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Modern Technique in Treatment.
1265 for weight white bread is better than wholebread. It has been found that on a mixed diet including white bread 8 per cent. of the energy value of the food was lost in the faeces, while with wholemeal bread the amount lost was 14 per cent. The vitamin B contained in wholemeal can be supplied in other ways and any laxative effect produced by the indigestible carbohydrate residue can be secured - equally well by the consumption of other vegetable products, so that the authors of this report see no reason at present for any universal advocacy of wholemeal bread.
weight
meal
____
Modern Technique in Treatment. A Series of Special Articles, contributed by invitation, on the Treatment of Medical and Surgical Conditions.
CCXCIV.-TREATMENT OF EMPYEMA. THE principles which should guide the treatment of empyema will be discussed under two headings : (1) Tuberculous, and (2) Non-tuberculous cases.
WE are happy to be able to announce that the King’s convalescence is making progress. The collec-
Tuberculous Empyema. This condition may arise as a late result of pleural tion of pus which formed under the site of the old effusion but more frequently found as a complication is scar has now drained and the abscess is nearly healed. of artificial or spontaneous pneumothorax, and X rays show the existence of one or two minute should be called pyopneumothorax. strictly sequestra, but there is good prospect of the condition When a clear effusion develops in the course of further interference. dearing up without artificial pneumothorax treatment the prognosis does not become more serious, but if that effusion is the outlook at once becomes very grave. William Sir Thompson, whose death occurred last purulent in a few cases of ruptured lung the condition Except Sunday at Dublin in his sixty-ninth year, had not is due to the tubercle bacillus alone and not to a long retired from the position of Registrar-General mixed infection, for not only is the pus characteristic for Ireland. in appearance, but no other organism except the tubercle bacillus is found. As soon as tuberculous I the annotation on the Birthday Honours in pus has developed in the pleural cavity the following our last issue it should have been stated that Dr. principles of treatment should be adopted H. K. Graham Hodgson, honorary radiologist to 1. Remove the pus by aspiration and not by open King’s College Hospital, receives a C.V.O. in recog- drainage. nition of his services during the King’s illness. the to in order to obliterate 2. ____
Encourage lung expand pneumothorax or empyema cavity. 3. Should the lung fail to re-expand, some thoracoplastic Mr. T. Franklin Sibly, D.Sc., has accepted the operation should be performed to obliterate the cavity. 4. Attend to the general condition of the patient. post of Vice-Chancellor of the University of Reading. the
The severance of his’ connexion with the University of London, where his short term of office as Principal has entailed heavy responsibilities during a period of reorganisation, will be widely regretted. The good wishes of the many friends he has made in London will follow him to his new work.
Mr. Arthur Greenwood, the Minister of Health in the new Government, was a student of Victoria University who became head of the Economics Department of Huddersfield Technical College and lectured on Economics in the University of Leeds. He was Assistant Secretary of the Ministry of Recon.-struction in 1917-19 and Parliamentary Secretary to the Ministry of Health during the last Labour Parliament. He has been a close student of the ilealth and physique of school-children to which he lias made some personal contribution. Miss Susan Lawrence, M.P., has been appointed Parliamentary :Secretary to the Ministry of Health. Dr. Christopher Addison has been appointed Parliamentary Secretary to the Ministry of Agriculture and Dr. Drummond Shiels Parliamentary Under Secretary to the India Office.
Mr. F. G. H. Holt has been appointed Secretary .and Manager of THE LANCET in succession to the late Mr. R. E. Sare.
DONATIONS
AND
BEQUESTS.-Mr. Richard Berriman
Chellew, of Tremorvah, Truro, Cornwall, shipowner, left tIO00 each to the Royal Cornwall Infirmary, and St. Dun-
stan’s Hostel for Blinded Sailors and Soldiers.-Mr. Lawrence Matthew, of Elmsholme, Grange-road, Ealing, left .S500 each to King Edward’s Memorial Hospital, Ealing, and to the Hostel of St. Luke’s, Fitzroy-square, W.-Miss Maria Margaretta, Horrocks, of Ribblesdale, Preston, left 2500 to the Preston and the County of Lancashire Queen Victoria Royal Infirmary, and 2300 each to the Preston Industrial Institution for Blind Children, the Harris Orphanage, Fulwood, and the Royal Cross School for Deaf and Dumb
Children.
