Volume 3 — DISEASES OF THE RESPIRATORY SYSTEM. (continued 21)

¹¹⁶ Clin. Méd., edited by Neligan.

Chronic purulent pleurisy is marked by symptoms somewhat different. It commences in a similar manner to that of acute pleurisy, with fever, but in a few days the fever disappears. In the evenings there may be some febrile action with slight chills. It is remarkable that frequently vast collections of purulent fluid do not give rise to chills. The fluid augments progressively, but sometimes very slowly, and often it appears to remain stationary for a long time. This condition continues sometimes for many months. The patients are pale and feeble, although they may get up and walk until the quantity is increased to such an extent as to impair their breathing capacity. Then the forces of the body by degrees diminish, and the appetite is impaired to a serious extent. The face becomes pale and the lips discolored. From time to time diarrhoea supervenes and oedema of the chest-walls is noticed, and general anasarca comes on without albumen in the urine. If nature does not open an orifice through the parietes of the chest or through the bronchi for the discharge, the patients finally succumb in the last degree of wasting with profuse sweats and fetid colliquative diarrhoea.

PHYSICAL SIGNS.—These, with some modifications, are very similar to those of ordinary sero-fibrinous pleurisy. We have the same dilatation of the chest, but it is more frequently localized. The oedema of the thoracic walls is almost characteristic of the presence of pus in the pleural cavity. We may, however, meet with it in fibro-serous pleurisy and in cachectic subjects on the side of decubitus. Then, again, there are cases of purulent pleurisy where it does not occur. It must be looked for with care, especially at the lateral portion beneath the armpit.

Mensuration and percussion afford especial evidences of purulent pleurisy, and frequently they discover encysted points.

The tubular quality of respiratory sounds is more pronounced, as are also the amphoric characters at the apex, caused by long-continued pressure of the compressed lung around the large bronchi. Ægophony is less frequently heard, the bronchophony is distant and less distinct, and vocal fremitus is more completely abolished. The non-transmission to the ear of the whispered voice through the walls of the chest (Bacelli's sound) in purulent pleurisy is a sign of considerable significance in tracing the transformation from serous fluid into pus. We must, however, bear in mind that when the sero-fibrinous effusion contains fibrinous flocculi, it has the same effect as a purulent fluid in interfering with the passage of the voice. (See article ACUTE PLEURISY.)

DIFFERENTIAL DIAGNOSIS can be but indifferently reached by considering the points mentioned. An exploratory puncture enables us to decide with certainty as to the nature of the fluid. Without this the diagnosis is often very difficult. In acute purulent pleurisy the diagnosis is most difficult, especially at an early period, because the general symptoms and the local signs resemble closely those of ordinary pleurisy. When, however, the disease is further advanced, and we have the earthy aspect of countenance with oedema of the thoracic walls, we can be nearly positive in our opinion. Moutard-Martin¹¹⁷ speaks of this localized oedema at the level of the fluid as a certain indication of the purulent character of the fluid. But this oedema, as he admits, does not always exist. It is wanting in many cases, and it may be found in cases of sero-fibrinous effusion where the patient has been lying on the side, and in other cases of advanced cachectic disease. Formerly, there were many more errors of diagnosis, which were only discovered at autopsies, but now, thanks to aspiratory punctures, the diagnosis is much more accurate, and indicates to us the rational treatment. In both varieties of purulent pleurisy there is a tendency to discharge by making orifices through the walls of the chest or through the lung. This is nature's mode of spontaneous cure. The most common is the pleuro-bronchial fistula, and the period of the disease at which this accident may occur is very variable. Woillez¹¹⁸ cites a case where it occurred as early as the twenty-eighth day; ordinarily it occurs at a much later period, sometimes as late as the eightieth day. It comes on early in purulent pleurisy. In infants the perforations take place as early as in fifteen or twenty days, and are favorable to the cure in one-half of the cases. Saussier in 29 perforations of this kind counted 15 cures. The symptoms of this accident are easy of recognition. They vary according as the pleuritic effusion is diffused through the whole pleural cavity or is limited, encysted, or interlobular. In the first variety, where we have the physical evidences of the presence of pus, suddenly, during a paroxysm of coughing, the pus is forced up through the bronchi, and the patient in a very short time expectorates a considerable quantity, varying from a few grammes to a liter or more. The quantity thus thrown off depends upon the diameter of the fistula. It may be excessive, as in a case recently observed by the author where suffocation was produced, causing syncope, asphyxia, and death, the flow being so rapid as to fill up the bronchi to such an extent that the patient could not get rid of it. In many cases the pus is brought up more gradually, with successive coughs or with changes of position. Frequently vomiting is produced by the flow from the vomica. After the first instantaneous evacuation of pus (ordinarily continuous, sometimes intermitting) purulent expectoration takes place. The patient may pass hours without any discharge, when suddenly a severe cough brings up a quantity of pus, and again may spend days without further expectoration. Pleuro-bronchial fistulæ may have a valvular character, so that air may or may not be admitted into the pleural sac as the pus is discharged. With or without the formation of pneumothorax there is a tendency to cause putridity of pus. In cases of children, who swallow their expectoration, it often produces a very troublesome diarrhoea. The course of the disease and its prognosis are necessarily altered according to conditions met with. When the air does not penetrate, we observe that the diseased side becomes depressed and the swelling, previously noticed, disappears. The flatness on percussion diminishes or disappears entirely. On auscultation we have coarse râles, sometimes just inside the fistulous orifices, sometimes at a considerable distance. The general symptoms, as well as the physical signs, improve, and the case advances slowly toward cure. Ordinarily, the pus expectorated from the pleura, when free from contact with the air, is odorless, but it is rarely as unpleasant as in bronchial dilatations, unless it is long retained in the cavity, when putrefaction ensues. When the air enters from the bronchi, it frequently acquires a disgusting odor. If the air enters the pleura and takes the place of the pus, the chest remains enlarged. Indeed, it sometimes increases in size to such an extent as to cause suffocation unless the pus and gas are withdrawn. The valve made by the false membrane allowing the air to enter the cavity, but not to escape from it, causes the fluid to accumulate rapidly, and we have pneumothorax to a very painful degree. The diaphragm is pushed down, and, if the disease is on the right side, the liver is forced down, and descends to a level with the umbilicus.

¹¹⁷ Purulent Pleurisy, 1872.

¹¹⁸ Traité Clin. des Mal. Aigues des Organes Resp., 1872.

The collection of gas and fluid may be in such excess as to produce a concavity of the upper surface of the liver, while the organ is forced down into the abdomen. E. Moutard-Martin¹¹⁹ explains this extreme condition by the fact that the fistulous orifice being at the superior portion of the lung, the air having equalized the interior pressure with the exterior pressure, the liquid obeys the laws of gravity, and depresses the diaphragm. The fluid thus does not reach the level of the pulmonary fistula. Under these circumstances the expectoration may cease altogether unless the patient, by change of position, allows it to flow outward through the orifice.

¹¹⁹ Loc. cit.

The physical signs of this condition of pyo-pneumothorax are very marked and characteristic. Above the level of the fluid there is ordinarily a great exaggeration of resonance on percussion, especially at first. At the end of a few days, however, this resonance is sometimes materially modified, and we have obscurity of the percussion vibrations. Percussion, by itself, may lead us into error of diagnosis which the other modes of physical exploration will correct.

On auscultation we hear the amphoric murmur, which is sometimes of great intensity, and at others so feeble and distant as to require great attention on the part of the auscultator. These varieties of the amphoric respiratory sound appear to depend more upon the position of the pleuro-bronchial fistula, and upon the greater or less free circulation of air through the fistula, than upon the extent of the cavity (E. Moutard-Martin). This sound and the amphoric voice are the two principal auscultatory phenomena. There is also the vibrating metallic tinkling produced always in expiration. Although the physical cause may exist, this latter is by no means a constant sign. It may disappear for hours, and even days together, and then be heard for a short time. Sometimes it is only heard when the patient coughs suddenly and violently. When heard it is a very valuable indication of the presence of a pleuro-bronchial fistula. Auscultatory percussion gives us a still more valuable diagnostic phenomenon—the metallic amphoric reverberation—especially if we percuss with a metallic percussor over a metallic pleximeter. The Hippocratian splashing caused by succussion is a more characteristic sign of pyo-pneumothorax than any other we have mentioned. Other signs may fail, and often this is the only sign present. Almost all the symptoms and signs that have been considered characteristic of the presence of pus may coexist with a perfectly limpid sero-fibrinous effusion. We may even have in serous effusions a high, fluctuating temperature, profuse sweats, and quick pulse lasting several weeks. On the other hand, purulent effusions may be associated with symptoms of so mild a character as to lull suspicion. Previous to the application of exploratory punctures for purposes of accurate diagnosis, purulent pleurisies were confounded with the milder disease until so far advanced as to be too late for effective treatment. Now we can without risk discover purulent pleurisies at their very commencement, and before they reach the point of great danger to the subject we can relieve them by thoracentesis, and afterward pursue the treatment for a radical cure.

