
although they may be reduced in size, something remains, and that
something is highly infectious. It has been claimed that, even
when aspiration cures the empyema, the patient invariably suc-
cumbs to tuberculosis within three years. This may or may not
be true.

Incision and Drainage. — This, the most commonly employed
procedure for the relief of empyema, has many things to commend
it. It is easy to do, it is not dangerous, and, ordinarily, it
accomplishes its purpose.

Where Shall We Incise ? — The rule to open an abscess at its low-
est point, thus favoring drainage, applies with equal force in the case
of empyemata. The real difficulty is in determining what is the
lowest point. This must, of course, vary with the position of the
patient, so that, in choosing the site of our incision, we must settle
upon what position the patient will take most constantly during



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pabmentbb: empyema. 331

the time when drainage is most important, yiz., the first few days
(seven to ten) after operation. This position will, most probably,
be the dorsal, or inclining to the affected side. In such position,
the lowest point in the thoracic cavity will correspond pretty accn*
rately to the mid-axillary line or jnst in front of it, at about the
sixth intercostal space. In addition to the advantage of drainage,
the thoracic walls are here quite thin, so that the operation can be
more easily performed than posteriorly, where the muscles are
deep and the intercostal spaces narrow, making insertion of the
tube and resection of a rib (where necessary) often quite difficult.
Again, when the lung begins to expand, it touches the posterior
walls first, and in this way -an opening behind the axillary line
may easily become occluded by the expanding lung and prevent
free drainage. The diaphragm may do this same when the open-
ing is made too low. The occurrence of the above undesir-
able conditions will induce us, then, to regard the fifth or sixth
intercostal space, in or slightly in front of the mid-axillary line, as
the best in which to incise and drain an empyema.

T?ie Operation. — The skin over the region having been thor-
oughly disinfected and the patient brought well to the edge of the
table, in order that he may lie as nearly on his back as possible
and still give room for the surgeon, the arm of the affected side, is
raised to a right angle, and the incision (which should be from one
and one-half to three inches long) made at the level of the upper
border of the lower rib of the intercostal space selected. The
position of the arm is important, inasmuch as lifting the
arm causes the skin to slide upward upon the thoracic wall ;
and if the amount of this displacement be not noted, the
incision in the skin and that in the intercostal muscle will not
be in the same plane when the arm is lowered, and thus the open-
ing will be a valvular instead of a direct one. When the pleura
has been reached, a grooved director is thrust through the pleura
and the opening further widened with a pair of forceps. The pus
is then allowed to escape slowly and the expulsion of caseous
masses facilitated with the finger introduced into the cavity.
Should examination show that a counter opening is advisable, this
can easily be made by introducing some stiff instrument, such as
long forceps or a sound, and cutting down upon the same at
the point over the end of the instrument. A drainage-tube
is then inserted in as many openings as are made, i, e. , one for
each opening.



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332 PARMENTEB I EMPYEMA.

When it is. found that the intercostal spaces are too narrow to
permit the introduction of a good-sized drainage-tube, or the finger,
for examination purposes, it is well to reseet a portion of one or
two ribs. The rib is bared of its periosteum, and the intercostal
artery avoided, and then, being steadied with forceps, it can be
divided with a fine saw, or partially divided, and the section fin-
ished with cutting forceps. The ribs should not be divided with
forceps alone, as they are easily splintered in this way. After an
inch, or more, of rib has been resected, the periosteum should be
removed, as its retention may easily lead to an irregular callous
formation.

I^orm of Drainage-tube, — The tube should be of good size,
flexible, and just long enough to penetrate completely the thoracic
wall. A longer tube very soon begins to fret against the expand-
ing lung and to cause distress, if not positive injury. To prevent
an accident which has happened very often, viz., dropping of the
tube into the pleural cavity, some expedient must be resorted to, to
anchor the tube in place. Personally, I am quite partial to the
Baxter tube. It is made as follows : Take a piece of sheet India-
rubber, one and one-half to two inches square, and punch in the
center of it a hole as large as the drainage-tube. Pass the tube
through and split it into four pieces long enough to reach to the^
four corners of the shield, and fastened or sewed to the same with
fine silver wire. The tube, on the other side of the shield, should
have no holes cut in its side, as granulations can easily enter them
and distress the patient or occlude the tube.

THE AFTER-TEEATMENT.

Shall We Irrigate the Cavity f — In the vast majority of
empyemata, irrigation is unnecessary. It may be injurious. Many
cases are on record in which the antiseptic solution employed has
caused severe toxic symptoms and even death. Again, the injec-
tion fluid, striking against the pericardium, or from some unknown
cause, has caused sudden arrest of the hearths action with fatal
result. This is the more apt to happen when the fluid has been too
cool when used. Irrigation is, then, to be employed only in
exceptional cases, such as putrid empyemata with severe symp-
toms. When employed, irrigation should be done with a fountain
syringe, raised about a foot above the level of the cavity, or, at
least, the fluid made to enter the cavity slowly and steadily. The
amount allowed to enter at one time is, of course, determined by



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parmenteb: emptbma. 333

the size of the cavity. The sensations of the patient are a reliable
guide, and the first sign of discomfort made the signal for ceasing.
The solutions used to wash out the pleural cayity have been many
and various. In general, it may be said that the stronger solutions
are not to be used. Carbolic acid, in any strength, ought not to
be employed. Sublimate, 1-4000, and followed by boiled water,
makes an excellent injection. My own preference, however, is for
iodine, which should be added to the water until it has a light
sherry-red tint. The amount and number of the irrigations must
vary with each individual case. Ordinarily, to flush out the cavity
once each day suffices, but now and then a case will occur when
it should be done three, or even more times, in twenty-four hours.

