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The treatment of acute suppurative pleurisy in children
THE TREATMENT
ACUTE
OF
SUPPURATIVE PLEURISY IN CHILDREN* JOHN V.
BOHRER, M.D., F.A.C.S. NEW YORK
PECULIARITIES
T
OF IN
SUPPURATIVE
PLEURISY
CHILDREN
HE treatment of suppurative pIeurisy in chiIdren has received but littIe attention from those writing on this subject, as such cases have usuahy been incIuded in adult groups. There are certain features, however, that differentiate these groups, the most important of which are: I. Thickness of chest waI1. 2. Diminished power of resistance. 3. Cooperation of patient. 4. Nature’s abiIity to repair in chiIdhood. I. Thickness of Chest Wall. In the average chiId suffering from suppurative pIeurisy, the thinness of the chest wall, when exaggerated by emaciation, has some operative advantage. (a) Diagnosis is more exact in outhning the encapsuIated pocket, both by physica signs and by roentgenography and ffuoroscopy. (b) An underIying pneumonia is readiIy detected, which is of vast significance in determining the question of operation. 2. Diminished Power of Resistance. (a) Most chiIdren with suppurative pIeurisy do not have enough power of resistance to withstand the shock of any severe operation, so the simpIest efficient operation is Even the shock of dressing demanded. the wound is vitaIIy significant, and particuIarIy so during the first few days after operation. In these cases it is of the greatest importance to use simpIe tubes that are heId in pIace in a position that does not irritate, and yet are effective.
(b) In very young chiIdren suffering from suppurative pIeurisy, where mortality is exceptionaIIy high, forced feeding before and after operation is often necessary. When these chiIdren, who refuse food, are gavaged, regurgitation foIIows. This occurs in very sick patients whose emaciation wouId indicate a Iong period of starvation. ApparentIy during their primary disease, when feeding is diffrcuIt, their stomachs contract. This contraction is overcome by frequent feedings of smaI1 amounts which are graduaIIy increased in quantity. This treatment requires constant nursing, but it is the means of saving Iife. With the exception of the first few days after operation, it rareIy is necessary to urge eating, as a properly drained empyema patient wiI1 consume Iarge quantities of food. The dietary must be of high caIoric vaIue and the food shouId be given in as great a quantity as the child’s gastrointestinal tract wiI1 assimiIate. The reasons for requiring so much food are: to overcome Ioss of weight due to the emaciation which obtained during the primary disease and the formative period of the suppurative pIeurisy; to overcome the negative nitrogen baIance that is aIways present in underfed suppurative pleurisy cases; and to supply warmth to overcome the extra Ioss of heat that is concomitant with an open pneumothorax. 3. Cooperation of the Child. This is necessary and can be obtained by some simpIe device such as a toy balloon used in pIace of the customary bIow-bottIe. To prevent spina curvature, which is
* Read in part before the Section of Surgery, New York Academy of Medicine, February 4, 1927. An abstract of this paper, and the discussions, were published with the Transactions of that meeting in THE AMERICAS JOURNAL OF SURGERY.,May, ,927.
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IikeIy to occur, get the chiId out of bed as earIy as possibIe. Encourage him to run unti1 short of breath, which wiII create deeper breathing with greater expansion and better drainage. Exercise in any form is particuIarIy desirabIe. BaIcony sunlight treatment, after acute symptoms have subsided, is of great value. The average chiId wiI1 cooperate, so this may be carried on even in mid-winter. In chiIdren the reaction to exposure is very noticeable and it is out of a11 proportion to that of adults. It is most vital directly after operation and for the next four to six days. The percentage of complications is very much higher in windy winter months, which is due to exposure to coId and prevalent infections. 4. Nature’s Ability to Repair in Childhood. In suppurative pleurisy, as in many other diseases of children, growth is a great adjunct to the final resuIt. If there is a curvature or a flattening of the chest or incomplete expansion of the lung this fault wiI1 be graduaIIy overcome as the chiId deveIops. The management of suppurative pIeurisy is based on possibilities and directed by probabilities. The pIan of treatment should fuIfil1 the following requirements and, in so far as it yieIds good results, must be accepted as satisfactory: I. Proper treatment of the primary disease with early recognition of the suppurative pIeurisy. 2. Low mortaIity. 3. Minimum anatomical and physioIogicaI deformity. 4. Prevention of complications. 3. EarIy restoration to health. In comparing treatment of suppurative pIeurisy by different surgeons, with that of a suppurative process in the peritoneal cavity as, for instance, suppurative appendicitis, we are forced to the conclusion that there are stiI1 worIds to conquer in the reaIm of suppurative pleurisy. PracticaIIy a11 agree on the general plan of treating suppurative appendicitis, but onIy in a few general principles are
PIeurisy
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surgeons agreed in the treatment of suppurative pieurisy. AI1 beIieve in the dictum of “where there is pus, Iet it out.” However, the time to act; the amount of pus to be removed at the operation; the method of attack, whether by rib resection, simple thoracotomy, expIoratory thoracotomy, with removal of foreign substance (congealed fibrin) ; the method of cirainage, whether by the cIosed suction method, syphon drainage, double drainage, through and through drainage tubes; aspiration with injection of bactericidal agents; the pIacing of Dakin tubes in the cavity so al1 parts may be irrigated and disinfected; these are a few points on which we are not fuIIy in accord. Every writer wishes to impress the fact that prevention of chronic empyema is one of our chief aims; yet we a11 continue to operate on chronic suppurative pleurisy, and we believe that a certain percentage, varying with the particuIar pathology, will continue to develop chronic suppurative pIeurisy. In other words, it is the particular type of suppurative pleurisy rather than the particular type of operation that is the determining factor. COMPLICATIONS
CAUSING
CHRONICITY
Many of the compIications that prevent closure of the chest waI1, such as osteomyeIitis of rib, inadequate drainage, foreign bodies and multiple pockets can be controIIed by adequate surgery. A few, however, wil1 develop a chronic form in spite of the management of the acute. We refer particularIy to those cases with (I) large bronchopuImonary fistuIae; (2) interstitia1 changes in the puImonary parenchyma; (3) muItiple septic foci in the lung which apparentIy, from time to time, rupture through the visceral pleura and reinfect the cavity; (4) primary tubercuIosis or a secondary infection with tuberculosis. The pathology of suppurative pleurisy does not come within the scope of this paper and will be referred to only by statements of accepted ideas, insofar as
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it is inseparabIe from a discussion of treatment. I. With the use of Dak?n soIution we frequentIy find a more or Iess sudden appearance of a bronchopulmonary j&da. At first we thought that the soIution had eroded a spot of partiaIly devitahzed Iung tissue. A more probabIe expIanation is that the fistuIa deveIoped during the course of the disease but had been temporariIy cIosed by the thick layer of fibrin that adhered to the viscera1 pleura. When this became detached the fistuIa suddenIy appeared. This is iIIustrated by the foIIowing case: CASE I (234 D-4). A chiId of two years, in whose case the reguIar two-hourIy Dakin’s irrigation was not used but the wound was daily irrigated at the time of dressing. This was without ilI-effect for severa days. Later, when the sohrtion was introduced, the patient on account of the opening became “gassed” of a fair-sized bronchus. There was a severe paroxysm of coughing; the chiId strangIed, became cyanotic and deveIoped marked shock from which it did not recover. Death is very uncommon from such a cause. SmaII puImonary communications cIose spontaneousIy and are not a cause of chronicity. For instance, in doing a decorthe parenchyma is invariabIy tication, damaged enough to cause bubbIes to appear. If irrigation is started at once the patient becomes “gassed,” but in three to six days after operation it is perfectIy safe to institute this treatment. When a Iarge bronchus communicates with the pIeura1 cavity it wiI1 not cIose spontaneousIy. This is iIIustrated by the foIIowing case : CASE II (299 D-4). A boy, aged six years, suffering from post-tonsiIIectomy pneumonia, who did not recover in the usua1 time, deveIoped signs of fluid in the chest. A roentgenogram confirmed this diagnosis and an exploratory puncture reveaIed pus. The operation showed that a Iung abscess had spontaneously ruptured into the pIeura1 cavity, producing an encysted suppurative pleurisy. This wound had every advantage for spontaneous cIosure but resisted al1 efforts and
Pleurisy
SEPTEMBER, ,927
deveIoped a chronic state. It, of course, rightfuIIy belongs in the cIass of Iung abscesses, but with its resuIting bronchopuImonary IistuIa it serves to JIustrate in a magnified way the fact that when the pIeura1 cavity communicates with Iung parenchyma it wiI1 not spontaneousIy hea if that communication is of any appreciabIe size.
