No. 3052.

FEBRUARY 25, 1882.

LectureON

DISEASES OF THE CHEST CAVITYREQUIRING

SURGICAL TREATMENT.Delivered at the Hospital at Brompton, Jan. 23rd, 1882,

BY JOHN MARSHALL, F.R.S.,PROFESSOR OF SURGERY AT UNIVERSITY COLLEGE AND SENIOR SURGEON

TO THE HOSPITAL, CONSULTING SURGEON TO THEHOSPITAL FOR CONSUMPTION, BROMPTON.

(Reported by HENRY MAUDSLEY, M.B.Lond., and revised andamplified by the Lecturer.)

LECTURE II.-PART I.

GEXTLEMEr,—In this lecture, I have to treat of Diseasesof the Chest Cavity requiring Surgical Treatment. Theseare - Mediastinal and Subpleural Abscesses; the Non-

inflammatory Intrathoracic Effusions, Hydrothorax and

Hydropericardium; the Inflammatory Effusions into the

Pleura, with the complications of these, due to variousmorbid conditions; Abscesses and other cavities in thesubstance of the lungs themselves; and, lastly, Inflamma-tory Effusions into the Pericardium.I shall necessarily consider chiefly the pathological effects

of those diseases which determine their surgical manage-ment ; and I shall, as in the former lecture, illustrate thepathology of the subject by reference, where possible, to

preparations selected by permission from the Museums ofthe College of Surgeons and University College, and to

drawings from the Carswell Collection in the last-namedInstitution.To commence with mediastinal abscesses. These must

be distinguished from sternal abscesses, as they readily maybe, on both anatomical and clinical grounds. Sternalabscesses are fLxed, and more or less closely limited, beingbounded, at least for a long time, by the periosteum ; butmediastinal abscesses are altogether behind the sternum, andare not limited by its periosteum. Again, the symptomsare different. In sternal abscess the early stages of thedisease are more painful, and the inflammation, being moresuperficial, shows itself earlier on the surface than inmediastinal abscess. In the former the skin on the sternumsoon becomes red and inflamed ; but in the latter there isfor a long time no evidence of inflammation on the surface,no reddening of the integument. Hence the deep mediastinalabscesses are not often clearly diagnosed early ; but for-tunately there is no hurry as regards surgical interference,for there is ample room for the abscess to spread upwards,downwards, and to the sides. After a time, however, fluc-tuation can be made out to one or to both sides of thesternum, in the fork of the neck, or even below the xiphoidcartilage, this variety of position not being usually observedin sternal abscesses. A mediastinal abscess, if prominent,expands and yields an impulse when the patient coughs ;and it may even pulsate synchronously with the heart’sbeat, like an aneurism, or may simulate a distended peri-cardium ; but there will be no great difficulty of diagnosis,as the other symptoms attending so large an aneurism or apericardial effusion would be absent. An hydatid or othercystic tumour might, I suppose, be located in the anteriormediastinum. But from ordinary sternal abscess themediastinal abscess is distinguished by the absence of earlysymptoms, the non-limitation of the swelling to the bone, iits slower aclvance to the surface, and the greater extentand variety in the position of the places where fluctuationfirst appears.The surgical management of mediastinal abscess is easy.

As soon as fluctuation is detected, it is well to explore with afine a-pirator needle attached to a small syringe. If pus bewithdrawn the diagnosis is complete, and an effectual treat-ment becomes necessary. This should not consist in simpleaspira ±i,n, for the pus will rapidly collect again ; aspirationfol owed by iodised or carbolised injections is also unsatis-fficM’y. It is better to make a free incision, and introducea fu i xized drainage-tube, the operation being performedstrictly antisepticallv. The incision should be vertical, and

