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A NEW PROCEDURE IN PARACENTESIS THO
By Thomas F. ROCHESTER, M. D., of Erie County.
Read November 18, 1884.
Those who have often practiced paracentesis thoracis in chronic pleurisy, and especially in empyema, have frequently experienced great difficulty in making a sufficiently large and free opening to admit of the proper placing of drainage-tubes or even of introducing a good-sized trocar and canula through the chest-walls. This is doubtless caused by the approximation of the ribs due to the influence of chronic pleuritis upon the intercostal muscles. To obviate this, various expedients have been resorted to, such as gradual dilatation with sponge-tents and even the trephining or excision of a rib. The writer thinks he has hit upon a method which will overcome the contraction with certainty and safety and will greatly facilitate all necessary local operations. Perhaps a brief account of three cases will present the procedure more clearly to you than a simple description of the method.
CASE I.-In September, 1883, I was invited by Dr. Seeley, of Attica, to see Mr. P., a well-to-do farmer, forty-five years of age. He had been ill for three months. I found him sitting up, as he could not lie down on account of dyspnæa. Both legs and both feet were much swollen. He had cough, with muco-purulent expectoration, irregular chills and night-sweats; pulse 100 and irregular; no appetite ; percussion-resonance fair over the entire posterior portion of the chest, and flat over the anterior surface of the right side from the second rib downward, with bulging of the intercostal spaces. The percussion-resonance was clear over the left chest anteriorly, except over the præcordial region. The heart-apex was
in the sixth intercostal space and two inches to the left of a line drawn through the left nipple. On auscultation posteriorly, there was respiratory murmur, with occasional bronchial râles, which were distinct everywhere. Anteriorly, there was bronchial respiration in the right subclavian region as far as the third rib. Below that point there was no respiratory sound whatever. Puerile respiration was marked in the left lung.
The diagnosis was sacculated empyema. A large and long hypodermic needle, with the syringe attached, was passed between the fifth and sixth ribs, anteriorly, on the right side, and the syringe was filled with thick, white, odorless pus drawn from the chest. Paracentesis was decided upon. A sharp-pointed bistoury was inserted close to the upper border of the sixth rib, and an incision two inches long was made in the intercostal space. A very slight purulent discharge followed. We now endeavored to insert a large drainage-tube, but found it impossible on account of the close approximation of the ribs. These we tried to separate by various instruments, but in vain. I then examined the wound with the forefinger, and found that, as I pressed firmly, the ribs began to yield and separate, and then, to my great satisfaction, the finger passed into the chest-cavity, and, on its withdrawal, was followed by a copious discharge of purulent fluid. “Ah !” exclaimed Mr. P., with a sigh of relief, “I would have given you five hundred dollars just now to take away your finger; and now, if I had it, I would give you as much for having put it in.” Cod-liver oil, 3 j, with twenty drops of the muriated tincture of iron, three times daily, were prescribed—a favorite prescription of the writer in such cases. In about two months, Mr. P. was entirely restored to health. The chest-cavity was twice washed out with warm water slightly carbolized.
CASE II.—Mr. F., twenty-one years of age, commercial traveler, of the Jewish race, extremely nervous and timid ; previous history good ; parents and brothers and sisters healthy ; has been ill for two months; has slight cough and night-sweats; is greatly emaciated; pulse 120 ; respiration 32 ; has all the physical signs of effusion in the right pleuritic cavity. The hypodermic needle withdrew thick, white, odorless pus. The operative procedure was precisely the same as in Case I, except that the ribs were separated more easily, more quickly, and with less pain, as would be expected,
considering the age of the patient. Rapid and entire recovery ensued. The chest-cavity was several times washed out with a weak solution of boracic acid. I was invited to see this patient by Dr. Frank, of Buffalo.
CASE III.-John G., inmate of the Buffalo General Hospital, German, forty-five years of age; habits had been intemperate for many years; has chronic pleurisy with very large serous effusion; had been aspirated by Dr. Herman Mynter twice before admission to the hospital ; since his admission has been aspirated twelve times in eight weeks; bas been placed upon tonics and diuretics; chest has been painted often with the tincture of iodine, and the recumbent position has been almost constantly maintained. He has, however, steadily lost ground, and the effusion recurs rapidly after aspiration. Abdominal dropsy and edema of the lower extremities also became apparent. There is no albuminuria and no cardiac disease. Cirrhosis is suspected. It was decided to introduce a drainage-tube. This was done as in the first two cases, but it was not as well borne. For four days he had sinking turns, and for the first two days the discharge was deeply tinged with blood. He began to rally at the expiration of a week, and for three weeks distinctly improved, but again failed, and died five weeks from the date of the operation. The post-mortem examination showed half a pint of bloody serum in the pleural cavity, the costal pleura very red and engorged, the pulmonary pleura covered with thick, false membrane, and the lung pressed upward and backward and so small and condensed that it was about the size of an adult hand. It did not, however, present any other evidence of disease. The pericardium was pretty fully distended with serous liquid. The left lung and the left pleura were healthy. The liver was contracted and cirrhosed. All the other organs were healthy.