Thus we have two extremes: first, where chronicity is practicaIIy unavoidabIe; second, where the openings are smaI1 in coIIapsibIe tissue ‘with spontaneous closure. The determining factor is the size and Iocation of the communication. I am convinced that certain cases do not have such an easiIy demonstrabIe pathoIogic process which undoubtedIy accounts for our faiIure to prevent chronic suppurative pIeurisy. 2. Interstitial Changes in the Pulmonary Parenchyma. Th ere are few cases in which the Iung wiI1 not expand. In these cases the roentgenogram shows marked changes in the parenchyma together with thickening of the pIeura. When decortication is done the lung does not expand in the usua1 manner. There is an accompanying bronchitis, and the sputum is persistently negative for tubercIe baciIIi. By proIonged Dakinization the chest wound finaIIy cIoses Ieaving an apparentIy sterile pneumothorax. CASE III (365 D-4). A gir1, two years old, who had thickening of the pIeura and some interstitiar changes in the Iung. Her condition was not good enough to warrant an expIoratory thoracotomy with decortication of the Iung. This patient was thoroughIy Dakinized unti1 smears from the cavity showed few organisms and her chest wound was aIIowed to she continued to show an close. However, unexpIained temperature eIevation. The pneumothorax was steriIe so the temperature was due to other causes. GraduaIIy it subsided and the pneumothorax disappeared. It took about six months for the Iung to expand compIeteIy and Ii11 the chest. EventuaIly the pIeura1 thickening disappeared. In some other cases the pneumothorax did not become obIiterated, due to the marked interstitial changes in the Iung
NFW
SERIES
VOL.
parenchyma is inevitable.
III.
No.
Bohrer-Suppurative
3
and recurrence
in such cases
CASE IV (304 D-4). A boy, aged eight on ApriI I 6, 192 I, to years, was admitted the Pediatric Service, Bellevue Hospital, with pneumonia; on May 9 a thoracotomy was done, fiftv ounces of pus were removed and a colon bacillus was recovered. This case ran a very unsatisfactory course with elevations of temperature, considerable cough and expectoration. The sputum was negative for tubercle baciIIi. The chest wound ultimately closed after prolonged Dakinization with a smaIIpneumothorax persisting, and the patient was sent to the country Julv 19. On July 29, he was readmitted to the hospital with fever. Roentgen-ray examination showed a smaI1 effusion in the lower portion of the right pIeura1 cavity and a thickening of the pleura. The wound was opened, considerable pus was evacuated, the cavity was Dakinized. On August 28, the patient was again discharged in good condition with the wound closed. On September 23, he was again readmitted and a roentgen-ray examination showed a smaI1 cohection of air in the right pleural cavity, also fibrosis of the right lower lobe with marked thickening of the pIeura. On September 29, exploratory thoracotomy revealed a smah amount of pus with marked thickening of the pleura. This patient cooperated and every effort to expand the Iung was made. On October 12, he was discharged for the third time. Roentgenograms then showed but did show interstitia1 no pneumothorax, lung changes. Physical examination suggested a bronchiectasis. On June 16, 1922, he was again readmitted. A sinus was found at the site of the scar and a further roentgen-ray studs revealed more interstitial changes in the right lower Iobe. An exploratory thoracotomy showed a smaII pneumothorax but no Ioculi of pus. This wound eventuaIIy healed and the patient has remained we11 to the present time. This case, which received routine care in dealing with acute suppurative pIeurisy, developed chronic suppurative pleurisy, due to the Iung having Iost its abiIity to expand properly and to fill compIetely the pIeural cavity. 3. IVlultiple Septic Foci in the Lung Which Rupture and Reinfect the Pleural Cavity. CASE v (15;s D-4). years of age, admitted
A boy two and a haIf January 24, 1921, to
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Journal
of Surgery
234
the Pediatric Service, BeIIevue HospitaI, with Iobar pneumonia of the upper left lobe. This patient developed a suppurtive pleurisy and was operated on March 3. A moderate amount of pus was evacuated and the culture showed pneumococci. In eighteen days the wouncl had entirely heaIed and the Iung fuully expanded. One week later he was transferred to the medical service with pneumonia of the right lung and on ApriI 14 he was returned to the surgica1 service and operated on the Ieft. side (recurrent suppurative pleurisy) ; a Iarge amount of pus was found and a culture again reveaIed pneumococci. FoIlowing the operation for recurrence, this patient had a stormy career. He would have periods of normal temperature, take food readily, respond to blood transfusions and encourage us to believe him on the road to recovery. This was foIlowed by periods of reinfection and the wound again discharged profusely. He had a poor appetite and fever. The pleura was so thick that roentgenographic and fluoroscopic physical, examinations were decidedIy unsatisfactory from a diagnostic point of view. The condition of the patient did not warrant an expIoratory thoracotomy but it was hoped he would eventually reach a stage of being a reasonable operative risk. It was suspected that this patient had multipIe IocuIi or subpleural abscesses, which continued to develop. One month after operation for recurrence, a pocket of pus was found at the IeveI of the left fourth interspace anterior to axiIIary Iine. This was drained by an additiona incision as it had no communication with the former pocket. Pneumococci again appeared in the cuIture. The origina incision in the seventh space was stiI1 open but draining a very smaI1 amount of thin seropus. The patient continued an up-and-down course for two months, repeated transfusions keeping up his constantIy decIining vitaIity. No dehnite evidence of further developing IocuIi couId be diagnosticated. The case eventuaIIy terminated by the deveIopment of an acute nephritis with marked genera1 anasarca. FortunateIy, an autopsy was performed. A partia1 protocoI foIIows: On opening the pleura1 cavity, the Ieft Iung was found to be partiaIIy coIIapsed. The pIeura1 cavity on the Ieft side showed both surgica1 incisions to be wide open and there was good drainage so there was no pus in the chest cavity. The Iung was firmly bound to the
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American Journal of Surgery
Bohrer-Suppurative
chest wall in the upper and posterior portions. On removing the Iung, the pIeura was found to be markedly thickened. On section, the Iung was dark red in coIor and studded throughout by numerous abscesses varying in size from one-fourth to one-eighth of an inch. The right Iung was firmIy bound to the chest wal1 throughout its entire extent by numerous adhesions. The pleura over this Iung also was markedly thickened. The other organs were practicaIIy negative except the kidneys which showed an acute nephritis.
