SUPPURATIONS OF THE CHEST CAVITY?^5.

BY EMIL G. BECK, M.D.

CHICAGO, ILL.

It is evident that during the past year we have met quite a different type of empyema from that which we have been accustomed to see. The cases here reported by the previous speakers usually began with a violent infection of the throat, or measles, a pneumonia which terminated in an accumulation of pus in the pleura. The high mortality which accompanies this type marks the principal difference.

We have in the past regarded drainage of an empyema as of very little danger and could usually promise the patient a speedy recovery. In my experience, at least nineteen out of twenty cases would close with the ordinary method of drainage within two months after the operation. The type with which we deal now not only has a high mortality, but the tendency to spontaneous closure is not as favorable.

The paper read by Dr. Stewart shows that even with the best methods employed there was a mortality of twelve out of forty-four cases, and those remaining did not close as readily as we would expect.

In addition to the large number of cases which will persist suppurating after empyema resulting from pneumonia, there will be a vast number from the thousands of gunshot wounds of the chest now produced in the war. I trust that the Carrel-Dakin method of irrigation will minimize the number of these chronic suppurative cases, but even under best conditions there is bound to be a large residue of cases when we consider the enormous number occurring through the war. This is one of the reasons why I have chosen the discussion of this subject at this time.

During the past ten years I have had an exceptional opportunity to see and treat many of these chronic suppurative chest cases. Practically all had been treated previously and in some of them the resection of several ribs and decortication of the lung had been tried, but the suppuration persisted nevertheless.

In order to treat these cases intelligently, we must first study the cause for the persistence of the suppuration. The following causes have been found:

1. The retracted and infiltrated lung tissue cannot expand sufficiently to fill the dead space existing between itself and the rigid chest wall. Nature tries to diminish this space by contracting the chest wall; so that the ribs must overlap, and in many cases there are no intercostal spaces except at the insertion of the ribs at the spine. The diaphragm very often is drawn up two or three inches in its attempt to obliterate the space. The pleura also thickens and diminishes this space to a certain degree. Nevertheless there often remains a cavity holding two or three hundred cubic centimeters of fluid.

2. The pleura often contains microorganisms which are very difficult to reach by flushing with any antiseptic solution, and thus the secretion of pus continues indefinitely.

3. At times there are foreign bodies present, such as rubber tubing which has slipped in unknown to the surgeon and remained there, keeping up suppuration.

4. In cases of abscess of the lung, the tendency to non-closure is greater because there is usually a communication with a bronchus, which is very often dilated, and reinfection of the abscess cavity after drainage keeps up the suppuration.

5. These chronic suppurative abscesses are often multiple, and when one or two are opened, the drainage and suppuration persists in many small recesses,and only communicate through the branches of the bronchi.

6. In abscesses due to tuberculosis of the lung, the reason for non-closure is still more apparent when we consider the pathology of the tuberculosis lobe.

In some cases, especially those of tuberculous origin, the lung retracts upwards toward the hylus, leaving a space below and to the sides. The various shapes of these cavities can be visualized by introducing some substance which produces, a shadow on the x-ray plate, preferably the bismuth paste, and then taking a set of stereoroentgenograms. Such roentgenograms will give us a clear picture of the location, size, and depth of these cavities. Studying them, we can judge whether the cavity is anterior or posterior and thus plan our operation and treatment accordingly. To illustrate this, I here present this first patient.

This patient is a man of thirty, was in good health before and became ill about one month ago with an infection of his throat, which was followed by a severe pneumonia. The temperature ran from 103° to 105° for ten days, at the end of which time the left chest was filled with a fluid.

After probatory puncture (pus with numerous streptococci) an inch of the ninth rib was resected posteriorly. A counter opening was made at the same time anteriorly and a large perforated rubber tube was introduced, passing through both openings.

This drainage was kept up for two weeks, the patient improved rapidly, and the pus changed somewhat in character, becoming thicker and more purulent. I then withdrew the tubes and injected the cavity with 300 grams of bismuth paste, a mixture containing 10 per cent, bismuth subnitrate and 90 per cent, vaseline.

A set of stereoroentgenograms was taken, the patient being in a horizontal position. From the single plate we would judge that the entire left chest cavity is filled with the mixture. Viewing, however, this set of roentgenograms through the stereoscope, we find this is not the case. We note that the mixture simply gravitated to the posterior surface of the pleural cavity, producing a shadow covering practically the entire left chest. It does not fill the entire depth of the pleural space; the somewhat retracted lung and heart are in front of it. This fact can only be visualized by the stereoscopic roentgenogram and not by the single plate.