Limited, circumscribed pleurisies, such as are found at the base of the surface of the diaphragm and in the interlobular fissures, as well as those involving the pleural cavity itself, may empty their contents through the bronchi. As we have shown, the diagnosis of these forms is often very obscure and difficult. The fine capillary exploring-needle is a safe, and often a reliable, means of diagnosis. It may happen that we can only guess at the nature of the disease until, after a protracted cough, there is ejected by the mouth a quantity of pus, and the diagnosis is made clear. We may perhaps discover a point of flatness at the base or about the centre of the lung, but often this flatness is very incomplete, because the collection of pus does not always reach the thoracic wall. It may, indeed, be separated from it by healthy lung-texture. Auscultation may discover coarse râles or even gurgling with cavernous respiration. The voice sometimes has the character of pectoriloquy, at other times of bronchophony: the cavity is rarely large enough or the walls sufficiently firm to give the amphoric tone. Under these circumstances there is neither metallic tinkling nor Hippocratian succussion. The diagnosis of bronchial fistulas caused by encysted pleurisies may be confounded with tubercular cavities or with dilated bronchi. The exact position, however, of the lesion, the rapid manner of the first purulent expectoration, and the nature of the pus expectorated, will enable us always to arrive at an accurate diagnosis. We must remember that in bronchial dilatation the disease is developed by degrees, and the patients do not expectorate suddenly a notable quantity of pus; tubercular caverns are ordinarily at the summit. The mode of expectoration is different, and the matter expectorated does not present the same purulent and homogeneous characters. The general health is very different where encysted pleurisies exist from what it is in patients suffering from tubercular cavities. In the former case it is comparatively good; there are no profuse night-sweats, diarrhoea, etc. Perforation through the thoracic walls may take place at a period more or less remote from the commencement of the disease. The first indication of this result is, ordinarily, a pain over a limited point of one or two of the intercostal spaces, followed, in a few days or a week, by a raised sensitive point on the surface, without change of color of the covering skin. This may remain a long time in an unchanged condition, but generally it increases gradually until it becomes soft and fluctuating, reducible by pressure, but increased in size by efforts to cough or by forcible expectorations. The skin over the raised point becomes thin with a purplish tinge; suddenly, from some effort to cough or unusual exertion requiring suspension of breath, it bursts and gives exit to a quantity of pus far out of proportion to the size of the small tumor. Sometimes there are several such points in the same subject, appearing simultaneously or consecutively, especially if the discharge is not free through the first one. Ordinarily, there is but one which appears on the anterior portion of the chest about the fifth intercostal space or in the intra-mamillary line. These orifices sometimes close and then reopen. Of 18 cases of empyema necessitatis collected by John Marshall,¹²⁰ 1 occurred in the sixth intercostal space and 17 in the fifth, and 6 of his own cases in the fifth, beneath the nipple. This is, as he states, the weak point of the chest, relatively unprotected by the adjacent muscles. The internal intercostal muscle, the weakest portion of the great pectoral, and the thin fascia, are the only coverings at that point. There is valid reason why special bulging and spontaneous perforation should occur there. The spot also corresponds nearly with the middle of the pleural cavity when distended. The fifth intercostal space is wider than those below, and its limiting ribs, held to the sternum, give firmness to its borders—conditions which help the thinness of the walls in determining the place of perforation. In children perforation often takes place in the very wide second intercostal space. The perforation, although it may contract in size, persists and remains a fistulous canal, permitting air to enter and to escape. The fluid rarely becomes fetid unless there is a pleuro-bronchitic fistula or air is otherwise freely admitted. Sometimes when the orifice is oblique, the air does not enter at all. When the purulent effusion escapes through the thoracic walls, the patient experiences at once manifest relief. The respiration becomes better, the fever decreases, the sweats disappear, the appetite improves, and the general condition is decidedly ameliorated. This improvement persists as long as there is free discharge, but if from any cause it ceases, we have a return of serious symptoms. If no air enters, percussion and auscultation show the gradual disappearance of the evidences of disease; but if air enters we have the signs of pyo-pneumothorax, amphoric breathing, metallic and succussion sounds. The diagnosis of parietal openings is comparatively easy: the quantity of pus, its odor, with the physical signs, show its nature. With care this form of pleural opening is distinguishable from a fistula made by caries of the ribs or by vertebral abscesses, and not communicating with the pleura. The existence of a thoracic fistula does not prevent the formation of pleuro-pulmonary fistula, and reciprocally a parietal fistula can be found where the other has been previously formed. The abscesses following purulent pleurisies and empyema have been long recognized. Hippocrates mentioned them as contributing to a favorable prognosis in empyema.

¹²⁰ London Lancet, March, 1882.

Pulsating empyema is where the lesion is situated in the neighborhood of the heart or of the aorta, which transmit their impulse. They are also sometimes called pulsating tumors, rising and falling with alternate movements of inspiration and expiration (Stokes, Graves, and Aran). These cases strongly simulate aneurisms. According to Fraentzel, the fluid is always purulent. In 1 case reported by him, and in 2 cases seen by Traube, pericarditis with effusion was present. Douglass Powell mentions two well-marked cases of pulsation in the left supra-mammary region where the diagnosis between effusion and aneurism was very difficult, but where paracentesis removed a large quantity of fluid and the signs of pulsation ceased. In these cases there was present neither pus nor pericarditis.

TERMINATIONS.—If allowed to take its natural course, pulsating empyema almost always ends in death from exhaustion or syncope, or by discharging through the lungs or through the intercostal spaces. Formerly, it was oftener fatal than now, but it is still justly considered the gravest form of pleurisy. We have seen that exceptionally it is cured by becoming encysted. It may be cured by spontaneous openings into the lungs, and more rarely by fistulous orifices¹²¹ through the walls of the chest. Is it possible for the disease to be cured by the absorption of the pus? The bearing of this inquiry upon the treatment cannot be over-estimated. If absorption can remove the pus, we may safely leave it in the pleural cavity. If the pus cannot be taken up by the absorbent vessels, we ought promptly to make use of radical measures and evacuate it. The literature on this point gives us few reliable cases. Spontaneous cure can rarely be produced by absorption. Douglass Powell¹²² writes that "the spontaneous disappearance of such effusions is too uncommon to be expected, and the process of reabsorption is one too full of peril to be anticipated with anything but dread. It is indeed an attempt at such absorption that occasions the most characteristic hectic symptoms." Surgical intervention is the rule. The writers previous to the introduction of exploratory punctures speak of cases where purulent pleurisies were diagnosed and the effusions were absorbed. We have shown that the differential diagnosis between serous and purulent effusions is very uncertain when made from the general symptoms and physical signs. Even Trousseau, with all his skill and vast experience, made the mistake of diagnosis, and performed the operation of pleurotomy in a case of serous effusion, and his patient died. There are well-authenticated cases where, after thoracentesis, small quantities of pus left behind have been absorbed, especially in children. That purulent pleurisies have been effectively cured by the pus becoming encapsuled has been demonstrated by autopsies of persons dying from other causes. E. Moutard-Martin reports a case where, after withdrawing with an exploratory trocar a few drops of pus, and thereby establishing the diagnosis of purulent pleurisy, he was unavoidably prevented from opening the chest. Two months afterward he found the effusion had entirely disappeared. He states that this was the only case he had ever seen of a spontaneous cure without evacuation. Douglass Powell has seen one case which has satisfied him as to the possibility of a local empyema becoming absorbed. Wilson Fox reports another similar case. Chronic pleurisies in childhood are almost invariably suppurative, yet Barthez and Rilliet report 7 out of 13 recovered. It must be, and generally is, admitted that cure by pus undergoing retrogressive fatty degeneration, and then being absorbed, is possible, but it rarely occurs. Should the more fluid portion be absorbed, the inspissated pus remaining on the pleural surface may at some future time, upon softening, give rise to secondary tubercular or purulent collections. It is also true that cure is quite often effected by spontaneous evacuation through the lungs and through the walls of the chest. This is especially the case in interlobular effusions and in cases sacculated by adhesions. Such cure is explained by the fact that adhesive inflammation, assisted by the elasticity of the lung on both sides, glues together the walls, isolates the fluid, and prevents air from entering, thus preventing the pus from putrefying.

¹²¹ In Andral's 8 cases of bronchial perforation there were only 3 deaths—a mortality less than by artificial opening previous to the application of Listerism.

¹²² Dis. of the Lungs and Pleura, London, 1878.

In cases of pulmonary perforations the probabilities of a favorable termination by absorption of gas, evacuation of fluid and the contents of the chest, are greater where air does not enter the cavity. The presence of air, especially if stagnant, in contact with the pus, makes a serious complication, causing putrefaction of the pus and consequent septicæmia, with all its dangers. The discharge of the purulent collection, through the parietes of the chest, after the manner of an ordinary abscess, is ordinarily made through the anterior part of the thorax, but it may take place in any part. At first this mode of evacuation, empyema necessitatis, is a great relief, but cures rarely result from it. Most frequently, owing to the imperfect evacuation through the tortuous canal and the entrance of air mingling with the pus, death supervenes unless the surgeon enlarges the orifice or produces a new one, and thoroughly empties the sac and persistently washes it out. From statistics collected by Wilson Fox, the mortality is not so great from spontaneous parietal openings as was formerly supposed. Of Andral's cases there were 2 deaths in 25. Goodhart had 11 cases, all of which recovered. Ewald lost 3 of his 6 cases. Cases of empyema necessitatis should be treated as artificial openings with every possible antiseptic precaution. The mortality would thus be decreased. The chances of cure by absorption are so small that when nature shows no tendency to either of the two spontaneous modes of cure, there is great danger of a fatal termination through hectic fever. The time for this result varies from a few weeks to months. When in empyema we have fistulous orifices they sometimes remain open for years. Near them are local points of depression, caused by external atmospheric pressure. When acute purulent pleurisy follows a low fever, such as typhoid or scarlet, a fatal termination may result in a short time; in other cases it is many months before the patient dies from exhaustion.