This was an extremely interesting case and was foIIowed cIoseIy from the beginning of the iIIness to its termination. Had this chiId not deveIoped a termina1 nephritis he wouId have deveIoped a chronic suppurative pIeurisy, and from a cause that surgery was heIpIess to prevent. 4. A tuberculous infection as a cause of chronicity is iIIustrated by: C 1s~ VI (308 D-4). A boy, aged eight February 14, 1922, to the years, admitted Pediatric Service with bronchopneumonia. He was transferred to the surgica1 division and roentgen-ray and physical examination reveafed an encapsuIated suppurative pIeurisy. He was operated upon February 20. An intercostal incision was made and a Iarge quantity of pus containing pneumocbcci, group I, was evacuated. Considering his Iong period of severe ihness the patient was in good condition. There was no apparent reason why he should not have recovered promptIy, especiahy as he was at an age where statistics show a favorabIe prognosis. Thirty days after the operation there was no discharge. The drainage tube was discontinued and the wound cIosed. Three days Iater he developed a rise of temperature and the tube was reinserted. This had to be repeated severa times. Each time we beheved the chest wouId permanentIy cIose. Roentgenograms and fl uoroscopic examination did not reveaI the cause of this condition. EventuaIIy an expIoratory thoracotomy reveaIed a smaI1 cavity that was being drained by the original incision, no undrained IocuIi were found. We did a partial decortication of the Iung by criss-cross incision and blunt dissection of the thickened pIeura. The Iung then expanded and fiIIed the pIeural cavity. A specimen of pIeura removed at operation did not show it to be tubercuIous, nor
SEPTEMBER, 192,
Pleurisy
did a specimen taken one month later. However, the wound refused to hea aIthough there was practicaIIy no cavity. A probe was passed far into the chest and an endoscopy showed the sinus to run aIong the posterior gutter toward the apex. An examination of the granuIation tissue showed it to be tubercuIous. Although two subsequent operations were done, this case drifted into the chronic cIass and has a discharging sinus at the present time. Whether this was a primary tubercuIosis or, what is more IikeIy, a tuberculosis grafted upon a pneumococcus suppurative pIeurisy, it is impossible to determine. The case just cited presents a condition very diffrcuIt to contro1. This patient has been given recognized surgica1 treatment combined with quartz Iamp therapy and the best hygienic care. He has remained in fair physica condition, but stiI1 has a smaI1 draining sinus. TREATMENT
Our genera1 pIan is as foIIows: In the formative stage, if there is distress, repeat aspiration as often as necessary. In a few instances, in streptococcus cases, where the reaccumulation of pus is very rapid, the air-tight syphon drainage or suction method is used, but this is not entireIy satisfactory; repeated aspiration is the better pIan. When the fluid is frank pus and, as is often the case, the temperature from the pneumonia has abated, open drainage is instituted. IntercostaI drainage with the so-caIIed “ffapper tube” is the method used. A “ ffapper tube ” is made by fitting a gIove finger (one that has been softened by repeated sterihzation) on the dista1 end of a fenestrated rubber tube as a projection, the tube having been cut with a sixty degree beveI, forming a vaIve that readiIy aIIows fluid and air to escape with expiration but cIoses with inspiration. This is an aid in Iung expansion as it tends to restore the negative intrapIeura1 pressure, and is of use in irrigating at the time of dressing as it forms a funneI through which irrigating ffuid is passed into the chest cavity. This principIe of vaIve action
NEW
SERIES
VOL.
III,
No.
3
Bohrer---Suppurative
is mentioned by various authors. Mathews speaks of it when he shows how the tissues tend to fall together and form a valve, which is aided by a dressing that is wet from drainage. The same principle is used by Soresi,’ who employs a meta tube with a rubber flapper valve. Mechanically, it is a more perfect valve, and it has the advantage of a projecting nipple which can be attached to a bottle by means of a rubber connecting tube thus keeping the dressing clean and avoiding the trauma of redressing. This is of distinct advantage in very sick patients, especiarly for the first few days It has also a distinct after operation. advantage over the Kenyon syphonage in that the patient is not anchored to the bottle, but the bottle to the patient, making it possible for free movement in any desired position. The operation for suppurative pleurisy is always done with local anesthesia. The patient, if not too sick, is allowed to sit up; cooperation is more likely to be had with him in this position. By preference a smaI1 incision is made in the seventh intercostal space near the mid-axillary line although the site of the incision naturally varies with the location of the pus. A ‘Yapper tube” is introduced and the pus is allowed to run out. The tube is held in place by one silkworm gut stitch. At no time have there been disturbing symptoms caused by completeIy evacuating the cavity at operation. Of course dressings become saturated the first few days after operation and must be changed frequently. At this stage the syphon drainage is much cleaner and easier for the surgeon, but the patient is not as comfortable, nor does his wound drain as eff%ientIy. Irritation is started in the next few days, the exact time depending on the condition of the patient and the amount and the character of the drainage. 1 Soresi, A. and
L. Correct conception of thoracic emits rational physiological treatment. Med. J. u Rec., cxxi, 460-465; $24-527. Late resuIts in empyema thoracis in children operated on by the author’s method. AM. J. SURG., 1926, n.s. i, 68. pyema
Pleurisy
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of suwv
237
Usually on the fourth day the cavity is irrigated, the patient reclining with wound uppermost. Saline solution is introduced through the “ ff apper tube,” the measured amount determining the size of the cavity. If no coughing is produced, Dakin’s solution is then used cautiously. If there is no “ gassing,” the cavity is daily cleansed by thorough irrigation with Dakin’s solution. This daily irrigation is not an attempt to sterilize the cavity, but is sufficient to keep thin and deodorize the discharge. Our experience with more complete Dakinization has been quite similar to that reported by many others. Even under ideal conditions rt has not materially shortened the time for complete closure of the wound. This simpIe procedure has effected a cure in about eighty per cent of our cases. The time of hospitalization ranges from fifteen to fifty days. None of the patients in this series was discharged while dressings were necessary. By this many recurrences were prevented. When, judged by temperature, appetite, type of discharge and general condition, it is found that the patient has not materially improved at the end of eight or ten days, and there is no acute otitis media or recurrence of pneumonic process, we conclude that we are dealing with a complicated form of suppurative pleurisy, such as multiple loculi or a markedly thickened pleura, preventing complete drainage. Then an exploratory thoracotomy is done. The patients are especially prepared for this operation; if anemic, they are transfused. As a routine measure they are partially digitaIized. Under light ether or gas anesthesia, an intercosta1 incision is made long enough to give proper exposure, and a rib spreader is introduced. If more exposure is required, a rib may be cut at one or both ends and teIescoped. This gives the advantage of visual guidance for dividing the vicious adhesions, doing a partial decortication or any other procedure necessary, thus converting muItiple loculi into a singIe cavity,
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or pIacing drainage where it is needed. This may appear to be radicaI surgery but, properly done, it produces IittIe shock. reduces mortahty, shortens convalescence and causes no deformity. In our series this has been done in twenty-five cases with onIy one mortaIity. This patient was a smaI1 coIored boy with ~-PIUS Wassermann reaction. Transfusion was not avaiIabIe. The wound broke down, causing a Iarge open pneumothorax, which wouId not hea1. He died tweIve days after operation. The statement has been made that a Iung expands because negative pressure in the pIeura1 cavity compeIs it to expand. That the negative pressure pIays a part is not denied, but it is onIy a minor part. The most potent factor is the intratrachea1 pressure, which is transmitted to the Iung tissue. This is easily demonstrated. For instance, when doing an expIoratory thoraacotomy with the pIeura1 cavity fuIIy exposed, we see the Iung expand and contract. Furthermore, in doing a decortication, the Iung expands under vision, and if the patient is alIowed to cough when only partiaIIy decorticated, there is danger of the Iung herniating through the incision in the thickened pIeura. AI1 this in the presence of an atmospheric pressure. That the Iung does not expand in the presence of a pneumothorax or positive pressure in a closed pIeura1 cavity is, of course, axiomatic. A Iung expands more easiIy in the presence of a negative pressure aIthough it expands to a surprising degree in atmospheric pressure provided there is an opening suffIcentIy Iarge for the easy and quick exit of air contained within the cavity. I am convinced that the important factor in curing a suppurative pIeurisy is Iung expansion and that the eIement obstructing is usuaIIy a thickened Iung expansion pleura. Therefore, any treatment that wiII prevent or, when once estabIished, remove a thickened, unyieIding pIeura wiI1 hasten Iung expansion, and foIIowing this, cIosure of the chest.
