Purulent Pleuritis.

Synonym.—Empyemia.

Definition.—A suppurative inflammation of the pleura.

Etiology.—A sero-fibrinous pleurisy may be converted through the chest-walls or generated from within. Not unfrequently it results from a penetrating wound, from a fractured rib, or from the aspiratory needle, where due cleanliness has not been observed. It may be due to malignant disease of the lung or esophagus, and not infrequently from abscess of the liver or from caries of rib or spine.

It is frequently due to tuberculosis, and it may follow infectious diseases, especially croupous pneumonia, diphtheria, and scarlet fever, more rarely typhoid fever, measles, and whooping-cough. It has followed a peritonitis and the puerperal state.

Children are peculiarly subject to this form, it being estimated that one-third of all pleural effusions in children are purulent. The organisms most frequently found in the purulent fluid are the staphylococcus, the streptococcus, the tubercle bacillus, and the micrococcus lanceolatus.

Pathology.—The effusion is usually general, though, as a result of adhesion, it may be encysted. Where the effusion is of long standing, the lung is generally pushed upward and backward, and is flat and almost entirely airless.

The pleura is but little thickened if the effusion is recent, but where it is of long standing, the membranes become thickened and leathery in character. Occasionally necrosis of its walls occur, and the purulent material makes its escape, the direction it takes depending upon the amount of resistance. When the perforation occurs in the pleura costatis, it finds it way outwards, sometimes resulting in necrosis of a rib. Should it perforate the pleura pulmonalis, it finds its way into the lung and is expectorated through the bronchus, or it may perforate the diaphragm, and result in a fatal peritonitis. In rare cases it has penetrated the pericardium.

The character of the pus varies. Sometimes it is of a creamy consistency; again of a sero-purulent form, or of a fibrinous-purulent material. After standing, it separates into an upper greenish or yellowish-green, transparent fluid, and a lower layer of thick greenish pus. When not of long standing, the odor is rather sweetish in character; but if of long standing, and especially if associated with gangrene of the lungs or septicemic condition, the odor will be peculiarly fetid.

Symptoms.—The symptoms vary greatly, depending somewhat upon their cause. Thus, if it occurs as a primary affection, the symptoms are those of acute pleurisy, namely, chills, high febrile action, pain in the side, dyspnea, and cough attended by slight expectoration of a muco-purulent material.

Should the pleurisy be associated with septicemic or pyemic conditions, the symptoms are typhoid in character, the tongue becomes dry and brown, the mind wanders, or coma appears. Such cases generally terminate fatally after running a short course.

Quite often, the disease develops insidiously, with no marked local symptoms to direct attention to the true condition. The patient's fever is irregular, night-sweats attend, and the patient loses flesh and strength. To render the true character of the disease more obscure, the purulent material, having perforated the pleura, sometimes burrows along the spine to the iliac fossa, resembling psoas or lumbar abscess. When the pus breaks in a bronchus, it is expectorated, and may be mistaken for tuberculosis.

Physical Signs.—The physical signs are practically the same as those of sero-fibrinous pleurisy, and need not be repeated. A few additional signs would be greater bulging of the intercostal spaces, especially where perforation occurs, the appearance of a red spot and fluctuation on palpation; enlargement of the superficial veins and edema of the integument, especially in young subjects, would suggest purulent form.

Diagnosis.—A positive diagnosis of this form of pleurisy can only be made by withdrawing some of the fluid with an aspirating or exploring needle.

Prognosis.—Empyemia is always grave, though much depends upon the age of the patient and the causes giving rise to it. More children recover than adults. When the previous health has been good and the family history shows no trace of tuberculosis, the outlook is more favorable.

Should rupture of the sac take place externally, the outlook is somewhat favorable, as it may be where it empties into a bronchus. With the evacuation of pus, there is a tendency to adhesion of its walls, effacement of the cavity, and retraction of the affected side.

Treatment.—Where there is an accumulation of pus in the pleural cavity, we can not expect much help from internal medication until after the cavity has been thoroughly drained. Irrigation should not be used, except in those cases where the fluid is fetid, and even here much care should be observed as there is danger from collapse.

A free incision should be made, or a good sized trocar used, in the mid-axillary line, in the fifth or sixth interspace, proper aseptic measures being used. The patient should be in the sitting posture when able. After thorough draining, the patient should take well-regulated respiratory gymnastics, to increase the expansive power of the compressed lung.

An efficient method is that used at the Johns Hopkins Hospital, and consists in transferring- the water from one bottle to another by means of expiration. Large bottles holding- at least a gallon, are used, and in these, tubes are placed. By expiring through the tubes the water is made to pass from one bottle to the other. This exercise, to be of benefit, should be carried out systematically and persistently as the strength of the patient will permit. The cavity is thus obliterated by the expansion of the lung on the one hand, and the retraction of the chest wall on the other.

Following the operation for the removal of the pent-up fluids, we will put the patient upon the antiseptic remedy indicated. The chlorates, sulphates, mineral acids, the vegetable antiseptic, echinacea, baptisia, and remedies of like character will be used.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.