We cannot forbear to urge the importance of promptly and definitely settling the diagnosis by exploratory aspiratory punctures. Properly guarded, no evil can result, whereas a positive diagnosis enables us to act promptly with effective mechanical means of relief. It is undeniable that purulent effusions in the pleural cavity are very serious in their results, and are followed by death unless Nature or the surgeon evacuate them. Even when Nature does so, it is often imperfectly done, and the termination may be death unless we assist her to get entirely rid of the fluid.

PROGNOSIS.—Formerly the prognosis in every case was of extreme gravity. The condition was looked upon as of necessity fatal. Surgeons despaired of a successful result in operating. Now, thanks to thorough drainage and Listerism, unless the case is an old chronic empyema, we are hopeful of cure and a favorable prognosis may be given. We may look for good results where the disease is early recognized and promptly treated. J. G. Blake¹²³ cured 16 in a total of 19 cases. Since 1869 he cured 9 out of 10 cases. Homer¹²⁴ saved 26 out of 52. Feidler¹²⁵ treated 112 patients, only 25 of whom died (all advanced tubercular cases); 21 were restored to good health; 66 (tubercular) were cured so far as return of effusion was concerned. Israel¹²⁶ had 10 recoveries out of 11 cases. A. T. Cabot¹²⁷ reports 11 recoveries out of 14 cases. Of the fatal cases, 2 died of phthisis; the third had existed four years.

¹²³ Med. and Surg. Rep. Boston City Hospital, 2d Series.

¹²⁴ Quoted from Med. Times, Philada., Aug., 1883.

¹²⁵ Ibid.

¹²⁶ Quoted from Dabney, Amer. Journ. Med. Sciences, Jan., 1883.

¹²⁷ Bos. Med.-Surg. Journ., Aug. 16, 1883.

When purulent pleurisy follows fibro-serous effusions, and when it occurs in vigorous children, the prognosis is more hopeful than when it is preceded by scarlet fever or occurs in subjects debilitated by diseases which have exhausted the recuperative forces of the body. Empyema of tubercular origin has necessarily a grave prognosis. In persons in advanced life the prognosis is very unfavorable. If hectic fever or septicæmia occur, the prospects of cure are comparatively slight. In cases of empyema necessitatis much depends upon the power of resistance of the patient, and upon whether the matter is discharged before it has produced caries of the ribs, sternum, or spine, or has prostrated the vital powers. If these sequelæ have been produced, the condition of the body is most unfavorable to the restoration of health. If the pus in pyothorax has been discharged through the bronchi, though it may give temporary relief, it is attended with great danger, and if the discharge continues it will gradually wear out the patient's strength.

TREATMENT.—The diagnosis being established, we at once realize the great responsibility of treating a disease of such gravity. In many other diseases of serious import we trust Nature to do her part toward cure; here, as we have shown, we find her unable to come to our assistance. One of the large serous cavities, connected as it is with the lungs, is not only disabled, but contains a deleterious fluid which cannot remain in a closed cavity without sooner or later affecting the processes of nutrition. We can do little by medical treatment save to sustain the organism by tonics and reparatory agents; we can give wine, quinine, arseniate of soda, and cod-liver oil; we can administer a sustaining diet and place the patient in the best hygienic and sanitary condition. We cannot conscientiously hold out to the patient a prospect of cure by medicines.

There is danger in resorting to the expectant plan of treatment. We lose valuable time, and finally we shall be forced to resort to surgical operations, which in fact constitute the modern treatment of purulent pleurisy. By them only are we able to promote the primary objects of our treatment, which are to get rid of the purulent matter and to stop the suppurative inflammation. We thus endeavor to obliterate the pleural cavity and promote the expansion of the lungs.

Surgical Treatment.—This has been the treatment which has been most effectively used from the time of Hippocrates to modern times. There has been, and still is, great diversity of opinion as to the best modes of withdrawing the pus contained in the pleural cavity, but it is settled that when the diagnosis is certain the fluid must be removed—if not by spontaneous openings, by artificial means. We must except to this rule cases of suppurative pleurisy of phthisical origin. Bowditch years ago stated that in this class of cases it was advisable not to make permanent openings into the chest. In these the suppuration does not stop, and the operation appears to hasten the fatal issue of the disease. Wilson Fox demonstrates from statistics that the mortality in phthisical cases is increased by operations.

There is no room for discussion as to the indications, as in cases of simple sero-fibrinous pleurisy. There is only one thing necessary to be ascertained—the certainty of pus in the cavity. This is shown by the pointing or by pus abstracted by exploratory puncture. The more promptly we act, the greater the prospect of cure. As Powell¹²⁸ emphatically says, "The prognosis is practically hopeless without surgical help. We must adopt some surgical measures or take upon ourselves responsibility for a large mortality." Bowditch, Trousseau, Hamilton Roe, Anstie, Parker, Marshall, and Moutard-Martin all concur as to the necessity of surgical interference. Clifford Allbutt¹²⁹ says: "If pus or septic material be present in the body, we must not rest until it is removed. I therefore dislike and reprobate all tampering with an empyema."

¹²⁸ Loc. cit.

¹²⁹ Brit. Med. Journ., Dec., 1877.

We propose to mention, as briefly as we can in justice to the subject, the several modes of operating, together with our conclusions and the results obtained by us and by others of much larger experience.

Modes of Operating.—These are numerous, but they may be divided into three classes: First, the simple immediate evacuation of the fluid by subcutaneous thoracentesis with the ordinary trocar or with an aspirator of some kind, without allowing the flow to be continuous: this is the closed method; secondly, the open method—the operation by incision with a bistoury, and the introduction of permanent canulæ or of drainage-tubes of metal, of hard rubber, or of soft tubing; thirdly, the more radical treatment by free incision (pleurotomy) with or without washings or injections by the aid of syphons. With all these modes of operating the strictest antiseptic precautions should be taken.

Thoracentesis.—For this operation we have a choice between the ordinary hydrocele trocar, the trocar protected by a soft valve at the orifice (Reybard's instrument), Jules Guérin's or Wyman's aspirating pumps, Dieulafoy's previous-vacuum aspirator with capillary needles, and numerous modifications by others of Dieulafoy's, including Potain's, and Reynard's modification of Potain's, or we can have recourse to Potain's, Southey's, or Williams's syphon. If we select the trocar (Reybard's), we prepare the instrument by cleansing it thoroughly and Listerizing it. Reynard¹³⁰ recommends a hypodermic of morphia previous to operation, to prevent the painful cough. The simplest method is to pass the aspirator needle through the flame of a spirit-lamp, and subsequently to plunge it in carbolic-acid solution. We spray with a carbolized solution the point of puncture, which should be at the sixth intercostal space, when possible, in the axillary line. Powell prefers a lower opening, in the seventh or eighth intercostal space and in the posterior axillary line. He wishes to completely empty the pleural cavity of pus and promote the obliteration of the abscess-sac by the descent of the lung as it re-expands, and by the return of the heart to its normal position: these processes converge toward the lower and postero-lateral position. We ordinarily prefer local anæsthesia by sprays of ether or rhigoline or by cocaine hypodermics to anæsthesia by inhalation. After drawing up the skin, so as to be able to close the orifice by the flap after the operation, we direct the trocar by the nail of the left index finger; we, with a quick movement, insert the trocar to the extent of three or four centimeters. By this quick insertion we do not run the risk of stopping the canula with the thick membranes. We allow the fluid to flow out slowly, but as completely as possible. In fibro-serous effusions we only draw off sufficient to remove intra-thoracic pressure, to avert the dangers caused by that pressure, and promote the process of absorption. In suppurative pleurisy, while we aim at relief from pressure, we wish to get rid of a fluid which is itself deleterious. Consequently, our object is to prevent absorption and to ward off the formation of fistulous outlets through the lungs or the parietes of the chest. Therefore we endeavor to completely evacuate the pus, and, as far as possible, to prevent its re-formation. While we desire to remove all the fluid if we can, we must not run any risk by doing so. If the cough annoys the patient, and the elasticity of the walls and the pressure from the displaced organs do not continue to force out the fluid, we had better stop the flow temporarily or renew the operation next day. We must desist if the cough becomes very persistent. We prefer Dieulafoy's aspirator or Potain's modification for the simple evacuation of the fluid, unless we wish to wash out the pleura; then we employ Potain's or Williams's (of Boston) syphon, because either can be applied with greater effect. It is best not to take needles of too small a diameter, for the flocculi may easily choke them. We prefer No. 2 (1 millimeter) or No. 3 (1 millimeter and a half). By using the small-sized dome-trocar we avoid the possibility of injuring the lung. Care must be taken in removing the canula to withdraw the aspiratory force by turning the stopcock; otherwise we may draw the pus into the texture of the walls and establish fistulous openings. In using the common trocar fistulæ have frequently been made, causing a serious complication.

¹³⁰ Brit. Med. Journal, Sept., 1881.

