In many cases of operations for pyo thorax some rise of temperature takes place after the operation. Among the many causes to which the rise may be attributed are intoxication by absorp tion from iodoform or carbolic-acid dress ings, constipation, secondary and extra thoracic abscesses, infection from some specific contagion, an unresolved lobar pneumonia or broncho-pneumonia, gem eral septic infection, and, sometimes, deep-seated multilocular accumulations of pus not reached by the primary oper ation. There is also a class which do well for several weeks, and then show an irregular rise of temperature, al though no local or general complications can be detected. In these cases the drainage-tube should be removed and the patient taken out-of-doors in spite of the fever. The successful management of 4thortx is not alone a matter of in cision and drainage, but often calls for accurate clinical investigation and obser vation. Cai (Archives of Bed., Aug., '9S).
Believing that if some substance could be brought into the pleural cavity which would cause a general deposit of fibrin on the pleural surfaces, then aspirate, adhesion of the cavity would prevent a return of the effusie' ; several different drugs—as iodine. issium permanga nate and the a; dyes, fuchsin and methylene-blue—w tried. The last— thought more des: ..1.1e than the rest, being antiseptic, an ne, and diuretic— was used in twenty our cases. To in sure success, sever3. '-:nditions must he satisfied. The ttsed should be in permanent its reaction and specific gravity correspond very closely to that of the fluid in the chest cavity. The material injected must be antiseptic or easily rendered aseptic, and the volume of fluid in the sac must re main unchanged. These conditions are accurately met by using a part of the contents of the pleural cavity for mak ing the solution. A portion of the ef fusion was therefore withdrawn, methy lene-blue dissolved in it: about 1 part in 50. The operation was performed with a medium-sized aspirating needle, fitted with asbestos piston and washers. The quantity of methylene-blue em ployed amounted to 5 to 15 grains, the most of them receiving over 10 grains. The amount of fluid removed varied from GO to 100 cubic centimetres. The drug appeared in the urine in from three to nine days, the rapidity depending upon the quickness of absorption by the dis eased membrane. The desired adhesions are thought to have been obtained. C. H. Lewis (Med. News, June 1, 1901).
Diaphragmatic Pleurisy.
In rare cases acute inflammation of the diaphragmatic pleura is characterized by extreme pain and distress. As inflamma tion of the pleura in this region without marked symptoms is of frequent occur rence,—for example, in all cases of pneu monia of the base of the lung,—the ex tremely distressing symptoms occurring in rare cases must be due to other causes than the inflammation of the pleura The most probable cause is the extension of the inflammation to the substance of the diaphragm, rendering it sensitive to every movement.
Symptoms.—Pain is the most impor tant symptom. It is referred to the line of insertion of the diaphragm or to the epigastric or hypochondriac regions, and over these areas there is usually much tenderness to pressure; also to pressure upward on the liver. The breathing is rapid, and, as far as possible, costal. The facies is anxious and the suffering evi dently extreme. The temperature is high and pulse rapid. If the inflamma tion is confined to the diaphragmatic pleura there are no signs of exudation; in many cases, however, the inflamma tion extends upward later and presents definite signs of pleurisy. This is well illustrated in the case of a young man whom I saw with Dr. Cleland, of To ronto. There was extreme pain in the splenic region, but without any signs of pleurisy until the fifth day, when fric tion-nib was made out at the lower mar gin of the lung in the anterior axillary line. Later empyema developed, and the germ present proved to be the strepto coccus. There was possibly also a peri splenitis. A good recovery was made.
A second case—a young man, also— seen with Dr. Shearp, of Milton, leaves no doubt of inflammation of the dia phragm. The left pleura was attacked, apparently also with consolidation of the lower lobe of the lung. Pain and distress were very severe. Three days later the lower lobe of right lung became affected and the pain was agonizing. Friction rub was very marked. In two days signs of inflammation of the perihepatic tissue developed, with marked friction down nearly to the umbilicus. The tempera ture was high and general condition grave, the pain being almost unendur able. There was occasional cough, and the only expectoration obtainable gave a pure culture of the staphylococcus. Death took place on the twelfth day; an autopsy was not permitted.
The chief cause of extreme pain in this case was, without doubt, the inflam mation of the diaphragm.