Gangrenous areas of limited size have in certain favorable cases cleared up and the patients have recovered, but ordinarily for this condition surgery affords the only prospect of relief, the operation being begun with a thoracotomy and completed by the removal of the gangrenous lung tissue. The operative procedure is essentially the same as that for abscess and above described.
Septic pneumonia is the term applied to those forms of pneumonitis which occur in connection with septic lesions in other parts of the body, or with the less typical forms—e. g., aspiration pneumonia, due to the passage into the finer bronchioles of material from the mouth or nose. It gives rise to the same physical signs, though it is perhaps more often irregularly located than is the consolidation of the ordinary lobar pneumonia. Viewed in this way it will be regarded as a serious complication of various other conditions, many of which are surgical, and it is frequently a primary expression of infection. The physical signs by which it may be recognized are scarcely different from those of ordinary pneumonia, except that, in addition to the latter, there may be distinct expressions of general septic infection and of profound toxemia, and that the disease may progress to the point of producing pulmonary abscess or gangrene. While the milder types of septic pneumonia are not necessarily fatal, it is always a serious complication, and, as such, dreaded by the surgeon. It is not, however, essentially a surgical complication, but calls for the treatment generally given to pneumonia, plus whatever may be needed for the primary condition behind it.
CHYLOTHORAX.
This implies a collection in one of the pleural cavities, usually the left, of fluid which is practically unchanged chyle, which has probably escaped from the thoracic duct. The number of cases on record is not over fifty, of which about one-third have followed unrecognized injury with probable rupture of the duct. Most of these cases have occurred in connection with fracture of the spine. The duct may be opened by the progress of ulcerative disease, and carcinoma is often the predecessor of chylothorax. Rupture may also occur in connection with tuberculous lymphatics about the course of the duct, and when the condition occurs in children this is the usual explanation. It should be differentiated from so-called chyloid effusions into the pleural cavity, which are more often seen in connection with cancer than tuberculosis, the fluid in this case being mixed with fat and degenerated leukocytes or cells. Pure chyle contains sugar, while chyloid fluid contains but a trace of it. The former also is thicker, and compares with the latter as does cream with skimmed milk.
The prognosis is not usually favorable. Nevertheless recovery has ensued without operation. Mere pressure of the effusion may occlude the opening through which it occurs until the latter shall heal. When the fluid gives rise to severe symptoms the chest should be aspirated.
HYDROTHORAX; HEMOTHORAX; PYOTHORAX.
Under these terms are included the presence of fluid in the pleural cavity, between the lung and the chest wall; this fluid, in the first instance, being serum, which may be slightly admixed with pus and blood; in the second, blood; and in the third, pus.
Hydrothorax may be a primary condition, the result of pleurisy with effusion, or of pleuropneumonia. It may also occur as does a similar collection in the abdomen, as the result of disease of the chest wall, the lung itself, or in consequence of serious cardiac or renal disease, with tendency to dropsical accumulations in various parts of the body. Thus it is seen in connection with tuberculous disease or cancer of the lung, as well as cancer of the chest wall. There is, moreover, a miliary expression of tuberculous pleuritis in which hydrothorax is always a complication.
The serious features of hydrothorax result from the compression which it may make upon a lung with consequent embarrassment of lung function and from the possibility of infection by pyogenic organisms and the consequent conversion of a hydrothorax into a pyothorax.
Collections of serum within the pleural cavity which manifest a kindly tendency to disappear by resorption do not require surgical intervention, but all such accumulations which do not quickly evince this tendency should be removed by the operation of paracentesis, which, applied to the thorax, is called thoracentesis, i. e., aspiration through the hollow needle. No lung should be allowed to have its capacity long reduced by compression.