Thoracentesis thus performed has often cured empyemas, especially in children. We find instances mentioned by Lacase, Duthiers, Dieulafoy, Lebert, Hamilton Roe, and others. It has been demonstrated that the operation is sometimes effective without resorting to injections and washings of the pleural cavity. Bouchet¹³¹ reports a case in a child following typhoid fever, where he aspirated thirty-three times and cured the patient; another case, a child four years of age, after two operations; another child, seven years of age, after six aspirations. Guérin¹³² reported several cases. M. Fouson¹³³ reported 19 cases of children treated by aspiration with success. The younger the child, the greater are the chances of success. He advised complete emptying of the cavity. Lewis Smith¹³⁴ prefers the use of an aspirator in operating upon children. He does not think it necessary to remove all the pus present. Cordet Gassicourt¹³⁵ reports cases of three infants, each of whom was cured by one aspiration. C. Gerhardt of Würtzburg¹³⁶ recommends in children complete evacuation of purulent fluid, through incisions and washings, avoiding entrance of air. Adolph Bajincke of Berlin¹³⁷ states that aspiration with antiseptic treatment is often successful in children. He advises, if after two or three aspirations the fever returns and the fluid increases, that free incisions be made, with injections of salicylic acid (3 per cent.), with antiseptic dressings. He recommends the removal of only a portion of the fluid. A. Jacobi¹³⁸ mentioned having in a single year 3 cases of empyema in young children, each of which required but a single aspiration; the quantity of pus in 1 case amounted to 300 or 400 grammes. The flexibility of the young ribs causes sufficient sinking in of the thorax to promote recovery. F. Richardson¹³⁹ advises two aspirations before incisions. R. W. Parker,¹⁴⁰ London, takes Richardson's view. He strongly advocates antiseptic precautions and injections of quinine (5 grs. to ounce j) and injection of filtered and carbolized air into the pleural cavity. Austin Flint¹⁴¹ advises that aspiration should be used first, but if not successful, then incisions should be made at the base of the thorax and a tent introduced to keep the orifice open. Anstie¹⁴² gives similar directions. According to Bowditch,¹⁴³ "whenever the pus is pure there is no immediate call for thoracotomy, for patients at times get well after simple aspirations. Youth and recent uncomplicated disease favor this. Heretofore, after three aspirations the author has resorted to thoracotomy." Dabney¹⁴⁴ says that aspiration occasionally gives good results, even in adults. S. C. Chew reported the case of an adult (twenty-five years of age) cured of empyema by one aspiration of sixteen ounces, and also a case of a child three years of age after three aspirations. Barnes¹⁴⁵ reports a case of a patient nineteen years of age who recovered after four aspirations of large quantities of pus. J. G. Blake¹⁴⁶ reports a case (boy ten years of age) where one aspiration of ten ounces accomplished a cure. He adds that in children repeated withdrawals of pus by aspiration are justifiable, but in adults after one unsuccessful operation he advises permanent opening. Dupuytren¹⁴⁷ cured a case after seventy-three aspirations. The author has had 3 cases perfectly cured by aspiration: a child eleven months old, after three operations; a child of five years, after five operations; a boy sixteen years of age, after two operations.

¹³¹ London Lancet, 1860.

¹³² De la Thoracentèse par asp. dans la Pleu. Pur., 1871.

¹³³ Thèse de Paris, 1877.

¹³⁴ Diseases of Children.

¹³⁵ Soc. de Thér., 26 April, 1882.

¹³⁶ Trans. Int. Med. Con., vol. iv.

¹³⁷ Ibid.

¹³⁸ Ibid.

¹³⁹ Ibid.

¹⁴⁰ Ibid.

¹⁴¹ Clinical Medicine.

¹⁴² Reynolds's Sys., vol. ii.

¹⁴³ Unpublished MSS.

¹⁴⁴ Amer. Journ. Med. Sci., Oct., 1882.

¹⁴⁵ Brit. Med. Journal, Dec., 1877.

¹⁴⁶ Med. and Surgical Reports Boston City Hospital, 2d Ser., 1877.

¹⁴⁷ Altimont, loc. cit.

Such being the record, we are in duty bound to try simple aspirations before making use of the more radical modes of treatment. The character of the fluid as drawn off by the exploring-needle furnishes valuable indications. Should it be found laudable and inodorous, we had better aspirate once or twice before resorting to the free incision. It can do no injury, and we thus enable the lung to expand, diminish the size of the cavity, and prepare for the more radical operation. In children we ought to try this mode repeatedly unless we have symptoms of emaciation and hectic approaching; in adults only two or three times. The operation is simple, painless, without danger, and occasionally perfectly effective. If the fluid re-forms quickly—and it sometimes does with astonishing rapidity—or there are evidences of depression from fever, sweats, and diarrhoea, we must promptly have recourse to one of the effective surgical methods producing free drainage. It is undeniable that the treatment by thoracentesis is frequently unsuccessful, notwithstanding repeated operations.

In sero-fibrinous effusions the close method is the most successful, but in purulent effusion this is not ordinarily the case, and we are forced to employ the open method to produce free, continuous discharges, as the purulent fluid re-forms rapidly.

Open Methods.—Of these we have—(1) drainage through a single orifice by the introduction of a permanent canula or soft india-rubber tube; (2) drainage through two openings; (3) use of syphon; (4) pleurotomy; (5) drainage by resection of ribs. Each of these modes has its advocates. They have all been frequently used with varying results. Each has its advantages and disadvantages.

The first point to be noted about these modes of operation is, that we cannot prevent the introduction of a greater or less amount of air to replace the fluid, and therefore it is of primary importance that we should always render the air aseptic. The incision must be made after thoroughly cleansing the point to be opened. The bistoury, the canula, the dressings, the receptacles of the pus, the sponges, and everything connected with the operation, should be purified to prevent the possibility of the contamination of the pleural cavity and its contents. At each subsequent dressing all these precautions should be renewed. Antiseptic gauze of six or eight layers in thickness, with finely-combed oakum or salicylated cotton, ought to be placed over and around the orifice for an area of twelve inches. In this way what little air enters after the operation may be rendered thoroughly aseptic.

Lister¹⁴⁸ recommends that the coverings of gauze should be in eight folds if the drainage be excessive—that these be charged with a disinfectant composed of one part of carbolic acid to four parts of resin and pure paraffin. The dressings, he directs, should be kept in place by elastic bandages. This treatment stops suppuration promptly, and converts the discharge into one of a serous nature. His views have been amply confirmed. A. T. Cabot¹⁴⁹ recommends that the dressings be covered with a piece of mackintosh large enough to project in every direction. In his cases he found it acted as a valvular fold, forcing the air and pus out and preventing air from entering.

¹⁴⁸ "Lectures on Clin. Surgery, etc.," London Lancet, Dec., 1879.

¹⁴⁹ Loc. cit.

Drainage by Canula through a Single Orifice.—The patient, having had about three hours previously a good substantial meal of easily-digested food, is placed in a semi-recumbent position, leaning over toward the healthy side. Before selecting the point of puncture, the side ought to be first washed with soap and water, so as thoroughly to remove all dirt and epithelium débris, and then bathed in a 1:20 solution of carbolic acid. As there is to be but one opening through which the fluid is to pass, it is desirable to have it low down. The eighth intercostal space, somewhat behind the posterior axillary line, is ordinarily the best point for the puncture. Lower than that we may encounter the diaphragm, and, as we must use a trocar of considerable size, we may inflict serious injury. As we desire to completely empty the pleural cavity, a higher point would not be as effective. After having satisfied ourselves of the presence of fluid at the point selected by the physical exploration, we ought always to insert, as a crucial test, a new exploratory hypodermic needle which has been rendered aseptic. Ordinarily, it is not necessary or expedient to resort to etherization, unless in case of a child, for local anæsthesia by cocaine hypodermically, by rhigoline or the ether spray, or by the application of a small piece of ice covered with salt (as suggested by Powell), will render the incision painless. It is needless to add that a weakened heart, a sluggish capillary circulation causing a cyanotic appearance, and marked dyspnoea contraindicate the employment of etherization. We prefer cutting through the integument with a bistoury, and then inserting the trocar, which must be pushed with a thrust through to the pleura. All of the pus should be allowed to escape, unless cough, oppression, or threatening syncope should be noticed, in which case it is better to insert the tube and arrest the flow by a cork. The outward flow should be rendered slow by covering the orifice with the dressings and allowing the fluid to soak into them. The tube should only be long enough to go well through the parietes into the pleural sac; otherwise it acts as an irritant, and interferes with the adhesion of the two pleural surfaces, which is necessary for the obliteration of the pus-secreting cavity and the expansion of the lung. The tube should be kept in position by a hard-rubber shield attachment, with bandages previously soaked in disinfectants applied around the body, and several layers of carbolized gauze. The firm canulæ, metallic or hard rubber, straight or curved, as proposed by Woillez and Dieulafoy, are now generally abandoned. These admit air either by the sides of the opening or through their canals, and they sometimes produce, at their extremities, local ulceration through the lung or even through the diaphragm, and cause peritonitis. Their only advantage consists in the facilities they offer for washing out the cavity. With canulæ made of soft india-rubber there is no danger of injuring the lung, etc. They are not painful to the patient, and they can be protected by valvular strips of gold-beater's skin or some soft substance at their orifices. Through these india-rubber tubes we can inject all fluids and washes, except those containing iodine. It has been proved by Dujardin-Beaumetz¹⁵⁰ that iodine hardens india-rubber, renders it extremely brittle, and destroys its elasticity in a short time, even after a contact of forty-eight hours. In a case of Bucquoy's¹⁵¹ the tube underwent such alterations that it could only be extracted by a long and painful operation. If these tubes are in use when iodized fluid is to be injected, they must be temporarily removed, and a metallic one, with arrangements for a double current, substituted during the process of washing. If the canulæ are to be kept in permanently, they must be of large size, so as to allow free flow outward of fluid.

