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 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, Maisonneuve175 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. Rome177 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 occasionally a few drops of pus; 7 were cured without fistula. Blake178 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 Oxley179 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. Dabney180 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.
175 London Prac., 1868.
176 Ranney, Annals of Anat. and Surgery, 1881.
177 Thèse de Paris, 1882.
178 Boston City Hospital Reports, 2d series.
179 Liverpool Medico-Chirurg. Journal, January, 1882; N.Y. Medical Abstract.
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. Cabot181 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's182 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 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. Mason183 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.