In order to cleanse the cavity and assist the lung re-expand it is best to wash it out with a 1 in 5000 solution of methylene-blue or with Dakin’s solution. I use two needles for this purpose ; through the upper one oxygen is introduced in a steady stream while the pus flows evenly out of the lower needle. By this means the intrapleural pressure is kept even throughout the procedure. When as much pus as possible has been removed, methylene-blue or Dakin’s solution is introduced through the upper needle the pleural cavity gently washed out. The lower needle is then removed and the intrapleural pressure taken by a manometer connected with the upper needle. The pressure is left at about - 6 cm. water. By these means the lungwill re-expand in a certain number of cases, although the aspiration may have to be repeated. If there is a perforation in the visceral pleura it may be difficult to wash out the cavity, and Dakin’s solution should not be used. In such cases, after removing the pus, oil of gomenol has been introduced, but in my experience this has not proved helpful, although good results in a few cases have been described by other writers. If the lung fails to re-expand, the pleural space should be closed by thoracoplasty, since the mortality in those cases which are left alone is very high. It is important to see that the patient’s condition is as good as possible before operation, and therefore he should be given a period of treatment in the fresh air with a generous diet, including plenty of glucose. A preliminary operation for phrenic evulsion is advisable and the subsequent thoracoplasty is usually performed in two stages, although some surgeons prefer to complete it at one operation. to
and is
Non-tuberculous Empyema. In these cases treatment depends largely on whether the pus is free in the pleural cavity, or whether it is in a local pocket cut off from the general pleural cavity by adherent pleura. If it is free in the pleural cavity, the condition is really one of pyothorax, and any operation for open drainage will convert it into an open pyopneumothorax, and in this condition the mortality is very high indeed.
1266 When
open wound is made into the pleural side the pressure is affected practically to the same degree on the other side, provided there are no adhesions and the mediastinum is free. Consequently, during inspiration much of the air that should enter the lungs through the trachea enters the pleural cavity through the open wound. In addition to this many of these cases have a pneumonic condition, so that the lungs are already getting insufficient air and an open pneumothorax results in a fatal
cavity
an
probably another factor in lowering the mortality preliminary aspiration, rather than early operation, is adopted. It is, of course, possible to operate too late as well On general principles it may be conas too early. sidered safe to operate when the effusion has developed into frank thick pus and when the patient has got The bad over the initial toxaemia of the pneumonia. results of early operation are due to the absence of adhesions with a freely movable mediastinum and to the toxic condition of the patient. when
on one
dyspnoea. The great principle of treatment should therefore be to avoid an open pneumothorax. This may be done by inserting a drainage-tube with a valve so that no air can enter the pleural cavity, but pus can leave-in other words, a negative drainage system is established. The tube may slip out, however, and treatment by repeated aspiration in this stage is perhaps better. In some cases the condition may be cured by aspiration alone, but usually the liquid, which is at first cloudy, becomes more and more purulent and drainage later becomes necessary. As a result of the aspiration, however, the lung. partially re-expands and adhesions form to the chest wall. Moreover, time is given for the acute pneumonic process to subside, so that the patient is in a better condition to stand an operation. In practice it is found that in a case of pneumococcal lobar pneumonia the empyema forms after the patient has recovered from the pneumonia, and there are so many adhesions that the empyema is shut off from the main pleural cavity, and consequently open drainage often gives excellent results. The pus is usually very thick and drainage is necessary. In cases of streptococcal pneumonia, however, especially in those very acute forms which follow influenza, a cloudy serous effusion forms early in the disease whilst the patient is still thoroughly toxic and I before adhesions have had time to form. It is in these cases that early operation and open drainage give such disastrous results.
I
’
Conclusion. To sum up, the following principles should be observed in the treatment of empyema :1. Remove the pus, but always avoid an open
pneumothorax. 2. Encourage the lung to re-expand and obliterate the empyema cavity. In order to do this the cavity should be irrigated with Dakin’s solution, and any drainage of a large cavity should be arranged as far as possible so that air cannot enter from outside. 3. Sterilise the cavity by frequent irrigations with Dakin’s solution.