quite close to the margin of the sternum, in any intercostalspace or other situation which may be most suitable. Theinternal mammary artery runs about half an inch or morefrom the margin of the sternum, and as the abscess pushesthe vessel aside outwards there is but little danger ofwounding it. The incision is, of course, vertical, so as tobe puallel with the line of the artery, and the abscess maybe finally laid open by perforation with a probe-pointeddirector and subsequent dilatation with dressing forceps.You will remember that in opening a sternal abscess you cuton the bone itse’lf, and with a raspatory tear through theperiosteum, and so set free the subperiosteal collection ofpus,; but in opening a mediastinal abscess you do not cut onthe bone itself, but in an intercostal space at a very shortdistance from the bone.As to subpleural abscesses, which are usually associated

with pleurisy, as soon as they can be detected, they pointbetween the ribs, not upon them; if they bulge at an inter-costal space they have a strong impulse and expand oncoughing, and are thus distinguished from costal abscesses,but they may be readily confounded with a circumscribedempyema. They must be explored, and then opened freelyin an intercostal space, with antiseptic precautions and sub-sequent drainage.The simple, serous, almost watery effusions which consti-

tute hydrothorax and hydrops periwrdii or hydropericardium,and are due to disease of the heart, liver, or kidney, or toan8emic or hydrsemic conditions, are almost or altogethernon-inflammatory. They are usually diagnosed by the phy-sician and treated medically, and only require the use ofsurgical means should there be extreme suffering, embarrass-ment of function, or danger to life, as indicated by gravedyspnoea, orthopncea, or palpitation, owing to pressure of fluidon the lungs or heart.The surgeon will note that the effusion in non-inflam-

matory hydrothorax is usually present on both sides of thechest, whilst the inflammatory effusions of pleurisy occur, asa rule, but not invariably, on one side only. The surgicaltreatment in hydrothorax consists in simple aspiration, which,from its being easier to accomplish without the entrance ofair into the pleural cavity, is preferable to the old method oftapping. Aspiration should be antiseptic, gentle, gradual,and limited ; thus performed, it is safe and may give greatrelief. If done non-antiseptically, forcibly, rapidly, and tocomplete evacuation, it may determine an attack of pleurisyor cause immediate difficulty of breathing or syncope. Itdoes not induce the pain and sense of constriction oftenobservable in emptying inflammatory pleuritic effusions.The aspirator needle, in a case of hydrothorax, may beentered in the sixth intercostal space on either side in themid-axillary line, provided of course that there be thepresence of fluid and the absence of lung at those spots.Aspiration in hydropericardium must be even more cautiouslyperformed than in hydrothorax. As to the selection of thespot for the needle puncture, the practice has varied from thethird to the seventh left interspace, and, indeed, the dis-tended pericardium often covers a very large area. A punc-ture one inch or so from the sternum in the fourth or thefifth left interspace, will be well outside the internal mam-mary artery, and in a suitable position. The object of aspi-ration in hydrothorax or hypopericardium is the evacuationof the fluid effusion for relief rather than for cure, but it mayfacilitate subsequent absorption. If the fluid reaccumulatesso as to cause renewed distress, aspiration may be carefullyrepeated.The inflammatory pleuritic effusions which require sur-

gical treatment present differences in the nature and quantityof the fluid, and, as you will find, are associated withpeculiar conditions of the chest walls, and with other com-plications. On a due consideration of these, the character ofthe surgical interference should depend. In the first place,the fluid effused into the cavity of the pleura is sometimeswhat is erroneously called " serous," for the fluid in questionis spontaneously coagulable, whereas serum is not; somewriters, again, designate it "fibrinous," but it contains morealbumen than fibrin. " Sero-fibrinous " is a more correctterm for it. This sero-fibrinous fluid, as present in simplepleurisies, is of a pale-yellow, straw, or golden colour, andquite or nearly transparent ; it is somewhat viscid, containsa certain number of leucocytes, and coagulates rapidly whenwithdrawn from the chest. In other cases, with an increaseof fibrin and leucocytes, it is either paler or darker, andopalescent, and coagulates very strongly when drawn into avessel. Again, it may be still more opaque, contain an

