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BY
WILLY MEYER,
M.D.
NEW
YORK.
This topic of discussion was placed on the program of this, our first
meeting, on account of the great importance of the after-treatment of
intrathoracic operations for the further evolution of thoracic surgery.
"Exclusive of empyema" was originally added to the title because the treatment
of empyema takes a place of its own in thoracic surgery. It was desired to call
particular attention in our deliberations here today, not to the treatment of
empyema, a question which it was known would be discussed by most able
gentlemen, but to the best method of after-treatment of operations that concern
organs situated in the thorax, beyond the pleura, particularly of operations
which reach beyond the "virgin"-pleura, not the infected one. That means,
operations on lungs and bronchi, heart and large blood-vessels, diaphragm, and
the anterior and posterior mediastinum, inclusive of the esophagus. But,
inasmuch as the president has now decided to include empyema in this
discussion, I shall venture later on to say a few words on that subject also.
Whoever attacks the thoracic cavity for operative purposes will
frequently find reason for drainage on general principles, same as in other
parts of the body. He will say to himself: "This case ought to be drained."
However, the colleagues who have the greatest experience in thoracic surgery,
principal among them Sauerbruch, have again and again emphatically advised
against post-operative thoracic drainage. On basis of clinical observations
they were convinced that these patients had a much greater chance for recovery
with the thorax closed air and watertight, than drained.
We have .just heard from Dr. Green what a difference it makes if the
thorax is not closed in acute injuries. We shall consider the question of
whether or not to drain in cases in which, for instance, on separating the
adhesions around a suppurating lung a superficial tear had occurred, or on
excising the esophagus the thin friable wall of the latter was injured.
In 1904 I saw Sauerbruch do a resection of the esophagus on a dog in
his negative chamber at Breslau the pleura was soiled, but he closed the wound
completely without drainage after the lung had been thoroughly distended. The
dog developed a septic pleurisy, but pulled through the infection, the
resulting empyema having been opened and drained in time. But he there had to
deal with a strong, healthy dog. If one has to deal with sick human beings,
conditions are generally entirely different. Their thorax must be drained from
the start, right after the operation, should they recover.
If we drain without taking special precautions, the result will be a
postoperative acute pneumothorax, which has the same great dangers to the
patient as an acute pneumothorax which sets in during the operation.
The question then arises, how can we avoid the postoperative
pneumothorax if we drain.
Having the differential pressure apparatus at our hospital, I worked
out a useful method with its help some six to seven years ago. I will describe
it by showing the lantern slides. The method provides for free drainage of the
pleural cavity through a special stab in a lower intercostal space, the
inevitably following acute postoperative pneumothorax being avoided by retaining
the patient under a difference of air pressure from eighteen to twenty hours.
I. The first illustration (see illustrations in Annals of Surgery,
Vol. 68, p. 156, 1918) shows the after-treatment bed which was specially built
for this purpose, and corresponds in height to the cut-out which allows the
patient's head to slip into the positive cabinet. The original thoracic
incision has been sutured throughout after the free cut had been made >in
one of the intercostal spaces, two or three ribs lower down, and such kind of
drainage put in place as the surgeon considered wise. The rubber tube or tubes
were cut through outside, close to the wound, and secured with safety pins.
Dressing is applied as usual, and the entire drainage wound with tubes and
gauze covered by a large square piece of sterile rubber dam, which was made to
adhere to the chest wall by means of freely used zinc ointment.
Immediately after operation the patient was left under differential
pressure. One nurse then wentwith the patient's
head inside of the cabinet, while a second one ministered to his needs outside,
just as though he were in his bed and under ordinary circumstances in his room
or the ward. The difference in pressure was kept up continuously, but inasmuch
as we made use of positive pressure - merely for convenience's sake - it was
necessary to relieve the right heart at regular intervals by stopping the
pressure and making artificial respiration a procedure which can be easily
effected with the apparatus. The collapse of the lung, followed by a thorough
distention,\is one of our best physical means of supporting the heart's action.
Usually, after fifteen to eighteen hours, the pressure was turned off and the
patient now observed under ordinary atmospheric conditions. If he remained well,
he was removed from the apparatus and wheeled into one of the observation rooms
in the Thoracic Pavilion, where he remained for another twenty to twenty-four
hours. If his condition continued satisfactory, he was returned to the ward or
to his private room. The method, which has been tested out in quite a number of
cases, proved very satisfactory and efficient; but it was cumbersome on account
of the necessity of having two special nurses.
II. A
second method was introduced not long after by Tiegel, who constructed a
special metal tube of flexible material which could be lengthened inside of the
chest by adding a piece of rubber tubing. Tiegel's drain carries at its outer
end a piece of rubber dam properly fastened, which acts as a valve, allowing
the fluid to be discharged from the thorax, but preventing air from entering
it. Although I have this apparatus in my possession, I have never used it, but
Tiegel states that he has seen satisfactory results with it. It is introduced
either at one end of the thorax incision or through a special stab.