¹⁵⁰ Quoted by Dieulafoy, Pneum. Asp., English ed.

¹⁵¹ Ibid.

After the operation the patient should always remain in bed in an easy, comfortable position, with the orifice covered by the dressings. His diet should be of an easily-digested and nutritious character. His temperature, pulse, and the condition of his secretions should be carefully watched. Ordinarily, it is not well to reopen the discharge-tube for three days. The same antiseptic precautions should be used then as at the operation, and a fresh tube inserted. The pus secreted ought, if the case be one of recent origin, to be small in quantity and without odor. After a few days it is best to allow the fluid to flow out on the dressings as it forms, which is done by turning the patient well over on his side. An occasional cough assists the discharge. Should the odor become putrid or gangrenous, or hectic symptoms show that the secretion is profuse and has no free exit, it becomes necessary at once to use washings and injections of simple warm water or warm water feebly alcoholized—1:45 or 1:80—or feebly iodized solutions. The greatest care should be taken with these washings that very gentle force be employed. (See Pleurotomy.) This mode of operating is most effective in recent cases, for it gives the best opportunity to the lung to expand. It is the easiest to perform, and, subsequently, the least troublesome. If it be found ineffective, an additional orifice can be made and a fenestrated tube inserted, or the orifice can be enlarged by a free incision. There have been many successful cases of this mode of operating, but, as the author has sometimes found, it is difficult to establish free drainage, which is most important for the success of the treatment. The result of his experience has been that, in chronic cases especially, the two-opening drainage or free incision without tubes (pleurotomy) has finally to be employed. Powell recommends, after removing intra-thoracic pressure by aspiration or syphon, in a day or two to completely evacuate the fluid under the antiseptic spray and insert a tube for a few days only; then to allow the wound to heal, and await results, trusting nature to secrete a fibro-serous fluid which can be easily absorbed.

Drainage by two openings, as first effectively employed by Chassaignac, is made by the introduction, through a large covered canula, of a tube of india-rubber, perforated with holes, drawn out at another orifice. The tube has its two extremities on the outside, and one posterior, in the eighth or ninth intercostal space, and the other in front, in the seventh intercostal space, after the withdrawal of the canula. The anterior orifice is first made, and a long curved probe with a bulb at the end is passed through backward and downward until it strikes the posterior lowest intercostal space. The operator cuts down on the probe, which points outward. To this end the fenestrated drainage-tube is securely fastened, and is then drawn out through the first orifice. Both ends are retained out of their orifices, by a shield firmly fixed on the tube, for at least an inch. The pus flows out little by little, but continuously, through one or other orifice, according to the position of the patient. This is the most effective method to prevent accumulation. Unfortunately, false membranes and flocculi sometimes stop up the orifices in its walls, the pus does not flow out as it is formed, and there are all the evils of air and fluid mixed and retained in the serous cavity. It is, however, generally admitted that by this system of drainage a number of cases have been cured; but it is not often employed as a primary operation, as we wish to avoid, if possible, the irritation which may result from the presence of so much tubing in the chest. Moreover, it is not the best operation if there is any hope of the lung expanding again. In old chronic cases we cannot hope for more than very limited expansion.

Gross¹⁵² speaks of drainage-tubes as harsh and dangerous. Flint, Sr.,¹⁵³ prefers free incisions, with introduction of tents, to drainage-tubes. Dabney¹⁵⁴ considers continuous drainage in some form vastly preferable in the majority of cases. Israel¹⁵⁵ had 10 cases recover out of 11 treated by thorough and continuous drainage. Cheadle believes that a large collection will certainly require a free opening in the end, and the sooner the pus is let out the better.

¹⁵² System of Surgery, vol. ii.

¹⁵³ Clin. Med.

¹⁵⁴ Amer. Journ. Med. Sci., Oct., 1882.

¹⁵⁵ Quoted by Dabney.

Chassaignac's method of drainage will answer well unless, as frequently happens, the purulent pleurisies contain large fibrinous masses, hydatid pouches, or pieces of sphacelous débris.

Syphons, as used in purulent pleurisies, have some very decided advantages. Potain's ingenious instrument, based upon the syphon principle, enables us alternately to empty the pleural cavity into a basin of water, and, by reversing the instrument, to inject the water into the pleural cavity, thus washing out as often as necessary and with ease the purulent collection and cleansing the cavity. Potain's syphon is composed of an india-rubber tube 30 centimeters in length, to be introduced and remain in the pleural cavity. This tube is introduced through the canula, after the withdrawal of the trocar, to the depth of at least 20 centimeters, in order that its extremity should reach the posterior wall, the tube having been previously filled with water. The outer extremity is put into a basin containing water. The part of the tube at the outside of the orifice is closed by a serre-fine just beyond the shield, as is also the extremity in the water. Another tube is connected with the chest portion. This can be used for introducing water to wash out the pleura. The syphon of Potain has very decided advantages over the metallic and hard-rubber drainage-tubes. It prevents the introduction of air and enables us completely to empty the cavity; it permits us to wash out the cavity as frequently as is necessary without fatigue to the patient, without pain, and without change of position, and thus prevents attacks of coughing. All this is done slowly, and the flow can be arrested at any moment by means of the stopcocks. Where repeated washings are required the patient himself can perform them with ease. With the other modes the washings are practised with difficulty. The improved syphon by F. H. Williams of Boston is simple in construction, of small size, and inexpensive. Revilloid of Geneva (1882) reports 10 cases thus treated, of which 6 were cured. Bénard¹⁵⁶ reports 8 cases treated by syphon, of which 4 were cured. Goodhart's¹⁵⁷ statistics are not favorable to the use of the syphon. Of his 28 cases thus treated, 10 died; in only 6 did the syphon method alone effect the cure. Powell¹⁵⁸ objects to the syphon method, because by it the chest cannot be drained unless the lung expands completely or air is freely allowed to enter the pleura. These conditions are impossible in such cases with a single opening and a single tube. Moutard-Martin, while speaking of the advantages of Potain's syphon, admits that in chronic cases where there are pieces of false membrane and flocculi floating in the fluid the tube may be clogged up, just as occurs in the metallic tubes and the drainage-tubes. The patient may thus die by retention of pus and by putrid absorption, unless pleurotomy is employed. It must be borne in mind that the syphon is a weak aspirating instrument. It ought to be 10 meters long to possess an aspirating force equal to that of a pneumatic pump (water being taken as the standard), and its long arm should measure from 7 to 8 meters, in order that its aspiratory force should equal that of a good pneumatic aspirator. Thus we see how weak is the aspirating power of a syphon which only measures the space which separates the bed of the patient from the floor. The ordinary aspirator can be easily changed into a syphon. The descending arm of the tube must be emptied by a stroke of the piston; the current is then established and the stream becomes continuous (Dieulafoy¹⁵⁹).

¹⁵⁶ Thèse de Paris, 1871.

¹⁵⁷ Guy's Hospital Reports, 1877.

¹⁵⁸ Loc. cit.

¹⁵⁹ Trea. Pneum. Aspiration, Eng. trans., 1873.

While all prominent modern authorities admit the value in some cases of double metallic tubes, of those of hard rubber, of drainage-tubes, and of syphons, with thorough and complete antiseptic treatment, yet observation has taught us that there are many disadvantages and uncertainties. The drainage-tube may give rise to considerable irritation and prevent the closing of the sac—a very important aid to the cure. If the flow is retarded, the fluid may decompose. Therefore it is well to remove the tube frequently, to wash, cleanse, and renew it. The admission of air and stopping up of tubes, the feeble force employed, the putrid pseudo-membranes, and sometimes sphacelous débris, cause, in many instances, fatal results. It frequently happens that at first, when trying the simple aspirations, we find a whitish laudable pus which subsequently becomes thick and fetid. We use drainage-tubes and Williams's syphon, with strict adhesions to Listerism, and yet there may ensue continuous fever, emaciation, sweats, drawn face, and general oedema. We resort to detergent washes, with salicylate of sodium, of tincture of iodine, very diluted, yet the patients get worse and the tubes become obstructed. There is not sufficient free flow of the contents of the chest.