PIeurisy
SEPTEMBER. 1927 PROGNOSIS
It is very difflcuIt to make a classification of suppurative pleurisy cases, but for cIinicaI purposes groups.
they may be divided into three
I. Cases having 2. Cases having
good prognosis. poor prognosis.
3. A middIe group whose prognosis is largely dependent upon the kind of treatment received. I. Good Prognosis. In this cIinica1 grouping about forty per cent of the patients come under the heading of good prognosis. By this is meant that the patient has inherited a heaIthy constitution, has been surrounded by fair conditions during heaIth, the primary disease was promptIy and properIy diagnosed and treated, and deveIoped encapsuIated supwhich in turn was purative pleurisy, promptly diagnosed and received proper care during the formative period of the disease. Such patients wiII recover if they are given adequate drainage by any of the methods advocated. The period of invalidism wiII be minimum. The type of organism is a minor matter. Recovery statistics in this group are very gratifying. In this group, our 2. Poor Prognosis. series at BeIIevue HospitaI shows about twenty-five per cent. Through the Social Service Department, we have found Iiving conditions bad, unheaIthy parents, dirty unsanitary homes, under-feeding and exposure. Rickets is almost universa1. Add to this background a virulent infection, the primary disease improperly diagnosed, a starvation diet, and the child sent to the hospita1 onIy when in extreme condition. Such cases, with an encapsuIated suppurative pIeurisy, wiII often do surprisingIy we11 if given adequate drainage and plenty of food. But in a patient with a viruIent infection with comphcated pleura1 invoIvement, or one who has already deveIoped compIications such as acute otitis media, or pneumonia of the opposite Iung, the prognosis is universaIIy bad regardIess of the type of operative procedure.
Bohrer-Suppurative 3. kliddle
Group where Prognosis
upon Surgical Procedure. The thirty-five per cent faI1 in this
group. In has been primary virulent,
this class, where the background only fair, the treatment of the disease good, but the infection the surgica1 treatment IargeIy the ultimate
American
is much
Dependent remaining
determines
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239
of Surgery
MORTALITIES
A statistica anaIysis has not been the aim of this paper, but to determine the resuIts of the above outIine of treatment, a few statistics are here presented. Died Cured MortaIity
NO.
outcome.
The order of treatment in suppurative pleurisy is, first, adequate drainage; second, skiIIfu1 nursing and high caIoric diet; third, blood transfusion. The Iatter requires a speciaiist; not mere technique, as that can be easiIy mastered, but carefu1 judgment is required in determining when and how much bIood should be given. It is more difficult to determine these points in children than in adults. Only whoIe bIood, is given and by the Lindemann method. With whoIe blood, accurateI)matched and given in proper amounts reactions are seIdom seen. The circulating fluid is quickIy brought up to the standard and it acts as an efficient tonic, which makes it possibIe to take greater amounts of food and in turn metaboSize it. This is a most important factor in recover>-. In an;\- case of secondary operation, it is our routine to give a preliminary transfusion. We have found it an excellent prophyIactic measure, and without doubt, it has been the determining factor in many cases and has shortened the period of convalescence in many more. In this series fifty cases were transfused, many having two or more transfusions. Had donors been avaiIable many more would have received the same treatment. Th e greatest number of transfusions to be given anv one case, was fourteen. It was an interesting case to fohow. BIood transfusion was the therapy that prolonged life and made recovery aImost in sight, even in this septic case. FoIIowing each transfusion the patient took more food and showed marked signs of improvement, but could not overcome the infection and died four months Iater.
Journal
per cent
I920
Age
o-
2
IS
331s
6
‘9
5 2
IO
2-
17
IO’:;
IO
0
IO
0
6-12 Total.
‘5-9 1921
Age
0-
2
2-
6
6-12 Total.
. . .
.
7i 16 7
3 I
4 14 6
30
6
24
3~ I
13
2
32 IZ’G
I4 _____ 20
1922
Age
o2--
2
9 16
6
6-12
71
Total. Age
4
24; I
IO
.
;
20 0
_;
0
13
13.3
9
40 8.3
I5
6
2-
I2
I
Total. Total jar series.
12’
3
2
O&12
28
0
0
Ij;
6
7
331:; 6’;
3
1924 o- 2
...’
6
0:
32 1023 om- 2 2-- 6 6-12
Total. Age
1
6
0
33 I54
7 26
II
6 26 128
0
161:~ 16.8
A gIance at this tabIe shows readily the fahacy of concIusions drawn from a smail number of cases during a short period of time. Thus in 1923 the mortaIity in infants was nil, whiIe in 1924 it was 40 per cent. For the entire time extending over five consecutive years it was 35.4 per cent. The number of infant cases was fortyeight, the exact number also reported by Ladd and CutIer,’ with the same percentage of mortaIity. The mortaIity for the entire group as shown in the tabIe is 16.8 per cent. This is somewhat higher than expected, due to 1Ladd, W. E., and CutIer, G. D. Mortality from empyema in children. Surg., Gpec. F Oh., 1924, XXXiX,429-43 I.
240
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Bohrer-Suppurative
the Iarge number of infants in the series. The mortaIity excIuding infants (106 cases with g deaths) is 8.49 per cent; in the group from two to six years (73 cases with 8 deaths) is 10.9 per cent; and in the group from six to tweIve years, which is universaIly found to be the lowest of any age (33 cases with I death) 3.3 per cent. In computing these statistics, onIy cases that were operated upon were incIuded. In the tota number of deaths (34) unfortunateIy onIy a few autopsies couId be obtained. ConsequentIy it was impossibIe to determine the exact cause of death in each case. Of these fata cases: One died suddenly during convalescence, evidentIy from an emboIus. One went into severe shock from “gassing ” whiIe being irrigated with Dakin’s soIution, and did not recover. In one whose chest was stiI1 draining but had no retention, a generalized peritonitis was discovered post mortem, but no foci of the peritonea1 infection were found. Two cases had severe nephritis with marked anasarca. One had cerebrospinal meningitis. One died six hours after bIood transfusion, there being severe shock induced by the transfusion.
SEPTEMBER, ,927
PIeurisy
One had pneumonia of the opposite side, folIowed by suppurative pIeurisy on that side. One had severe IaryngeaI diphtheria. One had ceIIuIitis of the arm. One had osteomyeIitis of the tibia. Five had pneumonia of the opposite side. Ten had acute otitis media. In a11 of these cases severe toxemia was the picture presented, and this was the rea1 cause of death, either from the suppurative pIeurisy or from the complications. SUMMARY I. The treatment of acute suppurative pleurisy in chiIdren differs from that in the case of ad&s. 2. High caIory diet is an essentia1 to overcome negative nitrogen baIance. 3. Repeated aspiration during formative stage for reIief of distress is advised. 4. IntercostaI incision and drainage is a method of choice. 5. Only IocaI anesthesia .shouId be used. 6. A “flapper tube” aids materially in Iung expansion. 7. Blood transfusions are of great vaIue. 8. A few cases will inevitably deveIop a chronic form. g. Exercise for Iung expansion is of great importance.