The dressing should be the ordinary one of iodoform, bichloride
gauze and cotton, held firmly in place with a well-fitting bandage.
It should be changed as soon as the discharge appears through it
and as often. This usually means twice during the first twenty-
four hours and then at gradually increasing intervals. The regu«
lation of the diet and the exhibition of reconstructive tonics will
follow in due course. Just about this time, it is not infrequent to
see patients who have been doing well, in every way, develop an
acute indigestion, quite violent in its symptoms. Such manifesta-
tions must be met in an appropriate way, but particularly must the
cause be removed, viz., feeding in excess of the patient's powers of
assimilation. A patient with a pleural cavity filled with pus, and
breathing forty to sixty times per minute, needs a generous supply
of food to compensate for the waste due to the rapid oxidation
going on within his body. Lessen the oxidation by restoring the
respiratory process more nearly to the normal, so should the
amount of food become proportionately decreased. So anxious for
his recovery, however, are relatives, and too often the physician
himself, that food is constantly urged upon the patient to his, at
least, temporary detriment.

When may the tube be removed ? This is frequently one of
the most puzzling questions that will arise in the treatment of
empyema. So long as a distinct cavity remains, the tube should
be retained. Usually, when the discharge has become serous and
small in quantity, it means that the cavity has become obliterated.
This change of the discharge from purulent to serous occurs
at varying times, from two weeks to months, and sometimes
years, depending upon the age, resistance of the chest wall, expansi-
bility of the lung, etc. Not long ago I removed a quart of pus



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334 PiLBMENTER : EMPYEMA.

from the chest of a boy of five years, and on the sixteenth day
after operation the tube was taken out and the woand allowed to
close. It must be remembered that the woand itself gives rise to
some pus, which, mixing with the serous discharge, could easily
deceive the over-anxious. Before removing the tube, it is good
practice to carefully examine the cavity with a probe, and thus
ascertain definitely the form and extent of the same. Too often
trouble arises from removing a tube at an improper time. This
improper time may be too late as well as too early, for, while we
all appreciate the danger of locking up purulent secretions by
taking away their means of exit, we do not so often remember that,
by leaving a tube in too long, we are apt to help the formation of
long sinuses, which may be very troublesome to heal.

Accidents During Operation. — Hemorrhage may occur. When
it does, it is usually due to a wound of the intercostal artery, at
the site of operation, and always due to the lack of skill of the
operator. It usually is caused by a partial severing of the artery.
This can frequently be remedied by cutting through the artery
down upon the rib with a tenotonic, in this way making a clean
division, when the edges of the vessel curl up and the hemorrhage
ceases. This failing, a hemostatic can be clamped upon the
vessel and left in position for twenty-four hours, or a small
portion of the rib exsected and the artery secured with a needle
and catgut. Usually, the accident is more annoying than serious,
but occasionally the bleeding may be severe enough to cause
alarming symptoms.

Wounding of the Diaphragm. — It has already been mentioned
that a large effusion may be present without appreciable descent
of the diaphragm, and it was hinted that, unless this fact were
remembered, an undesirable accident might occur. Such an acci-
dent occurred to me some three months ago. In operating, with-
out assistance, upon a child of sixteen months, with left-sided
empyema, and in which the pressure signs were so urgent that
haste was demanded, I used a bistoury and opened the chest wall
with one cut, in the sixth intercostal space (axillary line). Over a
pint of pus escaped, and was followed by a portion of the great
omentum. The child made a- good recovery, and without any
unpleasant symptoms, but died six weeks later of pneumonia
affecting the sound lung. While in this case nothing untoward
resulted, one does not enjoy opening the peritoneal cavity in the
presence of pus, or incising the liver under similar conditions.



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PABMENTSB : SMPTBMA. 385

Wounding the diaphragm is, then, a possibility, and due care
should be taken to ascertain its limits before operation.

Nervous Phenomena, — Epileptiform convulsions, various kinds
of paralyses, and sudden death have followed irrigation of the
pleural cavity, so that, when this is employed, the above-mentioned
possibilities must be borne in mind and the injection most care-
fully given.

The limits of this paper demand that mere mention only be
made of the more radical methods which may and have been used
in those obstinate cases in which, from one cause or another, the
pus cavity cannot be obliterated by simple incision and drainage,
with or without resection of the rib.

EaUander^s Operation, — This consists, essentially, in the resec-
tion of several ribs, a greater or less length of rib being removed^
according to the size of the cavity. I pass by the details of this
operation, and say of it simply that it often fails in its purpose,
unless accompanied with curetting of the pleura or more or less
extensive resection of the same. In moderately severe cases it is
of decided value, but, given a large cavity, with rigid pleura and
a very contracted lung, not much can be expected from this pro-
cedure.

Q^enu^8 Operation, — Quenu aims to get a movable chest wall
by resecting the fifth and sixth ribs anteriorly and posteriorly, the
intervening part acting like a mobile shutter, as it were. It can
be easily understood how great a hindrance to the success of this
method a rigid and thickened pleura must be, and, therefore, it has
serious limitations in those very cases where it is most needed.

Schede^B Operation. — More radical than either of the before-
mentioned operations is that of Max Schede. This surgeon resects
the entire thoracic wall, excepting only the superficial parts. The
ribs, intercostal muscles, and the pleura are all removed, and the
large flap put in opposition to the lung. The disadvantages of the
operation are obvious. The large flap does not fit accurately the
lung underneath, and often leaves part of the cavity exposed ;



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 34 of 78)