Pleurotomy.—We naturally shrink from freely opening the chest. It is right to try the simpler methods—aspiration, tubes to remain in the chest, drainage, use of syphons—but we are forced in many cases of chronic empyema to use pleurotomy, the thoracotomy of Bowditch, the operation of l'empyème of the ancients. It consists of a wide opening into the thorax between two ribs, permitting the escape of the effused liquids. If the orifice is large enough, we can remove from the cavity of the pleura not only the pus, but the large fibrous masses, gangrenous débris, hydatids, and putrefying material which produce septicæmia and death. The literature of this subject shows that bad results have ensued from this operation, and again and again it has been abandoned, but now that we can, by means of large openings, freely wash out the cavities, and can apply injections of antiseptic and alterative medicines to the suppurating surfaces, many lives are saved. Hippocrates' dogma as to the danger of free and rapid evacuation of pus had often a dangerous influence in preventing a thorough emptying of the sac. The object of this radical operation must be kept in view—to evacuate the pus by a free current, to permit the discharge of plastic products and organic débris, and to allow easy and frequent washings with healing and purifying injections. By these means we arrest suppuration, obliterate the sac, and allow the lung to expand. For this purpose wide orifices should be boldly made. They should be made where the chest bulges most, but not always at the most dependent portion. Ordinarily, the eighth intercostal space, somewhat behind the posterior axillary line, has been the one selected, because it has been supposed that thereby the cavity could be most effectually drained. The author has usually punctured higher, in the seventh intercostal space on the left and in the sixth on the right side, for the fifth and sixth ribs being more fixed, there is less danger of subsequent approximation. We cannot always determine the exact position of the diaphragm. The lung may be bound down by old adhesions to the diaphragm, and thus the latter may be injured by too low an incision; we can, moreover, better adapt the position of the patient to enable the matter to flow out from a higher orifice. Cases have occurred where the liver has been perforated on the right side by low punctures. In health the uppermost point of the diaphragm may be as high as the fifth space on the left side or the fourth space on the right. The cure does not depend upon the exact position of the puncture, because we expect to insert a mouth-tube to keep the orifice open, and probably resort to washings. It is not by its weight only that we expect the fluid to escape; incessant movements of the thorax assist in forcing the fluid through the tubes. Marshall¹⁶⁰ urges the fifth space on the right side, and as near the weak point of the chest under the nipple as possible. On the left the pericardium must be carefully avoided. He advises that the operation should never be lower than the sixth or seventh intercostal interval. Douglass Powell prefers a lower puncture, in the seventh or eighth space in the posterior axillary line. In the punctures lower down the tube as it ascends rubs upon the diaphragm and protracts the healing, and the orifice closes too early. The emptying of the sac and the washings can be thoroughly attended to higher in the chest. The weak point selected by nature for empyema necessitatis ought always to be examined to see if there be any thinning of the wall, for if that be the case, the puncture should be made there. The incision should be made on a plane somewhat below that of the aponeurotic and muscular portions of the chest, to prevent the liquids from infiltrating into the subcutaneous cellular tissue. If we ascertain first by exploratory puncture that there is pus lower down, it is safe to operate at that point. The exterior orifice should be wider and larger than the interior, and not parallel with it, in order to avoid the gaseous infiltration in the tissues by the respiratory movements. Care must be taken that the bistoury should pass close to the upper border of the inferior rib, to avoid the intercostal artery. In making the incision—about 6 centimeters in length—should the artery be cut, it can easily be remedied by torsion. We raise the skin, and thus make a flap over the orifice. The bistoury should not be introduced with one cut through the soft textures, as recommended by Woillez, but layer by layer should be cut through. This secures avoiding the intercostal artery, and gives a larger exterior than interior cut, thus preventing danger of liquid infiltration. We can be guided by the index finger, and feel the textures as we cut down upon them. Under a continuous spray to thoroughly purify the air that may enter, a free opening should be made large enough to allow the finger to be introduced. As air enters the fluid contents escape through the orifice, protected by antiseptic dressings of gauze, oakum, and salicylated cotton. At first it is well to remove the dressings containing the pus twice daily; later, once daily will be sufficient. The orifice must be kept patent by a short, wide tube with a fine wire around it. We can thus, by changing the position of the patient, get rid of the contents of the chest cavity. If there should be fetidity, it is desirable to use washes of warm water first, and afterward of feebly-alcoholized water—a solution of salicylate of soda, chlorinated soda, or permanganate of soda. Cabot¹⁶¹ had most success in the use of sol. chlorinated soda, one part to twelve or fifteen of water, for purposes of injection. The average time that the tubes remained in, with his cases, was only twenty-four days. His favorable results he imputed to the mechanical action of the india-rubber covering over the antiseptic dressings.

¹⁶⁰ Loc. cit.

¹⁶¹ Loc. cit.

Resection of Ribs.—The ancient operation of resection of ribs, dating back to Celsus, is strongly advocated by Pietavy, Thomas of Birmingham, Lane, and other modern writers as affording the best means of thoroughly evacuating the pleural cavity of its purulent contents and of keeping up constant drainage. John Marshall¹⁶² reports 4 cases where he resected the ribs to make permanent openings. In all of these cases the walls became gradually firm and new bone was formed. He concluded that the removal of a portion of one rib was not sufficient, but that a large space through four ribs is the proper size for the opening, that the sixth rib is the essential one to deal with, and that from one and a half to two inches of bone should be taken away. In one case he performed a subcutaneous division of costal cartilage with a view to weakening the thoracic walls and allowing them to fold in. A number of cases are reported of resection of ribs, with varying success, by Ewald,¹⁶³ Taylor, House,¹⁶⁴ and Thomas.¹⁶⁵ Taylor¹⁶⁶ advises the removal of the periosteum to prevent the rapid re-formation of bone. If after the puncture the rigidity of the ribs seems to keep up the discharge, and the lung does not expand to meet the rib, a resection of a considerable portion of two or three ribs may be made for relief. If, again, in the progress of the case the adjoining ribs have fallen in and have approximated, and thus become a source of pain in retaining a permanent drainage-tube, a portion of rib may be resected. The principal object of resection of ribs is to favor their falling in, for a sufficient orifice can thus be made between the ribs for the discharge. The upper two-thirds of the breadth of a rib may be trephined in order to give more room for exploration, evacuation, ablution, and prolonged drainage. This is the operation of Esthander,¹⁶⁷ who thus treated successfully 5 of his 6 cases operated upon. Fenger of Chicago¹⁶⁸ operated in this manner on fourth, fifth, and sixth ribs.

¹⁶² London Lancet, March, 1882.

¹⁶³ "Med. Soc. Berlin," Lon. Med. Rec., 1876.

¹⁶⁴ London Med. Record, Aug., 1876.

¹⁶⁵ Trans. Clin. Soc., vol. xiii.

¹⁶⁶ Brit. Med. Journ., Feb., 1881.

¹⁶⁷ "Resection du Côltes de Emp.," Revue Mens. de Méd. et Surg., 1879, vol. B.

¹⁶⁸ Med. News, Philada., Sept., 1882.

Jacobi¹⁶⁹ says that resections ought not to be practised upon children. W. A. Lane,¹⁷⁰ from the observation of 5 cases of empyema in children, strongly recommends that a portion of rib or ribs be removed at first, and the cavity thoroughly drained from the beginning. It assists, he argues, the cure by promoting the falling in of the ribs, the expansion of the lungs, and the ascent of the diaphragm. In children the difficulty in securing free drainage is that the spaces between the ribs are small, and after the cavity is opened they become much more contracted; soft tubes thus become compressed, and hard tubes cause much local irritation. Resection of ribs enables the operator to keep the orifice open and have perfect drainage. The opening should be large enough to allow the introduction of the finger and of an india-rubber tube of sufficient diameter to give free passage to the contents of the chest, without the tube being displaced by movement of the ribs. In only one of Lane's cases was trouble caused by rapid increase of bone. He operated as low as the ninth intercostal space in the axillary line, taking care always, by the hypodermic syringe, to ascertain that there was pus at that point. He divided the periosteum longitudinally, and removed with cutting forceps about three-quarters of an inch of rib. After he had thoroughly cleared out the cavity he introduced a short india-rubber tube, so that its inner end should not project into the cavity. Wire sutures were passed deeply through the intercostal tissues and tube, and, to render the position of the tube more secure, soft pins were fixed through the wall of the tube, and attached to them were pieces of elastic surrounding the chest.

¹⁶⁹ N.Y. Med. Record, Jan., 1881.

¹⁷⁰ Guy's Hospital Reports, vol. xli., 1882.

If necessary in order to have uninterrupted free drainage, children as well as adults should have their ribs resected. The important point in operating is to secure free exit to the fluid and purification of the cavity by the necessary washings by the open method. Pleurotomy by resection of ribs is almost universally acknowledged to be the most effective treatment, for it promotes most rapidly the agglutination of the pleural surfaces and the expansion of the lung.¹⁷¹

¹⁷¹ Lawson Tait strongly advocates this same method of treatment in peritonitis. He has performed laparotomy successfully in 20 cases, using washings and drainage-tubes (Bost. Med. and Surg. Journal, Aug. 16, 1883).

Good drainage is the essential consideration after the operation. We must prevent putrefaction or fetid decomposition in the pleural contents. So long as pus is retained within the sac, it does not putrefy, but putrefaction follows contact with the putrefactive agencies which abound in ordinary air, as shown by Pasteur and Tyndal. These are solid particles floating in the atmosphere. Although air must be admitted, it should be rendered aseptic. The drainage-tube, which should be just long enough to go thoroughly into the cavity, by itself is in many cases insufficient. The upper part of the cavity may retain on its surface pus and flocculi which may prove dangerous. By the syphon we can fill the cavity slowly with medicated tepid water without shock and without risk of tearing away the neo-membranes. Woillez¹⁷² advises that pleurotomy should be promptly used whenever pus is found. Béhier advocates the same treatment. E. Moutard-Martin,¹⁷³ whose authority is high from his great experience and conservatism, advises us always to commence the treatment with thoracentesis by aspiration. He says, if the fever persists and the general condition grows worse, he does not hesitate to resort to pleurotomy. The author's more limited experience coincides with his. I. Marshall¹⁷⁴ states as his opinion that purulent pleurisies require the immediate or early adoption of the open method. In fibro-serous pleurisy we wish to restore the physiological condition of the pleura, whereas in purulent cases the object is to obliterate the sac by adhesions throughout the surfaces, just as abscesses are cured. It is necessary that the costal and pulmonary pleura and that of the diaphragm should be brought closely in contact. This is produced simultaneously by the dilatation of the lung and the diminution in every way of the pleural cavity. The dilatation is produced by the disappearance of the intra-pleural pressure and the pressure in the opposite direction from the bronchial surfaces. This last depends upon the condition of the lung and of the visceral pleura. If the lung has been long compressed, it is almost carnified and reduced to a state of foetal atelectasis. It rarely happens that the bands which bind the lung down do not in time undergo granular fatty degeneration and disappear. This enables the lung to expand, if not to its original size, yet sufficiently to occupy the cavity, reduced in size by the approach of the walls. The heart, which previous to the operation was thrown more or less out of its normal position, comes back from the empty side, and often passes the position that it normally occupied. The lung follows the heart. The whole mediastinum finds itself altered in its position and in its contents. The depressed diaphragm rises promptly to its old position in the pleural cavity. The liver, spleen, and the rib-wall undergo striking modifications. We do not expect the lung to dilate to its full extent, as after aspirations in simple pleurisies. The lung, indeed, is already impaired in its movement. We admit air in order to secure treatment to these surfaces. When air is admitted into the normal chest, the lung is retracted to about one-half its size. In serous effusions we fear free admissions of air, because it assists in compressing the lungs, and may contain germs which promote suppuration. We must bear in mind that we may have double pleurisy from the pus producing pleural necrosis at the point of contact of the pleural sacs about the middle of the sternum opposite the middle of the third rib. Elsewhere there is no such danger, for the pleural surfaces remain a long distance from each other.