ACUTE
OF
SUPPURATIVE PLEURISY IN CHILDREN* JOHN V.
BOHRER, M.D., F.A.C.S. NEW YORK
PECULIARITIES
T
OF IN
SUPPURATIVE
PLEURISY
CHILDREN
HE treatment of suppurative pIeurisy in chiIdren has received but littIe attention from those writing on this subject, as such cases have usuahy been incIuded in adult groups. There are certain features, however, that differentiate these groups, the most important of which are: I. Thickness of chest waI1. 2. Diminished power of resistance. 3. Cooperation of patient. 4. Nature’s abiIity to repair in chiIdhood. I. Thickness of Chest Wall. In the average chiId suffering from suppurative pIeurisy, the thinness of the chest wall, when exaggerated by emaciation, has some operative advantage. (a) Diagnosis is more exact in outhning the encapsuIated pocket, both by physica signs and by roentgenography and ffuoroscopy. (b) An underIying pneumonia is readiIy detected, which is of vast significance in determining the question of operation. 2. Diminished Power of Resistance. (a) Most chiIdren with suppurative pIeurisy do not have enough power of resistance to withstand the shock of any severe operation, so the simpIest efficient operation is Even the shock of dressing demanded. the wound is vitaIIy significant, and particuIarIy so during the first few days after operation. In these cases it is of the greatest importance to use simpIe tubes that are heId in pIace in a position that does not irritate, and yet are effective.
(b) In very young chiIdren suffering from suppurative pIeurisy, where mortality is exceptionaIIy high, forced feeding before and after operation is often necessary. When these chiIdren, who refuse food, are gavaged, regurgitation foIIows. This occurs in very sick patients whose emaciation wouId indicate a Iong period of starvation. ApparentIy during their primary disease, when feeding is diffrcuIt, their stomachs contract. This contraction is overcome by frequent feedings of smaI1 amounts which are graduaIIy increased in quantity. This treatment requires constant nursing, but it is the means of saving Iife. With the exception of the first few days after operation, it rareIy is necessary to urge eating, as a properly drained empyema patient wiI1 consume Iarge quantities of food. The dietary must be of high caIoric vaIue and the food shouId be given in as great a quantity as the child’s gastrointestinal tract wiI1 assimiIate. The reasons for requiring so much food are: to overcome Ioss of weight due to the emaciation which obtained during the primary disease and the formative period of the suppurative pIeurisy; to overcome the negative nitrogen baIance that is aIways present in underfed suppurative pleurisy cases; and to supply warmth to overcome the extra Ioss of heat that is concomitant with an open pneumothorax. 3. Cooperation of the Child. This is necessary and can be obtained by some simpIe device such as a toy balloon used in pIace of the customary bIow-bottIe. To prevent spina curvature, which is
* Read in part before the Section of Surgery, New York Academy of Medicine, February 4, 1927. An abstract of this paper, and the discussions, were published with the Transactions of that meeting in THE AMERICAS JOURNAL OF SURGERY.,May, ,927.
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IikeIy to occur, get the chiId out of bed as earIy as possibIe. Encourage him to run unti1 short of breath, which wiII create deeper breathing with greater expansion and better drainage. Exercise in any form is particuIarIy desirabIe. BaIcony sunlight treatment, after acute symptoms have subsided, is of great value. The average chiId wiI1 cooperate, so this may be carried on even in mid-winter. In chiIdren the reaction to exposure is very noticeable and it is out of a11 proportion to that of adults. It is most vital directly after operation and for the next four to six days. The percentage of complications is very much higher in windy winter months, which is due to exposure to coId and prevalent infections. 4. Nature’s Ability to Repair in Childhood. In suppurative pleurisy, as in many other diseases of children, growth is a great adjunct to the final resuIt. If there is a curvature or a flattening of the chest or incomplete expansion of the lung this fault wiI1 be graduaIIy overcome as the chiId deveIops. The management of suppurative pIeurisy is based on possibilities and directed by probabilities. The pIan of treatment should fuIfil1 the following requirements and, in so far as it yieIds good results, must be accepted as satisfactory: I. Proper treatment of the primary disease with early recognition of the suppurative pIeurisy. 2. Low mortaIity. 3. Minimum anatomical and physioIogicaI deformity. 4. Prevention of complications. 3. EarIy restoration to health. In comparing treatment of suppurative pIeurisy by different surgeons, with that of a suppurative process in the peritoneal cavity as, for instance, suppurative appendicitis, we are forced to the conclusion that there are stiI1 worIds to conquer in the reaIm of suppurative pleurisy. PracticaIIy a11 agree on the general plan of treating suppurative appendicitis, but onIy in a few general principles are
PIeurisy
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surgeons agreed in the treatment of suppurative pieurisy. AI1 beIieve in the dictum of “where there is pus, Iet it out.” However, the time to act; the amount of pus to be removed at the operation; the method of attack, whether by rib resection, simple thoracotomy, expIoratory thoracotomy, with removal of foreign substance (congealed fibrin) ; the method of cirainage, whether by the cIosed suction method, syphon drainage, double drainage, through and through drainage tubes; aspiration with injection of bactericidal agents; the pIacing of Dakin tubes in the cavity so al1 parts may be irrigated and disinfected; these are a few points on which we are not fuIIy in accord. Every writer wishes to impress the fact that prevention of chronic empyema is one of our chief aims; yet we a11 continue to operate on chronic suppurative pleurisy, and we believe that a certain percentage, varying with the particuIar pathology, will continue to develop chronic suppurative pIeurisy. In other words, it is the particular type of suppurative pleurisy rather than the particular type of operation that is the determining factor. COMPLICATIONS
CAUSING
CHRONICITY
Many of the compIications that prevent closure of the chest waI1, such as osteomyeIitis of rib, inadequate drainage, foreign bodies and multiple pockets can be controIIed by adequate surgery. A few, however, wil1 develop a chronic form in spite of the management of the acute. We refer particularIy to those cases with (I) large bronchopuImonary fistuIae; (2) interstitia1 changes in the puImonary parenchyma; (3) muItiple septic foci in the lung which apparentIy, from time to time, rupture through the visceral pleura and reinfect the cavity; (4) primary tubercuIosis or a secondary infection with tuberculosis. The pathology of suppurative pleurisy does not come within the scope of this paper and will be referred to only by statements of accepted ideas, insofar as
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American Journal of Surgery
Bohrer-Suppurative
it is inseparabIe from a discussion of treatment. I. With the use of Dak?n soIution we frequentIy find a more or Iess sudden appearance of a bronchopulmonary j&da. At first we thought that the soIution had eroded a spot of partiaIly devitahzed Iung tissue. A more probabIe expIanation is that the fistuIa deveIoped during the course of the disease but had been temporariIy cIosed by the thick layer of fibrin that adhered to the viscera1 pleura. When this became detached the fistuIa suddenIy appeared. This is iIIustrated by the foIIowing case: CASE I (234 D-4). A chiId of two years, in whose case the reguIar two-hourIy Dakin’s irrigation was not used but the wound was daily irrigated at the time of dressing. This was without ilI-effect for severa days. Later, when the sohrtion was introduced, the patient on account of the opening became “gassed” of a fair-sized bronchus. There was a severe paroxysm of coughing; the chiId strangIed, became cyanotic and deveIoped marked shock from which it did not recover. Death is very uncommon from such a cause. SmaII puImonary communications cIose spontaneousIy and are not a cause of chronicity. For instance, in doing a decorthe parenchyma is invariabIy tication, damaged enough to cause bubbIes to appear. If irrigation is started at once the patient becomes “gassed,” but in three to six days after operation it is perfectIy safe to institute this treatment. When a Iarge bronchus communicates with the pIeura1 cavity it wiI1 not cIose spontaneousIy. This is iIIustrated by the foIIowing case : CASE II (299 D-4). A boy, aged six years, suffering from post-tonsiIIectomy pneumonia, who did not recover in the usua1 time, deveIoped signs of fluid in the chest. A roentgenogram confirmed this diagnosis and an exploratory puncture reveaIed pus. The operation showed that a Iung abscess had spontaneously ruptured into the pIeura1 cavity, producing an encysted suppurative pleurisy. This wound had every advantage for spontaneous cIosure but resisted al1 efforts and
Pleurisy
SEPTEMBER, ,927
deveIoped a chronic state. It, of course, rightfuIIy belongs in the cIass of Iung abscesses, but with its resuIting bronchopuImonary IistuIa it serves to JIustrate in a magnified way the fact that when the pIeura1 cavity communicates with Iung parenchyma it wiI1 not spontaneousIy hea if that communication is of any appreciabIe size.