4. Attend to the of the natient.
general condition
and nourishment
L. S. T. BURRELL, M.D., F.R.C.P., Physician, Royal Free Hospital and Hospital for Diseases of the Chest, Brompton.
Public Health Services. REPORTS OF MEDICAL OFFICERS OF HEALTH. THE following are 1928 statistics of three boroughs :! -
W. J. Stone1 has published the results of three series of cases:-
(a) Eighty-five cases treated by early operation drainage had a mortality of 61-2 per cent. (b) Ninety-six cases treated by early aspiration and
operation had a mortality of 15-6 per cent. (c) Ninety-four cases treated by early aspiration and operation with a mortality of 9-6 per cent.
and late late
The importance of avoiding an open pneumothorax is clear, and for practical purposes it may be assumed that when the effusion has developed into frank pus adhesions will have formed, and operation is safe.
Re-expansion. important principle in treating empyema is to encourage the lung to re-expand in order to obliterate the empyema cavity. If this is not done subsequent thoracoplastic operations may be necesAnother
sary in order to deal with a chronic empyema. The of the lung is prevented largely by the fibrinous exudate which forms and organises over the visceral pleura, and by the air which enters through the operation wound. To remove the fibrinous membrane from the lung-in other words, to decorticate the lung-the empyema cavity should frequently be irrigated with Dakin’s solution. Not only will this remove the membrane, but it will also tend to sterilise the empyema cavity and so prevent the pus from re-forming. The practice of washing out the cavity after operation is a very important one, and if carried out carefully will prevent many of the late complications of empyema. It is also important to attend to the general condition of the patient. As a rule, the appetite returns when the acute toxic effects of the pneumonia have passed off, so that it is possible to give a nourishing diet before operating; this increased appetite is
re-expansion
1 Amer. Jour. Med. Sci., 1919, clviii., 1.
* The standardised rate was: for Hove 11’2 and for Stafford 10"l. t Infant deaths in the first week of life only.
Hove.
Dr. Augustine Griffith says the chief event of the year was the extension of the borough, increasing its area from 1594 to 4010 acres. The county council has delegated its powers under the Nursing Homes Act and 30 homes have been registered, 3 for maternity cases, 8 for maternity and other, 3 for invalids, and 16 for medical and surgical cases. No applications. were refused. An epidemic of measles, with many severe cases and 10 deaths, raised the question of the inadequacy of the hospital to provide for this disease. There were 97 admissions for scarlet fever, which caused no deaths in the borough, to 10 for The council completed 86 houses during measles. the year, bringing the total of municipal houses up to 521. There are 46 more in course of erection and tenders accepted for another 50. There are still some families "living under bad conditions." The council contribute towards the cost of the Portslade child welfare centre which is used by the mothers of their housing estate.
weight
meal
____
Modern Technique in Treatment. A Series of Special Articles, contributed by invitation, on the Treatment of Medical and Surgical Conditions.
CCXCIV.-TREATMENT OF EMPYEMA. THE principles which should guide the treatment of empyema will be discussed under two headings : (1) Tuberculous, and (2) Non-tuberculous cases.
WE are happy to be able to announce that the King’s convalescence is making progress. The collec-
Tuberculous Empyema. This condition may arise as a late result of pleural tion of pus which formed under the site of the old effusion but more frequently found as a complication is scar has now drained and the abscess is nearly healed. of artificial or spontaneous pneumothorax, and X rays show the existence of one or two minute should be called pyopneumothorax. strictly sequestra, but there is good prospect of the condition When a clear effusion develops in the course of further interference. dearing up without artificial pneumothorax treatment the prognosis does not become more serious, but if that effusion is the outlook at once becomes very grave. William Sir Thompson, whose death occurred last purulent in a few cases of ruptured lung the condition Except Sunday at Dublin in his sixty-ninth year, had not is due to the tubercle bacillus alone and not to a long retired from the position of Registrar-General mixed infection, for not only is the pus characteristic for Ireland. in appearance, but no other organism except the tubercle bacillus is found. As soon as tuberculous I the annotation on the Birthday Honours in pus has developed in the pleural cavity the following our last issue it should have been stated that Dr. principles of treatment should be adopted H. K. Graham Hodgson, honorary radiologist to 1. Remove the pus by aspiration and not by open King’s College Hospital, receives a C.V.O. in recog- drainage. nition of his services during the King’s illness. the to in order to obliterate 2. ____
Encourage lung expand pneumothorax or empyema cavity. 3. Should the lung fail to re-expand, some thoracoplastic Mr. T. Franklin Sibly, D.Sc., has accepted the operation should be performed to obliterate the cavity. 4. Attend to the general condition of the patient. post of Vice-Chancellor of the University of Reading. the
The severance of his’ connexion with the University of London, where his short term of office as Principal has entailed heavy responsibilities during a period of reorganisation, will be widely regretted. The good wishes of the many friends he has made in London will follow him to his new work.