¹⁷² Bul. Soc. Méd. des Hôp., 26 April, 1872.

¹⁷³ Pleurisie purulente, 1872.

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.

¹⁸¹ Loc. cit.

¹⁸² Quoted by Dabney, loc. cit.

¹⁸³ Boston City Hospital Reports, 2d Series.

Cases of long-standing compression of the lung could hardly result in complete re-expansion, but the general health will be recovered and the chest, contracted by approximation of the pleural surfaces from the walls being pressed in or ribs resected, will cease to secrete pus. If fever persists, with diarrhoea, sweats, emaciation, and fetid suppuration, it shows that the washings are not sufficient in number. They can be repeated as often as every three or four hours, to be decreased in frequency as the patient improves. Under frequent washings Feyrot¹⁸⁴ reports favorable results in almost hopeless cases. Time is very precious when these symptoms of exhaustion or septicæmia set in, as it is of the utmost importance that we should endeavor to prevent promptly the absorption of the putrid products, the inevitable effects of which are to produce, before long, fatty and amyloid degeneration of the principal viscera. The most effective way of using detergent fluids is by syphons through two tubes perforated at their extremities and fastened with shields. A Thudicum douche-bottle or a fountain syringe can easily be used by patients themselves as often as is required. The orifice and the tubes should be protected by thorough and rigid antisepticism. As the case improves the cavity gradually gets smaller, the two pleuræ become adherent, and the quantity of fluid lessens until only a small amount flows out. Every eight or ten days we carefully draw out the tubes by degrees, until we have only a little canal beneath the walls. We can thus let the orifice heal slowly, for the sac is obliterated and the patient cured.

¹⁸⁴ Thèse de Paris, 1876.

In the hands of Boyer, Delpech, Dupuytren, and Sir Astley Cooper the bistoury gave bad results, but as now used, with all modern appliances and antiseptic precautions, it affords infinite relief and many cures. We claim that by early pleurotomy, with Listerism scrupulously used at every stage of the operation, and if necessary with detergent washings, the mortality from this extremely grave disease can be very materially lessened.

Double Pleurisy.

Pleurisy may occur on both sides at the same time. Double pleurisies are secondary, not primary, and result from rheumatism, or still more frequently, according to Louis, from tuberculosis. In 150 cases of pleurisy quoted by him, there were no bilateral cases which were not produced by rheumatism, gangrene, or tuberculosis. A double pleurisy in a previously healthy person creates a strong suspicion of tubercular origin. There is generally an interval of some days before the attack of one side is followed by that of the other. When effusion takes place the dyspnoea is very great. Death is imminent unless the fluid is withdrawn by aspiration. Maintenon¹⁸⁵ states that the inflammation may be so intense and the fever so high as to destroy life before the effusion is thrown out. The physical signs are the same as in unilateral cases. The effusion is never so great on one side as on the other. The progress of disease is rapid, and the result is almost always fatal.

¹⁸⁵ Thèse de Paris, 1873.

Diaphragmatic Pleurisy.

The serous lining of the upper surface of the diaphragm may be involved in an ordinary pleurisy, or inflammation may be limited to it without involving either the pulmonary or the parietal membrane. In this latter case we have modifications of the characteristic symptoms and physical signs. Functional disturbances and special symptoms enable us to diagnose it. There is a febrile movement with occasional delirium, and some of the prominent symptoms, but without the physical signs to indicate the exact locality. The pain is intense, and dyspnoea exists even to the extent of orthopnoea and respiratory anguish, the respiration jerky and convulsive. The pain comes on suddenly in one of the hypochondriac regions, extending up to the attachments of the diaphragm to the costal surfaces. The pain is intense, and increased by full inspirations, by physical efforts, by vomiting, and even by the eructations of wind. The position of the patient attracts attention: as he sits with the trunk inclined forward, he has an anxious and distressed expression of countenance, sometimes accompanied by nausea and vomiting with singultus. Pressure elicits a characteristic tenderness; if applied under the false ribs, it causes suffering. The phrenic nerve is painful on pressure practised over the accessible points of its course, between the two inferior bands of the sterno-cleido-mastoid at the base of the neck. There are also painful irradiations in the cervical plexus above the clavicle and in the scapular region. Pressure over a circumscribed spot of the epigastric region causes a sharp agony of pain. This point is at the intersection of two lines—one, the external border of the sternum; the other, at the osseous portion of the second rib. Guéneau de Mussey¹⁸⁶ has named this the diaphragmatic bottom. This pain extends sometimes to the vertebra and upward to the first intercostal space. Auscultation and percussion at the base of the lung give us some results: impaired expansion of the lung at the base and dulness on percussion; the diaphragm is in a great degree immobile, owing partly to the pressure upon it, and partly to a paresis from inflammation of its upper serous covering (Stokes¹⁸⁷). When the inflammation is on the right side, we may find an icteroid tint, with vomiting, delirium, etc., with the liver pushed below its normal position in the abdomen. The inflammation of the pleural covering of the diaphragm may be caused by sero-hepatitis extending through the diaphragm (Copeland¹⁸⁸).

¹⁸⁶ Archiv. de Méd., 1879, vol. ii.

¹⁸⁷ Dis. of Chest, 1837.

¹⁸⁸ Dict. Med., vol. iii., edited by Lee.

If the effusion is confined to the space between the lung and diaphragm, the diagnosis is obscure. There may indeed be cases where we have but few of the symptoms already mentioned. If the fluid is not confined to this portion, but flows into the pleural cavity, it gives great relief, and the result is favorable. Diaphragmatic pleurisy may, however, end in death, either by its discharge into the peritoneal cavity or by constitutional disturbances.

Interlobular and Mediastinal Pleurisies.

The effusion is sometimes confined by adhesions between two lobes. The mediastinal variety is situated between the pleural boundary of the mediastinum and the adjacent portion of the pulmonary serous membrane. It is but rarely met with, and may be diagnosed by local symptoms. The flatness on percussion in the interlobular variety is very circumscribed. Both forms cause local pains, but in the mediastinal variety the pain is very deep and perceptible at the middle of the sternum, and is increased by the respiratory movements. In both varieties there is more or less fever. If either variety exist on the left side, the condition of the pericardium must be carefully examined, as pericarditis may be confounded with it. These limited collections of fluid may burst into a bronchus and be expectorated.

Multilocular Areolar Pleurisies.

Multilocular encysted collections of fluid in the pleural cavity are due to the partitions made by pseudo-membranes which divide the pleura into subcavities. These occur generally in subjects who have had previously dry or adhesive pleurisies. They are more serious than ordinary pleurisies. We meet with them in aspirating, when, after draining off the fluid from the base of the pleural cavity, we find the lung expanding, but above that point there is absence of respiratory murmur and of other physical signs indicating the presence of fluid. Reybard¹⁸⁹ divides multilocular pleurisy into three varieties, with varying symptoms and physical signs, according to whether it exists at the upper, middle, or lower portion, right or left side. Owing to the thickness and distribution of neo-membranes, it is frequently difficult to localize the points of collections of fluid. Aspiration is the most accurate means of ascertaining the exact point and extension of the effusion.

¹⁸⁹ Bullétin Acad. Méd., 1879.

Rheumatic Pleurisy.

HISTORY.—The recognition of the fact that we can have local manifestations of rheumatism in the texture of the lung itself, of the bronchi, and of the pleura is of comparatively recent date. There had been indefinite, loose statements, or rather suggestions, in some of the writers in the early part of the century, such as Chomel and Andral, as to the possibility of rheumatism appearing in the pulmonary textures; but we believe that the first definite description of the disease was made by T. H. Buckler of Baltimore in 1865.¹⁹⁰ He claimed that the white fibrous tissue of the bronchi could be the seat of rheumatism, as well as similar textures about the joints. He illustrated his views by cases observed and reported by himself. He showed how, as a result, there were symptomatic engorgements, more or less solid, of the pulmonary parenchyma or rheumatic pneumonia. In 1854, Black¹⁹¹ found crystalline particles of uric acid and of urate of soda deeply imbedded in the thin white fibrous tissue of bronchi. Buckler showed the metastatic character of rheumatic inflammation in the bronchi and lungs as elsewhere. Buckler's subsequent papers¹⁹² published in connection with this subject, show remarkable success in treatment of fibro-bronchitis and rheumatic pneumonia based upon his views of their pathology.