Thus we have two extremes: first, where chronicity is practicaIIy unavoidabIe; second, where the openings are smaI1 in coIIapsibIe tissue ‘with spontaneous closure. The determining factor is the size and Iocation of the communication. I am convinced that certain cases do not have such an easiIy demonstrabIe pathoIogic process which undoubtedIy accounts for our faiIure to prevent chronic suppurative pIeurisy. 2. Interstitial Changes in the Pulmonary Parenchyma. Th ere are few cases in which the Iung wiI1 not expand. In these cases the roentgenogram shows marked changes in the parenchyma together with thickening of the pIeura. When decortication is done the lung does not expand in the usua1 manner. There is an accompanying bronchitis, and the sputum is persistently negative for tubercIe baciIIi. By proIonged Dakinization the chest wound finaIIy cIoses Ieaving an apparentIy sterile pneumothorax. CASE III (365 D-4). A gir1, two years old, who had thickening of the pIeura and some interstitiar changes in the Iung. Her condition was not good enough to warrant an expIoratory thoracotomy with decortication of the Iung. This patient was thoroughIy Dakinized unti1 smears from the cavity showed few organisms and her chest wound was aIIowed to she continued to show an close. However, unexpIained temperature eIevation. The pneumothorax was steriIe so the temperature was due to other causes. GraduaIIy it subsided and the pneumothorax disappeared. It took about six months for the Iung to expand compIeteIy and Ii11 the chest. EventuaIly the pIeura1 thickening disappeared. In some other cases the pneumothorax did not become obIiterated, due to the marked interstitial changes in the Iung
NFW
SERIES
VOL.
parenchyma is inevitable.
III.
No.
Bohrer-Suppurative
3
and recurrence
in such cases
CASE IV (304 D-4). A boy, aged eight on ApriI I 6, 192 I, to years, was admitted the Pediatric Service, Bellevue Hospital, with pneumonia; on May 9 a thoracotomy was done, fiftv ounces of pus were removed and a colon bacillus was recovered. This case ran a very unsatisfactory course with elevations of temperature, considerable cough and expectoration. The sputum was negative for tubercle baciIIi. The chest wound ultimately closed after prolonged Dakinization with a smaIIpneumothorax persisting, and the patient was sent to the country Julv 19. On July 29, he was readmitted to the hospital with fever. Roentgen-ray examination showed a smaI1 effusion in the lower portion of the right pIeura1 cavity and a thickening of the pleura. The wound was opened, considerable pus was evacuated, the cavity was Dakinized. On August 28, the patient was again discharged in good condition with the wound closed. On September 23, he was again readmitted and a roentgen-ray examination showed a smaI1 cohection of air in the right pleural cavity, also fibrosis of the right lower lobe with marked thickening of the pIeura. On September 29, exploratory thoracotomy revealed a smah amount of pus with marked thickening of the pleura. This patient cooperated and every effort to expand the Iung was made. On October 12, he was discharged for the third time. Roentgenograms then showed but did show interstitia1 no pneumothorax, lung changes. Physical examination suggested a bronchiectasis. On June 16, 1922, he was again readmitted. A sinus was found at the site of the scar and a further roentgen-ray studs revealed more interstitial changes in the right lower Iobe. An exploratory thoracotomy showed a smaII pneumothorax but no Ioculi of pus. This wound eventuaIIy healed and the patient has remained we11 to the present time. This case, which received routine care in dealing with acute suppurative pIeurisy, developed chronic suppurative pleurisy, due to the Iung having Iost its abiIity to expand properly and to fill compIetely the pIeural cavity. 3. IVlultiple Septic Foci in the Lung Which Rupture and Reinfect the Pleural Cavity. CASE v (15;s D-4). years of age, admitted
A boy two and a haIf January 24, 1921, to
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Journal
of Surgery
234
the Pediatric Service, BeIIevue HospitaI, with Iobar pneumonia of the upper left lobe. This patient developed a suppurtive pleurisy and was operated on March 3. A moderate amount of pus was evacuated and the culture showed pneumococci. In eighteen days the wouncl had entirely heaIed and the Iung fuully expanded. One week later he was transferred to the medical service with pneumonia of the right lung and on ApriI 14 he was returned to the surgica1 service and operated on the Ieft. side (recurrent suppurative pleurisy) ; a Iarge amount of pus was found and a culture again reveaIed pneumococci. FoIlowing the operation for recurrence, this patient had a stormy career. He would have periods of normal temperature, take food readily, respond to blood transfusions and encourage us to believe him on the road to recovery. This was foIlowed by periods of reinfection and the wound again discharged profusely. He had a poor appetite and fever. The pleura was so thick that roentgenographic and fluoroscopic physical, examinations were decidedIy unsatisfactory from a diagnostic point of view. The condition of the patient did not warrant an expIoratory thoracotomy but it was hoped he would eventually reach a stage of being a reasonable operative risk. It was suspected that this patient had multipIe IocuIi or subpleural abscesses, which continued to develop. One month after operation for recurrence, a pocket of pus was found at the IeveI of the left fourth interspace anterior to axiIIary Iine. This was drained by an additiona incision as it had no communication with the former pocket. Pneumococci again appeared in the cuIture. The origina incision in the seventh space was stiI1 open but draining a very smaI1 amount of thin seropus. The patient continued an up-and-down course for two months, repeated transfusions keeping up his constantIy decIining vitaIity. No dehnite evidence of further developing IocuIi couId be diagnosticated. The case eventuaIIy terminated by the deveIopment of an acute nephritis with marked genera1 anasarca. FortunateIy, an autopsy was performed. A partia1 protocoI foIIows: On opening the pleura1 cavity, the Ieft Iung was found to be partiaIIy coIIapsed. The pIeura1 cavity on the Ieft side showed both surgica1 incisions to be wide open and there was good drainage so there was no pus in the chest cavity. The Iung was firmly bound to the
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American Journal of Surgery
Bohrer-Suppurative
chest wall in the upper and posterior portions. On removing the Iung, the pIeura was found to be markedly thickened. On section, the Iung was dark red in coIor and studded throughout by numerous abscesses varying in size from one-fourth to one-eighth of an inch. The right Iung was firmIy bound to the chest wal1 throughout its entire extent by numerous adhesions. The pleura over this Iung also was markedly thickened. The other organs were practicaIIy negative except the kidneys which showed an acute nephritis.
