Empyema. *By F. A. LONG, M. D., Madison, Neb. Accepting "pus in the pleura" as the definition empyema, I shall not discuss serous pleurisy in this paper. Empyema results from the infection of a pleurisy, a pleuropneumonia, a broncho-pneumonia, or from a tubercular process involving the pleura, and also from infection carried by penetrating wounds of the chest wall. When due to pleurisy or pneumonia the most frequently found germs are the pneumococcus and the influenza bacillus, while if due to penetrating wounds the ordinary pus germs are the organisms most frequently found. If a pleurisy or a pneumonia fails to clear up in the usual time we may suspect empyema. An inspection of the chest may reveal immobility on one side in degree corresponding to the amount of effusion, fullness or obliteration of the intercostal spaces, there may even be bulging, and measurements will show a larger semi-circumference amounting to from one to one and a half inches over the other side. One must however remember that the right side is naturally larger than the left. One of the most valuable diagnostic signs in accumulations of any size is the absence of the voice vibrations in the affected side. I need hardly state that this sign is elicited by placing both hands flat with the fingers spread somewhat, on the upper part of the chest and having the patient count aloud or otherwise speak slowly and distinctly. There will be no vibrations noticeable to the hand over the affected side, or if there are vibrations they are correspondingly weaker. In children this sign is not so evident. In effusion of the right side of any extent, the apex beat of the heart is lifted and possibly pushed beyond the left nipple, the location depending on the amount of effusion. If the exudate is on the left side, the heart's impulse may be concealed; if the effusion is large the impulse is seen in the third and fourth interspaces on the right side in the neighborhood of the right nipple. Flatness of the percussion note is characteristic of effusion. Early, when fluid is just beginning to accumulate the flatness may not be so evident. In moderate effusion, movable *Read before the Elkhorn Valley Medical Society, at Norfolk, Neb., January 16th, 1912, as part of a Symposium on Diseases of the Chest. dullness may be elicited, the location changing with the patient's shifting from the recumbent to the upright position. Symptoms of infection are present. The disease through which infection has occurred, except in tubercular cases, has run its course, but the patient instead of convalescing, becomes paler and weaker, has sweats and irregular fever running as high as 103 1-2 in some cases. A patient having had a pleuropneumonia may appear to be convalescing for a short time before the symptoms of infection become evident. These are the symptoms mostly depended on in making a diagnosis. To one who has seen a case of empyema demonstrated, the diagnosis is, in most cases, comparatively easy; but it is not so easy to the physician who has not been fortunate enough to have seen a case during his college and hospital training. I speak advisedly, for I have had the opportunity to diagnose or to confirm the suspected diagnosis for a number of physicians who had not previously seen an empyema. My own first experience came with a very interesting case many years ago, and I well remember that my impression was that I had an abscess of the lung when bulging occurred. Exploratory puncture is called for to confirm the diagnosis, in every case. An ordinary hypodermic outfit sterilized for the purpose answers very well, and is the instrument of preference by the essayist on account of its size and innocent appearance. A rather long needle is needed in adults. Aspiration as a method of cure need be mentioned, but to be condemned. The method has practically fallen into disuse and justly so. There may be an occasional case where owing to conditions, aspiration may be called for as a temporary expedient to afford immediate relief. Incision and drainage by and through a tube is the remedy for empyema. The operation may be done under local anaesthesia, but general chloroform anaesthesia seems to have the preference, rather than ether, because it tranquilizes the patient quicker, and avoids in a greater degree the coughing and retching peculiar to ether, and which might result in rupture of the empyema into a bronchus, and consequent strangulation. The incision is made on a level with the posterior axillary line preferably between the fifth and sixth ribs, (some prefer the seventh or eighth interspace) care being taken to cut close to the lower rib to avoid the intercostal artery. The incision must be large enough to admit a good sized tube, taking into consideration the size of the patient, varying say from 14 American catheter scale for a child to 24 or larger for an adult. Personally, I prefer to put in a tube doubled on itself so as to make two drains believing that better drainage is thus afforded and that in case of clogging by placques of fibrin the drain can better be freed without removing the tube. The tube may extend into the cavity at first in an adult, to the extent of two or more inches, but must be shortened as expansion of the lung progresses. I do not think it advisable to have the tube project into the cavity more than an inch as a rule, and as the case progresses toward recovery, it should project very little. (Introduction of the tube is facilitated by raising the arm to cause separation of the ribs.) The tube is fixed on the outside with a large safety pin and adhesive straps. To this I like to add a perforated plate, usually made of zinc sheeting, through which the tube projects, the pin being on the outer side of the plate. This aids, it seems to me, in fixing the tube. A liberal gauze and an especially liberal cotton dressing completes the operation. If there is a large amount of pus, it is well to apply the dressings expeditiously, not waiting for the flow of pus to cease, lest collapse may follow the relief and expansion of the lung. The after-treatment of a case consists practically of a change of dressings