Mr. Arthur Greenwood, the Minister of Health in the new Government, was a student of Victoria University who became head of the Economics Department of Huddersfield Technical College and lectured on Economics in the University of Leeds. He was Assistant Secretary of the Ministry of Recon.-struction in 1917-19 and Parliamentary Secretary to the Ministry of Health during the last Labour Parliament. He has been a close student of the ilealth and physique of school-children to which he lias made some personal contribution. Miss Susan Lawrence, M.P., has been appointed Parliamentary :Secretary to the Ministry of Health. Dr. Christopher Addison has been appointed Parliamentary Secretary to the Ministry of Agriculture and Dr. Drummond Shiels Parliamentary Under Secretary to the India Office.
Mr. F. G. H. Holt has been appointed Secretary .and Manager of THE LANCET in succession to the late Mr. R. E. Sare.
DONATIONS
AND
BEQUESTS.-Mr. Richard Berriman
Chellew, of Tremorvah, Truro, Cornwall, shipowner, left tIO00 each to the Royal Cornwall Infirmary, and St. Dun-
stan’s Hostel for Blinded Sailors and Soldiers.-Mr. Lawrence Matthew, of Elmsholme, Grange-road, Ealing, left .S500 each to King Edward’s Memorial Hospital, Ealing, and to the Hostel of St. Luke’s, Fitzroy-square, W.-Miss Maria Margaretta, Horrocks, of Ribblesdale, Preston, left 2500 to the Preston and the County of Lancashire Queen Victoria Royal Infirmary, and 2300 each to the Preston Industrial Institution for Blind Children, the Harris Orphanage, Fulwood, and the Royal Cross School for Deaf and Dumb
Children.
In order to cleanse the cavity and assist the lung re-expand it is best to wash it out with a 1 in 5000 solution of methylene-blue or with Dakin’s solution. I use two needles for this purpose ; through the upper one oxygen is introduced in a steady stream while the pus flows evenly out of the lower needle. By this means the intrapleural pressure is kept even throughout the procedure. When as much pus as possible has been removed, methylene-blue or Dakin’s solution is introduced through the upper needle the pleural cavity gently washed out. The lower needle is then removed and the intrapleural pressure taken by a manometer connected with the upper needle. The pressure is left at about - 6 cm. water. By these means the lungwill re-expand in a certain number of cases, although the aspiration may have to be repeated. If there is a perforation in the visceral pleura it may be difficult to wash out the cavity, and Dakin’s solution should not be used. In such cases, after removing the pus, oil of gomenol has been introduced, but in my experience this has not proved helpful, although good results in a few cases have been described by other writers. If the lung fails to re-expand, the pleural space should be closed by thoracoplasty, since the mortality in those cases which are left alone is very high. It is important to see that the patient’s condition is as good as possible before operation, and therefore he should be given a period of treatment in the fresh air with a generous diet, including plenty of glucose. A preliminary operation for phrenic evulsion is advisable and the subsequent thoracoplasty is usually performed in two stages, although some surgeons prefer to complete it at one operation. to
and is
Non-tuberculous Empyema. In these cases treatment depends largely on whether the pus is free in the pleural cavity, or whether it is in a local pocket cut off from the general pleural cavity by adherent pleura. If it is free in the pleural cavity, the condition is really one of pyothorax, and any operation for open drainage will convert it into an open pyopneumothorax, and in this condition the mortality is very high indeed.