This was an extremely interesting case and was foIIowed cIoseIy from the beginning of the iIIness to its termination. Had this chiId not deveIoped a termina1 nephritis he wouId have deveIoped a chronic suppurative pIeurisy, and from a cause that surgery was heIpIess to prevent. 4. A tuberculous infection as a cause of chronicity is iIIustrated by: C 1s~ VI (308 D-4). A boy, aged eight February 14, 1922, to the years, admitted Pediatric Service with bronchopneumonia. He was transferred to the surgica1 division and roentgen-ray and physical examination reveafed an encapsuIated suppurative pIeurisy. He was operated upon February 20. An intercostal incision was made and a Iarge quantity of pus containing pneumocbcci, group I, was evacuated. Considering his Iong period of severe ihness the patient was in good condition. There was no apparent reason why he should not have recovered promptIy, especiahy as he was at an age where statistics show a favorabIe prognosis. Thirty days after the operation there was no discharge. The drainage tube was discontinued and the wound cIosed. Three days Iater he developed a rise of temperature and the tube was reinserted. This had to be repeated severa times. Each time we beheved the chest wouId permanentIy cIose. Roentgenograms and fl uoroscopic examination did not reveaI the cause of this condition. EventuaIIy an expIoratory thoracotomy reveaIed a smaI1 cavity that was being drained by the original incision, no undrained IocuIi were found. We did a partial decortication of the Iung by criss-cross incision and blunt dissection of the thickened pIeura. The Iung then expanded and fiIIed the pIeural cavity. A specimen of pIeura removed at operation did not show it to be tubercuIous, nor
SEPTEMBER, 192,
Pleurisy
did a specimen taken one month later. However, the wound refused to hea aIthough there was practicaIIy no cavity. A probe was passed far into the chest and an endoscopy showed the sinus to run aIong the posterior gutter toward the apex. An examination of the granuIation tissue showed it to be tubercuIous. Although two subsequent operations were done, this case drifted into the chronic cIass and has a discharging sinus at the present time. Whether this was a primary tubercuIosis or, what is more IikeIy, a tuberculosis grafted upon a pneumococcus suppurative pIeurisy, it is impossible to determine. The case just cited presents a condition very diffrcuIt to contro1. This patient has been given recognized surgica1 treatment combined with quartz Iamp therapy and the best hygienic care. He has remained in fair physica condition, but stiI1 has a smaI1 draining sinus. TREATMENT
Our genera1 pIan is as foIIows: In the formative stage, if there is distress, repeat aspiration as often as necessary. In a few instances, in streptococcus cases, where the reaccumulation of pus is very rapid, the air-tight syphon drainage or suction method is used, but this is not entireIy satisfactory; repeated aspiration is the better pIan. When the fluid is frank pus and, as is often the case, the temperature from the pneumonia has abated, open drainage is instituted. IntercostaI drainage with the so-caIIed “ffapper tube” is the method used. A “ ffapper tube ” is made by fitting a gIove finger (one that has been softened by repeated sterihzation) on the dista1 end of a fenestrated rubber tube as a projection, the tube having been cut with a sixty degree beveI, forming a vaIve that readiIy aIIows fluid and air to escape with expiration but cIoses with inspiration. This is an aid in Iung expansion as it tends to restore the negative intrapIeura1 pressure, and is of use in irrigating at the time of dressing as it forms a funneI through which irrigating ffuid is passed into the chest cavity. This principIe of vaIve action
NEW
SERIES
VOL.
III,
No.
3
Bohrer---Suppurative
is mentioned by various authors. Mathews speaks of it when he shows how the tissues tend to fall together and form a valve, which is aided by a dressing that is wet from drainage. The same principle is used by Soresi,’ who employs a meta tube with a rubber flapper valve. Mechanically, it is a more perfect valve, and it has the advantage of a projecting nipple which can be attached to a bottle by means of a rubber connecting tube thus keeping the dressing clean and avoiding the trauma of redressing. This is of distinct advantage in very sick patients, especiarly for the first few days It has also a distinct after operation. advantage over the Kenyon syphonage in that the patient is not anchored to the bottle, but the bottle to the patient, making it possible for free movement in any desired position. The operation for suppurative pleurisy is always done with local anesthesia. The patient, if not too sick, is allowed to sit up; cooperation is more likely to be had with him in this position. By preference a smaI1 incision is made in the seventh intercostal space near the mid-axillary line although the site of the incision naturally varies with the location of the pus. A ‘Yapper tube” is introduced and the pus is allowed to run out. The tube is held in place by one silkworm gut stitch. At no time have there been disturbing symptoms caused by completeIy evacuating the cavity at operation. Of course dressings become saturated the first few days after operation and must be changed frequently. At this stage the syphon drainage is much cleaner and easier for the surgeon, but the patient is not as comfortable, nor does his wound drain as eff%ientIy. Irritation is started in the next few days, the exact time depending on the condition of the patient and the amount and the character of the drainage. 1 Soresi, A. and
L. Correct conception of thoracic emits rational physiological treatment. Med. J. u Rec., cxxi, 460-465; $24-527. Late resuIts in empyema thoracis in children operated on by the author’s method. AM. J. SURG., 1926, n.s. i, 68. pyema
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of suwv
237
Usually on the fourth day the cavity is irrigated, the patient reclining with wound uppermost. Saline solution is introduced through the “ ff apper tube,” the measured amount determining the size of the cavity. If no coughing is produced, Dakin’s solution is then used cautiously. If there is no “ gassing,” the cavity is daily cleansed by thorough irrigation with Dakin’s solution. This daily irrigation is not an attempt to sterilize the cavity, but is sufficient to keep thin and deodorize the discharge. Our experience with more complete Dakinization has been quite similar to that reported by many others. Even under ideal conditions rt has not materially shortened the time for complete closure of the wound. This simpIe procedure has effected a cure in about eighty per cent of our cases. The time of hospitalization ranges from fifteen to fifty days. None of the patients in this series was discharged while dressings were necessary. By this many recurrences were prevented. When, judged by temperature, appetite, type of discharge and general condition, it is found that the patient has not materially improved at the end of eight or ten days, and there is no acute otitis media or recurrence of pneumonic process, we conclude that we are dealing with a complicated form of suppurative pleurisy, such as multiple loculi or a markedly thickened pleura, preventing complete drainage. Then an exploratory thoracotomy is done. The patients are especially prepared for this operation; if anemic, they are transfused. As a routine measure they are partially digitaIized. Under light ether or gas anesthesia, an intercosta1 incision is made long enough to give proper exposure, and a rib spreader is introduced. If more exposure is required, a rib may be cut at one or both ends and teIescoped. This gives the advantage of visual guidance for dividing the vicious adhesions, doing a partial decortication or any other procedure necessary, thus converting muItiple loculi into a singIe cavity,
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Journal
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Eohrer-Suppurative
or pIacing drainage where it is needed. This may appear to be radicaI surgery but, properly done, it produces IittIe shock. reduces mortahty, shortens convalescence and causes no deformity. In our series this has been done in twenty-five cases with onIy one mortaIity. This patient was a smaI1 coIored boy with ~-PIUS Wassermann reaction. Transfusion was not avaiIabIe. The wound broke down, causing a Iarge open pneumothorax, which wouId not hea1. He died tweIve days after operation. The statement has been made that a Iung expands because negative pressure in the pIeura1 cavity compeIs it to expand. That the negative pressure pIays a part is not denied, but it is onIy a minor part. The most potent factor is the intratrachea1 pressure, which is transmitted to the Iung tissue. This is easily demonstrated. For instance, when doing an expIoratory thoraacotomy with the pIeura1 cavity fuIIy exposed, we see the Iung expand and contract. Furthermore, in doing a decortication, the Iung expands under vision, and if the patient is alIowed to cough when only partiaIIy decorticated, there is danger of the Iung herniating through the incision in the thickened pIeura. AI1 this in the presence of an atmospheric pressure. That the Iung does not expand in the presence of a pneumothorax or positive pressure in a closed pIeura1 cavity is, of course, axiomatic. A Iung expands more easiIy in the presence of a negative pressure aIthough it expands to a surprising degree in atmospheric pressure provided there is an opening suffIcentIy Iarge for the easy and quick exit of air contained within the cavity. I am convinced that the important factor in curing a suppurative pIeurisy is Iung expansion and that the eIement obstructing is usuaIIy a thickened Iung expansion pleura. Therefore, any treatment that wiII prevent or, when once estabIished, remove a thickened, unyieIding pIeura wiI1 hasten Iung expansion, and foIIowing this, cIosure of the chest.