Proof of this is seen in another roentgenogram taken in the sitting posture. In rising the bismuth mixture has gravitated downward and left the upper two-thirds of the cavity empty and thus transparent. The mixture accumulated at the bottom, giving a square shaped-shadow. We note, however, that a portion of the mixture has been retained in a pocket in the upper portion of the chest. It evidently ran in front of the lung, near the apex. It gives a distinct outline of another walled-off abscess, with a straight waterline mark on its upper margin. Such radiograms as this are essential for a correct diagnosis and greatly facilitate the treatment.

In other cases the pleura obliterates nearly the entire chest cavity and leaves a long sinus leading into a pocket not larger than a crabapple, and this accounts for the persistence. The injection of bismuthinto the sinus will here likewise give a clear picture of the existing condition. In some instances radiograms will show a straight channel from the drainage opening of the chest wall directly into the bronchus, which indicates that the pre-existing abscess cavity has shriveled down to a straight sinus, but has not closed on account of the communication with a bronchus.

If there is a suspicion of a foreign body being the cause of a lung abscess, it is of course absolutely necessary that the foreign body be discovered and localized before any treatment is attempted. Here also the stereoroentgenogram is almost indispensable for the determination of the exact location of the foreign body. I have made an extensive study of this subject and refer the reader to my publication entitled: "The Localization of Foreign Bodies by Means of Stereo-roentgenograms," published in the "Stereo Clinic" in 1917.

To determine the presence of a communication between the abscess cavity and a bronchus, the injection of bismuth paste is most dependable, because the patient will cough up the mixture. As soon as the existing cavity has been completely filled, the overflow will penetrate into the bronchus and the patient will get a coughing spell, in which he will eject some of the paste.

A word of caution is here necessary, namely, that the paste should in such a case be injected very slowly and the patient be asked not to inhale during this injection, for he may aspirate some of the mixture into the other side of the lung while it is passing up through the trachea. It may also produce a choking spell if a large amount of the paste is forced into the trachea. The mixture must be liquid for this reason. If you realize that the trachea is several inches long and its lumen not very wide, you will realize that it is very easy to clog up this lumen by a column of thick paste and the patient will be unable to inspire. Since there is very often an accumulation of pus in the abscess cavity, the paste mixture will displace this pus and the patient will cough up a quantity of pus before any paste will appear in the expectoration.

I could illustrate to you a large variety of conditions which have been disclosed by means of these roentgenograms, but lack of space for illustrations forbids. I recommend to you very highly the stereoscopic roentgenograms with the injected cavity or sinus before any treatment is attempted. They have been a most useful adjunct in my armamentarium for the treatment of chronic empyema.

After a satisfactory anatomical diagnosis has been made by means of these radiograms, the next stepis to ascertain the character and quantity of the discharge. In some cases it is a green, foul smelling pus, in others a serous semi-purulent fluid resembling dirty dishwater, in others a pinkish or chocolate colored thick pus. The color of the pus depends very often upon the substances which have been used in treatment. Irrigations of permanganate or of silver nitrate especially change the character and color of the secretion.

We invariably take a culture and smear of the pus, and, whenever it seems necessary, we inject one or two guinea pigs with a ten per cent, solution of the pus. In practically all the cases we find the staphylococcus; in addition .to. this we find the streptococcus in about 20 per cent, of the cases. The tubercle bacillus is rarely found in the secretion even in the cases in which the empyema is positively of tuberculous origin.

We have observed one remarkable fact in this connection, namely; that in the cases known to be of tuberculous origin in which tubercle bacilli could not be found in the secretions with repeated examination, we have, after inspecting the cavity with bismuth paste, found the tubercle bacilli within twenty-four hours in very large numbers in each smear preparation, often as many as a hundred in each field. This surprising finding was verified in a great number of cases during the past ten years. The tubercle bacilli, however, differ somewhat in their appearance and staining qualities from those which we usually find in the tuberculous sputum; they are beaded, resembling somewhat a miniature chain of streptococcus, staining also much darker than the tubercle bacillus usually does. The number of these bacilli gradually diminish, and within two or three weeks the secretion will be free from the same.

My explanation for the appearance of these bacilli after the injection is the following: The tubercle bacilli live within the walls of the sinuses or the abscess wall and not in the secretions. It requires some irritating substance to provoke their exit. The injection of a substance like bismuth subnitrate produces a leucocytosis within the walls and by this "means the bacilli are carried out in the discharge. 1 suppose the modus operandi consists in a battle between the tubercle bacilli and the leucocytes, resulting in the death of the bacilli and their expulsion in the secretion. Possibly the same action may hold good in the case of other microorganisms, and this would in a degree account for the surprisingly rapid sterilization of large infected cavities. I .have as yet no confirmatory laboratory evidence of the above theory, but the theory seems plausible and supported by many clinical corroborations.