1266 When
open wound is made into the pleural side the pressure is affected practically to the same degree on the other side, provided there are no adhesions and the mediastinum is free. Consequently, during inspiration much of the air that should enter the lungs through the trachea enters the pleural cavity through the open wound. In addition to this many of these cases have a pneumonic condition, so that the lungs are already getting insufficient air and an open pneumothorax results in a fatal
cavity
an
probably another factor in lowering the mortality preliminary aspiration, rather than early operation, is adopted. It is, of course, possible to operate too late as well On general principles it may be conas too early. sidered safe to operate when the effusion has developed into frank thick pus and when the patient has got The bad over the initial toxaemia of the pneumonia. results of early operation are due to the absence of adhesions with a freely movable mediastinum and to the toxic condition of the patient. when
on one
dyspnoea. The great principle of treatment should therefore be to avoid an open pneumothorax. This may be done by inserting a drainage-tube with a valve so that no air can enter the pleural cavity, but pus can leave-in other words, a negative drainage system is established. The tube may slip out, however, and treatment by repeated aspiration in this stage is perhaps better. In some cases the condition may be cured by aspiration alone, but usually the liquid, which is at first cloudy, becomes more and more purulent and drainage later becomes necessary. As a result of the aspiration, however, the lung. partially re-expands and adhesions form to the chest wall. Moreover, time is given for the acute pneumonic process to subside, so that the patient is in a better condition to stand an operation. In practice it is found that in a case of pneumococcal lobar pneumonia the empyema forms after the patient has recovered from the pneumonia, and there are so many adhesions that the empyema is shut off from the main pleural cavity, and consequently open drainage often gives excellent results. The pus is usually very thick and drainage is necessary. In cases of streptococcal pneumonia, however, especially in those very acute forms which follow influenza, a cloudy serous effusion forms early in the disease whilst the patient is still thoroughly toxic and I before adhesions have had time to form. It is in these cases that early operation and open drainage give such disastrous results.
I
’
Conclusion. To sum up, the following principles should be observed in the treatment of empyema :1. Remove the pus, but always avoid an open
pneumothorax. 2. Encourage the lung to re-expand and obliterate the empyema cavity. In order to do this the cavity should be irrigated with Dakin’s solution, and any drainage of a large cavity should be arranged as far as possible so that air cannot enter from outside. 3. Sterilise the cavity by frequent irrigations with Dakin’s solution.
4. Attend to the of the natient.
general condition
and nourishment
L. S. T. BURRELL, M.D., F.R.C.P., Physician, Royal Free Hospital and Hospital for Diseases of the Chest, Brompton.
Public Health Services. REPORTS OF MEDICAL OFFICERS OF HEALTH. THE following are 1928 statistics of three boroughs :! -
W. J. Stone1 has published the results of three series of cases:-
(a) Eighty-five cases treated by early operation drainage had a mortality of 61-2 per cent. (b) Ninety-six cases treated by early aspiration and
operation had a mortality of 15-6 per cent. (c) Ninety-four cases treated by early aspiration and operation with a mortality of 9-6 per cent.
and late late
The importance of avoiding an open pneumothorax is clear, and for practical purposes it may be assumed that when the effusion has developed into frank pus adhesions will have formed, and operation is safe.
Re-expansion. important principle in treating empyema is to encourage the lung to re-expand in order to obliterate the empyema cavity. If this is not done subsequent thoracoplastic operations may be necesAnother
sary in order to deal with a chronic empyema. The of the lung is prevented largely by the fibrinous exudate which forms and organises over the visceral pleura, and by the air which enters through the operation wound. To remove the fibrinous membrane from the lung-in other words, to decorticate the lung-the empyema cavity should frequently be irrigated with Dakin’s solution. Not only will this remove the membrane, but it will also tend to sterilise the empyema cavity and so prevent the pus from re-forming. The practice of washing out the cavity after operation is a very important one, and if carried out carefully will prevent many of the late complications of empyema. It is also important to attend to the general condition of the patient. As a rule, the appetite returns when the acute toxic effects of the pneumonia have passed off, so that it is possible to give a nourishing diet before operating; this increased appetite is
re-expansion
1 Amer. Jour. Med. Sci., 1919, clviii., 1.
* The standardised rate was: for Hove 11’2 and for Stafford 10"l. t Infant deaths in the first week of life only.
Hove.
Dr. Augustine Griffith says the chief event of the year was the extension of the borough, increasing its area from 1594 to 4010 acres. The county council has delegated its powers under the Nursing Homes Act and 30 homes have been registered, 3 for maternity cases, 8 for maternity and other, 3 for invalids, and 16 for medical and surgical cases. No applications. were refused. An epidemic of measles, with many severe cases and 10 deaths, raised the question of the inadequacy of the hospital to provide for this disease. There were 97 admissions for scarlet fever, which caused no deaths in the borough, to 10 for The council completed 86 houses during measles. the year, bringing the total of municipal houses up to 521. There are 46 more in course of erection and tenders accepted for another 50. There are still some families "living under bad conditions." The council contribute towards the cost of the Portslade child welfare centre which is used by the mothers of their housing estate.