PIeurisy
SEPTEMBER. 1927 PROGNOSIS
It is very difflcuIt to make a classification of suppurative pleurisy cases, but for cIinicaI purposes groups.
they may be divided into three
I. Cases having 2. Cases having
good prognosis. poor prognosis.
3. A middIe group whose prognosis is largely dependent upon the kind of treatment received. I. Good Prognosis. In this cIinica1 grouping about forty per cent of the patients come under the heading of good prognosis. By this is meant that the patient has inherited a heaIthy constitution, has been surrounded by fair conditions during heaIth, the primary disease was promptIy and properIy diagnosed and treated, and deveIoped encapsuIated supwhich in turn was purative pleurisy, promptly diagnosed and received proper care during the formative period of the disease. Such patients wiII recover if they are given adequate drainage by any of the methods advocated. The period of invalidism wiII be minimum. The type of organism is a minor matter. Recovery statistics in this group are very gratifying. In this group, our 2. Poor Prognosis. series at BeIIevue HospitaI shows about twenty-five per cent. Through the Social Service Department, we have found Iiving conditions bad, unheaIthy parents, dirty unsanitary homes, under-feeding and exposure. Rickets is almost universa1. Add to this background a virulent infection, the primary disease improperly diagnosed, a starvation diet, and the child sent to the hospita1 onIy when in extreme condition. Such cases, with an encapsuIated suppurative pIeurisy, wiII often do surprisingIy we11 if given adequate drainage and plenty of food. But in a patient with a viruIent infection with comphcated pleura1 invoIvement, or one who has already deveIoped compIications such as acute otitis media, or pneumonia of the opposite Iung, the prognosis is universaIIy bad regardIess of the type of operative procedure.
Bohrer-Suppurative 3. kliddle
Group where Prognosis
upon Surgical Procedure. The thirty-five per cent faI1 in this
group. In has been primary virulent,
this class, where the background only fair, the treatment of the disease good, but the infection the surgica1 treatment IargeIy the ultimate
American
is much
Dependent remaining
determines
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239
of Surgery
MORTALITIES
A statistica anaIysis has not been the aim of this paper, but to determine the resuIts of the above outIine of treatment, a few statistics are here presented. Died Cured MortaIity
NO.
outcome.
The order of treatment in suppurative pleurisy is, first, adequate drainage; second, skiIIfu1 nursing and high caIoric diet; third, blood transfusion. The Iatter requires a speciaiist; not mere technique, as that can be easiIy mastered, but carefu1 judgment is required in determining when and how much bIood should be given. It is more difficult to determine these points in children than in adults. Only whoIe bIood, is given and by the Lindemann method. With whoIe blood, accurateI)matched and given in proper amounts reactions are seIdom seen. The circulating fluid is quickIy brought up to the standard and it acts as an efficient tonic, which makes it possibIe to take greater amounts of food and in turn metaboSize it. This is a most important factor in recover>-. In an;\- case of secondary operation, it is our routine to give a preliminary transfusion. We have found it an excellent prophyIactic measure, and without doubt, it has been the determining factor in many cases and has shortened the period of convalescence in many more. In this series fifty cases were transfused, many having two or more transfusions. Had donors been avaiIable many more would have received the same treatment. Th e greatest number of transfusions to be given anv one case, was fourteen. It was an interesting case to fohow. BIood transfusion was the therapy that prolonged life and made recovery aImost in sight, even in this septic case. FoIIowing each transfusion the patient took more food and showed marked signs of improvement, but could not overcome the infection and died four months Iater.
Journal
per cent
I920
Age
o-
2
IS
331s
6
‘9
5 2
IO
2-
17
IO’:;
IO
0
IO
0
6-12 Total.
‘5-9 1921
Age
0-
2
2-
6
6-12 Total.
. . .
.
7i 16 7
3 I
4 14 6
30
6
24
3~ I
13
2
32 IZ’G
I4 _____ 20
1922
Age
o2--
2
9 16
6
6-12
71
Total. Age
4
24; I
IO
.
;
20 0
_;
0
13
13.3
9
40 8.3
I5
6
2-
I2
I
Total. Total jar series.
12’
3
2
O&12
28
0
0
Ij;
6
7
331:; 6’;
3
1924 o- 2
...’
6
0:
32 1023 om- 2 2-- 6 6-12
Total. Age
1
6
0
33 I54
7 26
II
6 26 128
0
161:~ 16.8
A gIance at this tabIe shows readily the fahacy of concIusions drawn from a smail number of cases during a short period of time. Thus in 1923 the mortaIity in infants was nil, whiIe in 1924 it was 40 per cent. For the entire time extending over five consecutive years it was 35.4 per cent. The number of infant cases was fortyeight, the exact number also reported by Ladd and CutIer,’ with the same percentage of mortaIity. The mortaIity for the entire group as shown in the tabIe is 16.8 per cent. This is somewhat higher than expected, due to 1Ladd, W. E., and CutIer, G. D. Mortality from empyema in children. Surg., Gpec. F Oh., 1924, XXXiX,429-43 I.
240
American Journal of Surgery
Bohrer-Suppurative
the Iarge number of infants in the series. The mortaIity excIuding infants (106 cases with g deaths) is 8.49 per cent; in the group from two to six years (73 cases with 8 deaths) is 10.9 per cent; and in the group from six to tweIve years, which is universaIly found to be the lowest of any age (33 cases with I death) 3.3 per cent. In computing these statistics, onIy cases that were operated upon were incIuded. In the tota number of deaths (34) unfortunateIy onIy a few autopsies couId be obtained. ConsequentIy it was impossibIe to determine the exact cause of death in each case. Of these fata cases: One died suddenly during convalescence, evidentIy from an emboIus. One went into severe shock from “gassing ” whiIe being irrigated with Dakin’s soIution, and did not recover. In one whose chest was stiI1 draining but had no retention, a generalized peritonitis was discovered post mortem, but no foci of the peritonea1 infection were found. Two cases had severe nephritis with marked anasarca. One had cerebrospinal meningitis. One died six hours after bIood transfusion, there being severe shock induced by the transfusion.
SEPTEMBER, ,927
PIeurisy
One had pneumonia of the opposite side, folIowed by suppurative pIeurisy on that side. One had severe IaryngeaI diphtheria. One had ceIIuIitis of the arm. One had osteomyeIitis of the tibia. Five had pneumonia of the opposite side. Ten had acute otitis media. In a11 of these cases severe toxemia was the picture presented, and this was the rea1 cause of death, either from the suppurative pIeurisy or from the complications. SUMMARY I. The treatment of acute suppurative pleurisy in chiIdren differs from that in the case of ad&s. 2. High caIory diet is an essentia1 to overcome negative nitrogen baIance. 3. Repeated aspiration during formative stage for reIief of distress is advised. 4. IntercostaI incision and drainage is a method of choice. 5. Only IocaI anesthesia .shouId be used. 6. A “flapper tube” aids materially in Iung expansion. 7. Blood transfusions are of great vaIue. 8. A few cases will inevitably deveIop a chronic form. g. Exercise for Iung expansion is of great importance.