The writer has had quite an extensive experience in paracentesis thoracis and has often been annoyed in trying to make a sufficiently large and a permanent opening for a drainage-tube of proper caliber. He trusts that he has found a method which will obviate this difficulty for others and for himself, and respectfully submits it to the Association for consideration and comment.
DISCUSSION ON DR. FERGUSON'S PAPER AND ON
DR. ROCHESTER'S PAPER.
Dr. Austin Flint, of New York County.-I have listened to the reading of both papers with interest, and especially to the explanation offered by Dr. Ferguson of the effect produced by the complete withdrawal of liquid from the pleural cavity. I must confess, however, that the statement made by Dr. Ferguson with regard to the harm done by the aspirator seems to be rather strong. I can not agree with him in that statement, but still there are views set forth in the paper which are sound and appropriate. I have particularly been struck by the comparison made to the complete withdrawal of urine from the over-distended bladder. Some years ago, I saw a case in which the bladder was immensely distended, and, all the water being withdrawn at one sitting, the result proved disastrous.
Dr. E. M. MOORE, of Monroe County, asked Dr. Ferguson a question with regard to the use of the aspirator in the general domain of surgery.
Dr. Ferguson replied that the point which he wished to make was that, in the large majority of cases in which relief followed the use of the aspirator, such relief would have followed without the operation; and it had been his observation that the aspirator could be charged with causing death in not a few instances. In one portion of his paper, he referred to the use of this instrument in pelvic troubles, where he had seen it cause general peritonitis by allowing a small quantity of vicious liquid to flow upon the peritoneal surfaces.
DR. MOORE said he had no doubt that every surgical instrument had done some harm, and he would not except the aspirator ; but he hardly thought it proper to view the question of the value of this instrument from that stand-point. We could scarcely expect, every time we used the aspirator, to thereby save the life of a patient. We all knew that in cases of hydrothorax, absorption of the fluid would often take place if the case were left without surgical treatment; but sometimes this did not occur, and we were compelled to resort to the aspirator. He had a case in mind which illustrated the fact that empyema could be better treated by the aspirator than in any other way, but he did not doubt that an artificial opening could be kept patent by the means described by Dr. Rochester in his paper. He was fully convinced that the drawing off of a certain quantity of the liquid at stated times would, in a large number of cases, enable us to save life. This was a very strong statement to make, and yet, as just said, such was his strong conviction. It had been his misfortune to see a great many cases of empyema, and he could freely say that his experience had been very unfavorable, except in children, who were expected to get well as a rule. Adults he believed usually died. But, during the last two years, he had seen two cases of empyema, occurring in adults of at least fifty years of age, in which he had no doubt that the result would have been fatal except for the patient use of the aspirator. Under this treatment, however, which was employed not by himself, but by another physician, the patients each made a complete recovery. The thoracic walls were considered unyielding, and it was for this reason that but a small quantity of the pus should be withdrawn at a single operation. In this regard, he thought Dr. Ferguson had made a good point, as well, also, as with regard to the avoidance of hæmorrhage. If one would take the trouble to measure the circumference of the chest while withdrawing pus from the pleural cavity in a case of empyema, he would find that a retraction took place to the extent of an inch or an inch and a half.
Of course expansion would again occur with the secretion of more pus, and this would be an indication for a repetition of the operation. The gradual formation of cicatricial tissue would finally diminish this pus-cavity and cure the case. He had made use of drainage-tubes, but he regarded treatment with the aspirator as far superior.
With regard to the use of the aspirator in other parts of the body, as in diseases of the abdomen, he could not agree with the remark made by Dr. Ferguson. In the female, for instance, the abdomen seemed to be specially constituted to enlarge and afterward contract; and here the laws governing the use of the aspirator in the thoracic cavity did not apply. He recalled the case of a girl who had an ovarian abscess which contained as much as ten pints of pus; and, on withdrawing the liquid with the aspirator, the abdominal walls retracted by atmospheric pressure, and no