INFECTIONS OF THE LARGE CAVITIES OF THE BODY The pleura responds to infections of its cavity with pneumococci and other pus bacteria as well as with tubercle bacilli, usually with exu dation which may assume a purulent character (empyema).
The percentage of cases of purulent pleurisy is greater in children than in adults.
For the symptomatology of the disease see Peer, vol. iii.
The treatment of empyeina can only be surgical. Spontaneous recovery may happen in one of two ways, either by perforation of pus to the outside, when the soft parts covering the abscess are slowly lifted up and thinned until it finally breaks through the same as any other abscess (empyenta necessitatis), or the abscess will empty into a bronchus after the lung tissue at its edge has been destroyed and the pus will be coughed up similar to that from a cavity.
We have, however, observed two cases in which we had been able to show- pneumococci in the pus removed with a hypodermic syringe for examination, in which the parents refused all surgical intervention. These cases healed without perforation with formation of pleuritic thickening and a diminution of the horizontal axis of the affected side of the chest. After two years the function of the lung in its allotted space was good.
When we operate we must remember that we have to deal with an "abscess," though the conditions are complicated by the proximity of the lung. Therefore the only thing to do is to let out the pus, especially in eases in which the symptoms of displacement and poisoning demand immediate relief.
The simplest and best method in older children is to open the chest with the rove( ion of a rib.
General narcosis is superfluous as well as dangerous; chloroform because the heart is weakened by the suppuration, ether because it affects the respiratory organs which arc already affected. Local antesthcsia with 1 per cent. novocain suffices for this operation, which should occupy but a few minutes.
According to Schede we select the lowest point. In total empyema and in the scmilateral dorsal decubitus which these children generally occupy, this is found at the ninth or tenth rib between the posterior axillary line and the long dorsal muscles (an exploratory puncture should always precede the incision).
The incision should be as short as possible and goes at once through skin, soft parts, and periosteum, down to the rib. The periosteum is quickly separated from the rib, an elevator is pushed under this, thus bringing it nearer to the surface, and it is at once removed with a hone forceps to the extent of 1 or 2 ctn. We thus avoid injury of the inter costal artery. Should this, however, be severed, then we will rapidly finish our resection and tie the vessel later.
After removing the piece of rib we make a small puncture into the thickened pleura and widen this so far that we can just introduce our first finger through the opening. Now we let the pus out slowly, keeping close watch of the heart.
The introduced finger explores the position of the lung and removes clots of fibrin. Only when the general condi tion permits do we allow all the pus to escape. We consider the breaking up of adhesions and the washing out of the chest unnecessary, for the reason that this interferes with the of reparation.
A short drainage tube is then intro duced which will not irritate the visceral Pleura and secured with a safety pin pushed through it in its transverse axis and which is again fixed with a thread or a strip of adhesive plaster, so that the drain cannot be sucked into the pleural cavity with the respiratory motion.
The metal tubes of Lloyd built on the lines of a Murphy button are very handy, especially when we do not resect a rib but only do a thoracotomy, though we cannot recommend this latter opera tion on surgical grounds, because the narrowness of the intercostal space in a child makes it very difficult to keep the wound open and to introduce a drainage tube. Otherwise the wound is closed and a protective dressing applied, of which we only change the upper layers after three days on the advice of Hoffmann in order to give the lung a chance to become adherent to the chest wall and thus to avoid as much as possible the dangers of a pneumothorax.