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abundance of leucocytes, and so becomes sero-puriclent, as in sion. In the latter case, the corresponding part of thecertain empyemas, in which state it does not readily or thorax would be resonant on percussion and furnishusually coagulate when drawn ; for these reasons, that it has breath-sounds, and would have to be avoided in aspira-already thrown down coagula whilst within the pleural cavity, tion, or in making a trocar puncture or an incision into thehas deposited fibrinous flakes on the pulmonary or the costal chest.pleura, or on both, and perhaps has formed the commence- Again, adhesions, similar in their nature, may limit thement of adhesions between the two. Hence, a sero-purulent extent of an acute or chronic pleuritic effusion, and so give eeffusion does not always coagulate when it is removed from rise to a ci°ci4mscribed pleurisy or empyema, which mightthe pleural cavity. Lastly, in other cases, as in a genuine surprise an inexperienced operator ; but, on the other hand,empyema, the fluid is decidedly pur’ulent; and according to they may prove beneficial by preventing complete compres.its period of retention in the chest, it may resemble the sion of the lung, and assisting in its re-expansion. Here isuniform laudable pus of an acute abscess, only it is a drawing of a soft padding of opaque lymph, three-quarters ofusually a little whiter, or it may be curdled or contain an inch thick, exuded between the costal pleura and the lung,flakes of various shapes and sizes, consisting of meshes of from amongst the meshes of which pus copiously exuded;coagulated fibrin, enveloping multitudes of leucocytes or in this drawing, a similar soft material, of much more openpus corpuscles. The formation of these flakes is favoured texture, and at least an inch and a quarter thick, chargedby the presence of accompanying false membranes on the with pus, is shown-occupying the same position ; and, lastly,pleura; both may tend to fatty or caseous degeneration, or in this unique preparation of a diseased pleura, the plasticbecome the seat of earthy deposits. In any state, such loose material, owing to the combination of the movements of theflakes offer troublesome impediments to successful aspiration ribs, diaphragm, and lung, in vertical and horizontal direc-of the abnormal contents of the pleural cavity. Whatever tions, has become opened out and arranged in longitudinalthe nature of the effusion, red blood-corpuscles, more or less and vertical laminse or septa, enclosing large spaces or

altered, may always be found in it; but when the character loculi, resembling a monster honeycomb, which were filledof the inflammation is very intense, these may be in such with pus, and so produced a remarkable example of a locu.numbers that the sero-fibrinous effusion becomes pinkish or lated pleuritic effusion, or multilocular empyema. Such areddish in colour, and the sero-purulent and purulent nnids condition would, of course, complicate any evacuating opera.brownish or yellowish. The sero-fibrinous effusion appears tion, whether by aspiration, ordinary paracentesis, or in-to have a greater tendency to quick decomposition, when cision, and would impede subsequent drainage. Sometimes,air is admitted into the pleural sac, than the sero-purulent again, in a very old empyema, calcification of the falseor purulent product. This would scarcely be expected, but membrane lining the chest wall takes place, either in patches,it is so. Pus is more stable and less inclined to rapid as in this specimen, or along the direction of one or two ribs,putrefaction than the sero-fibrinous fluid; but of course in as in this, or over the entire parietal pleura, as in this reotime it undergoes serious changes. It is certainly of as markable preparation, which shows the whole pleura, exceptgreat importance to avoid the entrance of air into the pleural the part corresponding, I presume, to the root of the shrunkensac, in the case of sero-fibrinous, as in that of purulent lung, so completely calcified, that it has been removed as ifeffusions; and besides, in a recent acute pleurisy, with a it were a cast of the interior, resembling a huge egg.merely sero-fibrinous effusion, the parietal and visceral Localised calcified deposits might obstruct the surgeon inlayers of the pleura are excessively vascular and but thinly his operations, but such a universal earthy encasementcovered with exudation, and, accordingly, are very prone could only have occurred in a patient who had becometo absorb the products of decomposition; whilst in more tolerant of his empyema, and would need ,tno surgicalchronic cases, with purulent effusion, the pleural membrane aid.is often lined with thicker and less vascular lymph, through Pleuritic effusions, especially those with sero-purulent orwhich septic material is less easily taken up. Lastly, the purulent effusions, are sometimes associated with otherquantity of the fluid effused, independently of its nature, complications, more or less important, in reference to opera-may vary from half a pint to a gallon, and on this quantity tions for their relief. For example, the pleura may be per-the amount of bulging of the chest-walls and compression of forated either from or into the lung, or through thethe lung will depend, diaphragm, or through an intercostal space to the sur.