Treatment. - When the anatomical, pathological, and bacteriological diagnosis is -established, the treatment is very much simplified. In former times we used to irrigate these suppurating empyema cavities with various solutions, such as permanganate of potash, weak iodine, boric acid, and other similar substances, but this practice has been discarded by most hospitals, and during the past few years we have rarely seen this practice carried out. It was supplemented usually by secondary operations. These operations, however, were not always successful, unless they were very extensive, consisting of resection of the entire chest wall and decortication of the lung. The patient as a rule would not consent to this extensive, hazardous procedure unless he was very much inconvenienced by the chronic suppuration, and if the condition was not very annoying he preferred dressing his wound indefinitely.

Ten years ago we introduced into surgery a new method of dealing with this class of cases; namely, the injection of bismuth paste. It is unnecessary here to repeat in detail the advantages and technique of this method. By this time the bismuth method is well known and the results from its employment and its dangers are all well defined. Let it be said that after ten years of trial, in almost all parts of the world, it has retained its place and is employed more extensively now than ever. The reports in the literature indicate that at least four out of five cases of the very old neglected suppurative empyemata or lung abscesses may be cured by this simple procedure. Ochsner, of Chicago, reported to the American Surgical Association on June 4, 1909, fourteen cases of empyema, all of which had been operated on (two by Estlander's operation) with sinuses in all cases persisting nevertheless. He applied the bismuth paste in each of these cases, with the result that twelve cases healed completely and two were still under treatment at the time and very much improved. Others have reported equally good results. In my own series of 110 cases, approximately 80 per cent, were cured by the bismuth injection treatment alone.

Omitting minor details, it will be of benefit to mention some practical points in the technique:

Subsequent to a physical examination, a stereoscopic roentgenogram of the entire chest (plate size 14 x 17) should be taken and then the cavity injected with 10 per cent bismuth-vaseline paste: bismuth subnitrate, 10.0; vaseline, 90.0.*

* In former years I employed a mixture containing 30 per cent, bismuth subnitrate, but found that the above mixture produces equally good results and is not likely to cause symptoms from bismuth absorption.

When the cavity or sinus is completely filled with this mixture, another set of stereoroentgenograms is taken. This set will illustrate the exact size of the cavity and its relation to the ribs and other structures in the chest. Whenever a communication with a bronchus exists, the patient will at once cough up the excess quantity of paste.

The second roentgenogram shows the cavity entirely filled with bismuth, and plainly marks the inner boundary of the cavity formed by the thickened pleura. The sizes and shapes of these cavities vary so much that there are no two cases alike. Sometimes we find a small globular sac communicating with the outer chest wall by a long tortuous channel, and then again we find that there exists merely a long sinus which communicates with a bronchus, without any cavity whatsoever.

The first injection does not always produce healing. It requires at times repeated injections during several months, but whenever the discharge changes from pus to a serous character, the injections should be stopped because healing will usually follow. Only when the discharge continues to be purulent should we consider a more radical surgical procedure.

I have tried to ascertain why some cases respond to the bismuth treatment and why others do not. I have noted that whenever the cavity holds more than 200 grams it will be less likely to heal by bismuth injections. Cases which communicate with the bronchi are also more resistant than simple empyema. Some cases will heal shortly after the injection and remain closed for a year or two and the patient be in good health, often gaining as much as thirty pounds, and then the sinus will reopen. The injections are then to be repeated. Closure usually follows for another year or two, and then another relapse after a long period. The patient often prefers to keep on treatment in this way; not being much inconvenienced and perfectly well in the intervals.

There remains a small number, about one in five cases, which have no tendency whatever to heal under any form of treatment, and these require the most radical surgical procedure.

The methods in vogue in dealing with these refractory cases are known as the Estlander, the Schede operation, or the decortication of the lung. The patient who has to submit to one of these extensive surgical procedures is, of course, in a desperate situation. He is told that the operation causes a high mortality and the surgeon cannot promise him an absolute cure even with this method. Aside from that, the surgeon must warn him of the prospect of a considerable deformity of his chest, whether he becured or not. I have always hesitated to advise such an extensive procedure, and in the last seven years I have not resorted to any of the above mentionedoperations. In such cases I have resorted to the skin sliding operation, described in my previous publication on this subject.