only, and the administration of tonics. Irrigation, once so popular, is no more advised by the authorities, except in very putrid cases, and when done a one-half grain to the ounce permanganate of potassium solution, warm, is perhaps the best. It is advised to occasionally take out and clean the tube. I do not think this is imperative. The length of time required for an empyematous cavity to drain and heal varies greatly, according to the condition of the patient and the amount of effusion, but three weeks may be considered the minimal time. As the patient's condition improves he may be allowed to leave his bed. Just when to remove the tube and let the sinus close in a question calling for fine judgment in every individual case. Personally, I like to put in a smaller tube toward the last and remove this only when the discharge is practically nil, and that serous rather than pus-like. If, after the sinus is allowed to close, fever and pain develop, the sinus must be reopened for longer continued drainage. Simple acute empyemas readily respond to this treatment. The resection of a rib in connection with the establishment of tubal drainage in every case is advocated by many surgeons. That this is not absolutely necessary in acute empyemata is well known, and that this proceedure will not become popular in general practice, is pretty certain. The extra time required to resect a rib, is a great objection, owing to the fact that most empyema patients take the anaesthetic badly. This objection would have less force to a deft surgeon, than to one slower in his movements, or to a general practitioner. In the chronic forms of empyema in which collapse of a portion of the lung has become permanent, rib resection is necessary to allow collapse of the chest wall, to correspond to the defective lung tissue. In resecting a rib it is exposed for about three inches, the periosteum pushed to either side, and about one and one-half inches removed with a rib cutter or bone cutting forceps. This is done before incising the pleura. In some old neglected cases with complete collapse of the lung the Estlander operation is necessary to allow collapse of the greater part of the chest wall. Briefly, this operation consists of the resection of four or five ribs in a wedge shaped manner, the base of the wedge being below. More radical still, is the Schede operation, applicable to cases which have been long chronic and perhaps tubecular, and where the resection as above outlined is not sufficient to obliterate the cavity. In these cases Schede resects the entire chest wall overlying the cavity, a proceedure that has been quite generally followed with success. The cases we meet are not all classical, and special cases call for special consideration, as for instance, cases in which fistulae have formed, or in which there is bulging, denoting, impending fistula. Spontaneous evacuation almost never results in cure. Operation done in these cases should not seek to enlarge the fistulous opening, but the drainage should be made at the usual site. A case ever of much interest to myself follows: A family moved from Iowa one spring bringing a child about six years of age, said to have had a very severe attack of pneumonia during the winter just past, and from the effects of which she had not recovered. She had fever, rapid pulse, cough, and was so highly nervous and shy that a satisfactory examination of the chest wall was impossible. A little later a bulging occurred on the back near the lower point of the scapula. This was opened and a drainage tube inserted. The child improved considerably, began to eat and to play, but did not get well. One day my attention was called to an unusually free discharge of a milky consistency. A little later, pink particles of what proved to be (early) radish skins were found on the dressings. A fistulous opening through the diaphragm into the stomach had evidently formed, and milk and small particles of food passed from the stomach into the empyematous cavity and through the fistulous opening in her back. Drainage was later established in the axillary line in the sixth interspace, whereupon the child rapidly recovered. Rupture of an empyema into a bronchus does not result in cure except very rarely, and should not deter the physician or surgeon, from doing the drainage operation. I am very certain that many cases in general practice are insufficiently drained. A little stab wound, under local or general anaesthesia, and the introduction of a small catheter, is not an operation for the cure of an empyema, and one need not wonder at the failure to cure. Purpura Hemorrhagica During Convalescence From *By E. C. STEVENSON, B. Sc., M. D., Gothenburg, Neb. The infrequency of this complication in scarlet fever is apparent from the fact that a review of available literature in the Surgeon General's library of Washington, D. C., by Dr. Charles A. Pfender, resulted in finding only thirty-three cases reported. by foreign and American writers. Monnier (1904), states that post-scarlatinal eruptions are not uncommon. Murray (1893), states that little is said in English text-books about P. H. following scarlet fever, but is of the opinion that the hemorrhagic diathesis, though rare, is less uncommon than the literature would indicate. Von Juergenson (1902), states that hemorrhagic scarlatina is rare, and further says: "It is an interesting fact that Lichtenstern in his brief description of the severe and extensive epidemic in Cologne (he himself saw over 1,000 cases), makes no mention of hemorrhagic diathesis. Litten also fails to mention it." Voelcker (1905), states that of 4,926 autopsies at the children's hospital, London, fifteen cases of P. H. following infectious fevers are recorded, and remarks that symptomatic purpura is not infrequently met with in the acute infectious fevers, especially measles, variola, scarlet fever and diphtheria. He quotes Sanson as having seen purpura following influenza. Sterling Ruffin, Washington, D. C., states in a letter, that he has seen P. H. following infectious diseases, mentioning partic *Read before the Dawson County Medical Society January, 1910. |