If the amount and character of the pleuritic fluid are thus face of the chest, giving rise either to a bronchial, pul-important to the surgeon, so in the next place is the con- monary, diaphragmatic, or thoracic fistula. Thus a per-dition of the pleural sac itself. Allow me to illustrate this foration may take place from a phthisical excavationpart of our subject fully. Here, for example, is a wax cast or abscess into the pleura, and may be the cause of ashowing the costal pleura in a case of recent acute pleurisy; pleurisy, as was probably the fact in the case represented init is covered over with a thin layer of transparent, slightly these two drawings, showing the two aspects of a small,rough, and highly vascular lymph. In this coloured round aperture in the slightly inflamed surface of a lung,drawing a similar but somewhat thicker layer is shown. which in itself contains an abscess and is also studded withIn more prolonged cases, a thicker and less vascular adven- minute tubercular deposits. Again, in this other drawing,titious membrane is formed, as you observe in this small wet there is shown a very large irregular opening into the lung,preparation. In this perfect specimen, also in spirit, it with evidences of long-continued inflammation and thicken-forms a complete cast of the pleural cavity, soft, but thick ing of the pleura; here, probably the perforation took placeenough to sustain itself in its parietal portion, and covering in the opposite direction from the pleura into the lung. Inthe lung, by its pulmonary portion, with an equally thick and this next drawing there is depicted a local pulmonarydense coating. It is this abnormally thickened costal gangrene, with consecutive pleural perforation, and this

pleura which frequently offers an impediment to the entrance other one would seem to be taken from an example of per-of an aspirator needle, or is pushed in front of a trocar and foration from a dilated bronchus into the pleural sac. In

cannula, or leads the operator so unexpectedly deep, whilst this last case, air would certainly gain access to the cavitymaking an incision into the chest cavity. Again, it is this of the pleura through the bronchus, and the accompanyingdense plastic and partially organised layer, spread over the pleurisy, whether aero-nbrinous or purulent, would be com-pulmonary pleura, which clasps the lung, already com. plicated with pnell7Jwtlw1"ax,. and in the case of gangrene orpressed by the fluid, and hinders or prevents it from re- putrid abscess, if free communication existed, the ptienmo.expanding as the pleural cavity is emptied by absorption, thorax would be associated with more or less decompositionor, what is of more interest to us here, evacuated by opera- of the pus; for either contingency an operator must betion. Here is a wet preparation of the left lung of a child, prepared. Haemothorax seldom occurs except frominjuries,reduced to a fourth of its natural size, and here are two others which do not here concern us.of adult lungs, one shrunk to a tenth of its proper bulk, (To be continued,)quite solidified, and incapable of re-expansion. But other ____________________________________-

morbid changes of the pleural surfaces take place, of im- .

portance from a surgical point of view. Thus, localised ST. JOHN AMBULANCE ASSOCIATION.-His Serenepatches of plastic exudation are sometimes formed, as seen Highness the Duke of Teck has consented to become Pre-in this cast, or again in this drawing of portions of lungs. sident of the Richmond Centre. The Governor of Malta,If similar deposits are formed on the opposite costal pleura, General Sir A. Borton, C.C.M.G., has been elected Pre-with a moderate amount of effused fluid, adhesions of sident, and the Chief Secretary to the Government, Sir Victorvarious s:ze may occur between the lung and the chest Houlton, and the Bishop of Gibraltar, who is also a cLap-wall, as shown in these two drawings, one of which repre- lain of the order of St. John, Vice-Presidents of the Mabsents narrow? connecting bands, and the other a broad adhe. Centre, where the classes are a great success.