While the serious phenomena met with in acute traumatic pneumothorax vary in intensity according to individuals and circumstances, and in some cases are so slight that they may be disregarded, it is the duty of every surgeon whenever he is about to undertake an operation On the chest or neighboring region which might involve the pleura, to assume that sudden admission of air into the pleural cavity is inevitable and he must be pre pared to meet the evil effects of acute atelectasis.
The procedure that promises the most benefit in preventing pulmonary collapse in operations on the chest is artificial in flation of the lung and rhythmical main tenance of artificial respiration by means of a tube in the glottis directly connected with a bellows. The best means hitherto used for inflating the lung in cases of acute traumatic pneumothorax is af forded by a bellows devised by Fell by which air is passed through an O'Dwyer intubation-tube inserted, as in cases of diphtheria, into the glottis. Maths (An nals of Surg., Apr., '99).
In most cases the question of paracen tesis has to be considered. If the press ure within the chest becomes great and the dyspncea urgent in consequence, a small cannula should be passed to allow air to escape. The operation must be done with the most careful antiseptic precautions. The lowering of the pleural pressure may be followed by the reopening of the perforation if it had become sealed with lymph; but if the distress is urgent even this risk must be taken. Following the removal of the cannula there is a liability to subcutane ous emphysema; this may be avoided by making pressure on the puncture for a short time after withdrawal of the can nula.
In tuberculous cases with purulent pleural exudate the course may be chronic without marked disturbance. Such cases had better be left alone. Aspiration is only followed by tempo rary relief, and free incision with drain age results in improvement for a time, but as the lung usually does not expand decomposition of the exudate takes place and sepsis is produced. In many, greater activity of the tuberculous process is also excited. If the amount of fluid becomes great, we must interfere. Aspiration I should first be tried, and repeated from time to time as necessary, usually more active measures must be adopted. God lee recommends passing two aspirator needles into the chest, one in front and the other below the angle of the scapula.
To the anterior needle tubing is attached, which passes into a bottle of sterilized boric-acid solution,—temperature, 100° F.; to the other needle the aspirator is attached; as the fluid is drained off from the back of the cavity, the patient lying on his back at the edge of the bed, the boric-acid solution enters through the anterior needle. The aspiration is con tinued until the solution comes away quite clear, when the anterior needle is removed and the chest emptied by the aspirator as far as possible.
If the liquid is foetid, incision and free drainage offers the best, if not the only, hope of relief. A young man whom I saw several years ago seriously ill with this condition was able, shortly after free drainage was effected, to walk a few miles daily and attend to a little business for some months, dying ultimately of the tuberculosis, but relieved of the sepsis. Such tuberculous cases, however, rarely recover, succumbing usually to the tuber culous infection; but it seems better that they should die without, than with, the pleural cavity full of pus. As in em pyema, ribs may have to be resected, and pulmonary gymnastics should be per sistently practiced to secure re-expansion of the lung.
The position of the patient with the sound side upward is of great impor tance during anaesthesia in pyopneumo thorax. Two cases have been recently recorded in each of which death followed the turning of the sound side of the pa tient upward to facilitate operative pro cedures, death being due to a flow of pus into the bronchial tubes of the sound lung. Bowles (Med. News, Jan. 8, '98).
Hydrothorax.
Definition.—The occurrence of a se rous transudation into the pleural cavity apart from inflammation is termed hydro thorax, or dropsy of the pleura.
Symptoms.—The symptoms are those resulting from interference with respira tion. They are usually attributed to the primary disease, and the hydrothorax is overlooked, often from want of examina tion on account of the weakness of the patient. In all cases of increasing dysp ncea, cyanosis, and prostration the chest should be examined for pleural dropsy, as removal of the fluid may relieve the symptoms and afford the patient a chance of recovery.