¹⁹⁰ Fibro-Bronchitis and Rheumatic Pneumonia.

¹⁹¹ Edin. Med. Journal, 1854.

¹⁹² Boston Med. Journal, 1882, and Amer. Med. Journal, Oct., 1882.

SYMPTOMS.—We find rheumatic pleurisy coming on in the course of rheumatic fever with the characteristic mobility of the points of inflammatory action. Laseque¹⁹³ gives the symptom with accurate details—the acute pain in the side of the chest without cough or expectoration. He describes the pain as differing from that of ordinary pleurisy, in that the extent of pain is greater and not so limited, due to the fact that the rheumatism invades the aponeurotic tissue which forms the covering to the intercostal muscles. It persists longer and is wider spread. The dyspnoea is caused by the inability to move the respiratory muscles and by the disease invading the aponeurotic centre of the diaphragm.

¹⁹³ "Pleurésie rheumatismale," Arch. Gén. de Méd., 1873.

The rapidity of the inflammation causes the sudden pain and the accompanying effusion in even a few hours. In a well-defined case recently seen by the writer in a lady forty-seven years of age the rheumatism literally jumped from a large joint to the pleura, giving rise to a severe pain, without cough or expectoration, with an increase of 2° of temperature and 20 beats of pulse. There was a moderate effusion. In forty-eight hours, under the influence of an initiatory dose of quinine (20 grains), followed by free doses of salicylate of sodium, the attack subsided and the friction sound at the base of the lung disappeared. This case did not follow the rule mentioned by Senx,¹⁹⁴ that the disease, upon leaving the pleura of one side, appears in the same manner on the other. It sometimes goes to the pericardium and endocardium from the pleura. Chomel¹⁹⁵ insisted upon the frequent examination of the heart to ascertain whether this had occurred.

¹⁹⁴ De la Pleurésie rheumatismale, Paris, 1878.

¹⁹⁵ Art. Pleurésie Dict., in 30 vols., 1842.

Rheumatism of the pleura does not always appear and disappear suddenly. It sometimes is gradual in progress and slow in recovery. It usually occurs when we have manifestations elsewhere, but the pleura may be the point first attacked, as is more frequently the case in pericarditis.

DIAGNOSIS.—The diagnostic signs are hereditary or personal tendency to the disease, the character of the local pain, the mobility of the disease, violence of pain and its rapid disappearance, and the existence of profuse sweats. Suppuration rarely occurs.

PROGNOSIS is in its nature serious, not from the intensity of the disease, but from its being a visceral rheumatic affection. It is, moreover, frequently double, and may recur often in the same subject.

TREATMENT is that of rheumatism elsewhere—salicylic acid and its salts, alkalies with opiates. Thoracentesis is rarely indicated, because mechanically the effusion does not seriously impede respiration: if the pericardium be involved, it may be necessary in order to relieve the pleura or the pericardium.

Hemorrhagic Pleurisy.

DEFINITION.—Pleurisy complicated by hemorrhage. Hemorrhagic pleurisy is the union of an ordinarily slight hemorrhage in the pleura with inflammation of that membrane (Laennec).

ETIOLOGY AND PATHOLOGY.—These must be studied together, because the pathology of the disease explains its etiology. While hæmothorax designates hemorrhage into the pleural cavity without inflammation, hemorrhagic pleuritis involves necessarily the idea of inflammation accompanied by effusion of blood, whether this occurs before, during, or subsequently to the inflammation. We cannot assign the name hemorrhagic pleurisy simply because there may be slight red coloration of the effusion. Microscopic researches have shown that all effusions, even the simplest, contain more or less white and red blood-corpuscles. The presence of a certain number of the red discs no more justifies us in calling the pleurisy hemorrhagic than the presence of the leucocytes would entitle us to call it purulent pleurisy. Dieulafoy¹⁹⁶ states that there can be from 500 to 4000 red globules to the cubic millimeter without producing any coloration. They must reach 5000 before they will really attract attention. He says, however, that when the number of red corpuscles reaches 2000 the effusion is "histologically hemorrhagic," because the presence of blood is analogous to the state of engorgement or congestion of the first stage of pneumonia or other phlegmasia, and constitutes a particular phase of pleurisy which must produce purulent matter. The name hemorrhagic pleurisy ought to be used when the number of red blood-corpuscles is sufficient to enable us, by the unaided vision, to detect the presence of blood. We may, however, find a fluid in the pleural sac which is red and yet does not contain blood-discs, but their coloring principle, the dissolved hæmatin. Jaccoud¹⁹⁷ designates this condition pseudo-hemorrhagic pleurisy. Vulpian and Charcot explain the slight discoloration by the presence of hæmatin crystals, which, having been imbedded in the false membranes, escape into the flow of the chest. Nolais¹⁹⁸ included both of these discolored effusions among the varieties of hemorrhagic pleurisies: "Hemorrhagic pleurisies include all those of which the liquid borrows the red coloring matter of the blood." Moutard-Martin (R.)¹⁹⁹ divides hemorrhagic pleurisy into three varieties: simple, as produced in simple, acute, or subacute pleurisy; tubercular; and cancerous. Trousseau²⁰⁰ considered all hemorrhagic pleurisies as caused by cancer. Beigel²⁰¹ states positively that in cancerous pleurisy the effusion is limpid with a yellowish tinge. Walshe²⁰² held the same views. Nolais, Moutard-Martin (R.), and Fernet satisfactorily demonstrated that such is not the case, but that the hemorrhagic effusion may be simple and independent of any organic disease. It may be produced by acute inflammations of the pleura as well as by cancer of the lung or pleura. It may be connected with pleuro-pneumonia or miliary tubercle. It comes, although more rarely, from fevers, such as measles, and from certain dyscrasiæ due to renal, hepatic, or even splenic lesions. When hemorrhagic pleurisy follows hæmothorax, the blood, after remaining liquid at least one or two hours, initiates the inflammatory action which has, according to Ch. Nélaton,²⁰³ for its object the encystment of the clot. Cornil and Ranvier²⁰⁴ claim that the cyst is caused by the retracted clot, and that after absorption of the serosity this cyst may become organized. The presence of air causes fetidity of the blood and purulent pleurisy.

¹⁹⁶ De la Thoracentèse par Aspiration dans la Pleurésie aigue.

¹⁹⁷ "De l'Humorisme ancien comparé à l'Humorisme moderne," Thèse de Concours, 1863; Gazette Méd., 1860, quoted by Nolais.

¹⁹⁸ Thèse de Paris.

¹⁹⁹ Thèse de Paris, 1878.

²⁰⁰ Clin. Méd.

²⁰¹ Reynolds's Syst. of Med., 1871.

²⁰² Dis. of the Chest.

²⁰³ Thèse de Paris, 1880.

²⁰⁴ Path. Anatomy.

We may have hemorrhagic effusions occurring simultaneously with acute pleurisy, with pulmonary congestions, pneumonias, and apoplexy of the lung. They are caused by the violence of the inflammation with local plethora, producing a sanguinary stasis—a mechanical result of intense congestion. Moutard-Martin (R.) states that in these cases the red globules come through the walls of the blood-vessels, as do the leucocytes, by diapedesis. Jaccoud²⁰⁵ admits that the blood-vessels are altered by the inflammation, perhaps also by the derangement in the vaso-motor innervation. The tissue of the pleura is penetrated by both red and white blood-corpuscles, and the blood-vessels and lymphatics are dilated, red corpuscles being found in lymphatics. By far the greatest number of hemorrhagic pleurisies are secondary to pleural inflammations, either resulting from acute causes or from cancerous or tubercular disease, or from diseases causing a dyscrasia of the blood, such as nephritic diseases, hepatic, cardiac, scorbutic affections, or alcoholic excesses. The secondary result of these pleurisies is the formation of neo-membranes, fibrous in their nature, which pathological anatomy shows contain, as they become organized, abundant blood-vessels with thin and brittle walls. A slight exciting cause is all that is necessary to produce their rupture. The primary cause is the false membrane, and, in some cases, vascular granulations, which have rapidly formed, perhaps in twenty-four hours—conditions eminently favorable to the production of hemorrhage. In cancerous, tubercular, and dyscrasial conditions of the blood, the blood-vessels are especially weak and easily give way, owing to the defective nutritive properties of the blood itself, just as, in typhoid fever, we have nasal and intestinal hemorrhage, and in typhus, petechiæ. In 200 cases collected by Moutard-Martin²⁰⁶ there was found intra-pleural effusion in three-eighths of the cases. Only one-third of that number were hemorrhagic. In 42 cancers observed between 1872 and 1876, 35 were without pleural effusion, 1 only was hemorrhagic. M. Moutard-Martin reports 34 observations of hemorrhagic pleurisy produced by cancer, 19 by tubercle, and 31 following simple pleurisy. Of these last there were 7 cases of effusion complicated with a pneumonia, 3 with a cirrhosis, 6 with a cardiac affection: all except 12 of these cases had some complication. Most of these (12) recovered, so he had not the autopsies to verify his diagnosis. Rayer²⁰⁷ cites 4 cases of bloody effusion in the pleura occurring in the course of a nephritis. Poutin²⁰⁸ reports 1 in renal sclerosis. M. Natalis-Guyon²⁰⁹ reports an epidemic of measles where many infants died of hemorrhagic pleurisy. Marguerite cites 13 cases complicating pneumonia, granulations, chronic pleurisy, small-pox, etc.