III. In
looking around for a simplified method of postoperative drainage, I struck on
Dr. Kenyon's method employed for empyema in children, as described and
illustrated in "Johnson's Operative The-rapeusis." By special means a rubber
tube is fastened airtight in the small intercostal wound which otherwise is
closed by layer sutures tightly around the tube. Precautions are taken to
prevent its slipping in or out, and the pleural secretions are drained off by
syphonage into a bottle below the bed. After some discussion with Dr. Kenyon,
this method was adopted for ordinary thoracic operations in the adult.
It was tried for the first time by me in a case of resection of the
esophagus for carcinoma at the Post-Graduate Hospital in 1915. The method
proved very satisfactory. Air and fluid were seen bubbling out into the bottle.
Inasmuch as the tumor, which was situated behind the aortic arch, had
perforated intothe posterior mediastinum, ligation of
the vena azygos became necessary. The ordeal of the various steps necessary in
this operation was too much for the patient's general condition. He survived
the operation by but a few hours. However, the method had been tested and found
extremely satisfactory. The next suitable case presented thirteen months later,
in January, 1917, when a man of thirty-two, suffering from bronchiectasis,
needed operation. On incising the chest, a free pleural cavity was encountered
and the lung found adherent only in one area near the spine, where the
aspirating needle proved the presence of pus. Th pleural cavity was drained as
before, and closed, and then the lung incised. The abscess was found and the
cavity in the lung tamponed. On the second day of the after-treatment a
suppurative pleurisy' developed; the effusion could be nicely observed as
regards quality as well as quantity in the syphonage bottle. The patient pulled
through and made a complete recovery.
The third case was one of resection of the chest wall for tumor.
Although many successful cases of thoracic wall resection without drainage have
been reported, in this case drainage was employed, and the patient made one of
the smoothest recoveries imaginable. In two exploratory thoracotomies for
cancer of the esophagus it also proved successful. In the sixth case, a man
suffering from bronchiecstasis involving both lobes of the left lung, it was
decided to do the operation in two stages. At the first stage it was found that
adhesions bound the left lung to the costal pleura from base to apex. The lung
was loosened throughout, so that it could collapse, and then the cavity tightly
packed with gauze. The thorax was closed by suture and Kenyon's drain put in
place. More than 1000 cc. were discharged in the first twenty-four hours and a
pretty large amount in the following. On the fourth day the patient, who had
difficulty in expectoration, developed an aspiration pneumonia and died.
However, here again it was shown how freely, by means of this drainage, exudate
within the pleural cavity is discharged, the latter remaining at the same time
hermetically closed.
Kenyon's method of drainage, it seems to me, bids fair to greatly
improve the results of our thoracic operations, to make them oftener successful
than seen heretofore. The pleura is a membrane which is much more sensitive to
traumatism than the peritoneum. While the latter forms adhesions, the pleura
forms an exudate and usually an infected one. The sooner the contents are
drained off from this closed sac, the better for the patient. Therefore drainage
should be started immediately after the operation, or rather during the
operation.
Dr. Kenyon has tried the method in one case of so-called internal
injury of the thorax which seemed extremely dangerous. It occurred in a boy
whose chest had been crushed. In this case the airtight introduction of the
drainage method proved almost like magic. From the moment it was in place the
boy began to recover.
And now just one word on the treatment of empyema. I think it may be
worth while with the many cases of empyema in our cantonment and war-hospitals,
where the patients are under most scientific observation and treatment, to test
this method of drainage on a larger series of cases. Under local anesthesia the
tube might be easily introduced some time between the fifth and seventh day of
the original pneumonia and the thorax drained. By exchanging the syphonage
bottle for another sterile bottle containing Dakin's solution or
dichloramine-T, the chest might be filled with any quantity of the antisepticdesired, and as often as required, by simply raising
the bottle and then lowering it for syphonage. If the patient were then left
resting on his side and gently shaken like a barrel, afterwards moved on his
stomach, then on his side and his back, also brought into Fowler's or
Trendelenburg's posture, the fluid would be made to come into contact with the
entire pleural cavity. Inasmuch as Dakin's solution is able to dissolve the
coagulated fibrin, and the dichloramine-T also breaks up this material, it is
not impossible that one may perhaps be able to dispense with rib resection, as
done heretofore, as well as with the old method of the open treatment of the
empyema cavity. Of course, this is a mere suggestion. Should it be found
successful in practice, it would greatly help the treatment of these patients
on account of the immediate restoration of the physiological function of the
lung and allowing the pathological fluid to be drained off at the same time.
