Empyema

“ But if the abscesses disappear and go back, while expectoration does not take place, and fever prevails, it is a bad symptom; for there is danger that the man may get into a state of delirium and die. Of persons having empyema after peripneumonic affections, those that are advanced in life run the greatest risk of dying; but in the other kinds of empyema younger persons rather die. [502] In cases of empyema treated by the cautery or incision, when the matter is pure, white, and not fetid, the patient recovers ”

“ Difficulties of diagnosis arise in the case of an empyema discharging through the bronchi, or of an encysted empyema discharging through the third or fourth intercostal space in front; also, between abscess of the superior portion of the liver and one in the base of the lung, or between the latter and a pyo-pneumothorax. Very careful study of the history in each case is of the first importance. Where this is not attainable the difficulty is often much increased. ”

“ In all cases of empyema in which the lung is so bound down by adhesions that it cannot be expanded by the continued process of respiration, a cure can only be accomplished by an alteration of the form of the affected side of the chest, by which its cavity is diminished, and often nearly obliterated. ”

“ If made thick, how does it get from the windpipes into the venous artery? If the spirits be thinner than air, how are they held [66] by the tunic of the lung, since this lets pass the pus and serum of empyema? [65]
In the treatise of 1628 Harvey says that Laurentius
"asserts and proves that, in empyema, serosities and pus absorbed from the cavity of the chest into the venous artery may be expelled and got rid of with the urine and fæces through the left ventricle of the heart and the arteries." ”

“ Many fatal cases of empyema are complicated with phthisis; formerly these were added to the mortality for phthisis; where paracentesis was performed upon them they were added to the pleurisy column. Bearing in mind that chronic pleurisies, serous and purulent, are frequently consecutive to diabetes, Bright's disease, chronic alcoholism, cirrhosis of the liver, and other organic diseases, patients die of the primary lesions, though they have been relieved of the secondary ones. ”

“ The accessory sinuses of the nose are also prone to disease. The maxillary antrum may become filled with muco-pus, forming an empyema, pus escaping intermittently by way of the nose. The condition causes pain and swelling, and may require the irrigation and drainage of the antrum. The frontal sinuses may become filled with mucous, owing to the swelling of the nasal mucous membrane over the middle turbinated bone, or an acute inflammation may spread to the frontal sinuses, giving rise to an empyema in that locality. ”

“ Empyema may be recognized in all cases by the following symptoms: In the first place, the fever does not go off, but is slight during the day, and increases at night, and copious sweats supervene, there is a desire to cough, and the patients expectorate nothing worth mentioning, the eyes become hollow, the cheeks have red spots on them, the nails of the hands are bent, the fingers are hot especially their extremities, there are swellings in the feet, they have no desire of food, and small blisters (phlyctænæ) occur over the body. ”

“ If neither the erysipelas disappear on the critical day, nor any abscess form outwardly, nor any pus be spit up, and if the patient fancy himself well, and be free from pain, death, or a relapse of the erythema is to be apprehended. It is much less hazardous when the swelling and redness are determined outwardly; but if determined to the lungs, they superinduce delirium, and frequently some of these cases terminate in empyema. ”

“ Whoever is acquainted with the modern literature of the subject, or possesses a practical knowledge of the disease, will not fail, from the accompanying description of the last of these, to recognize a case of cavity of the lungs produced by the ulceration of tubercles. True empyema, however, as the result of chronic inflammation, is also described in distinct terms. The never-failing test by succussion is constantly adverted to in these cases. ”

“ No one who studies the results of empyema in the past can question that the greatest danger is from the blood-poisoning known as septicæmia, caused by the absorption of the septic infection by the lymphatics.176 No matter what may be the nature of septicæmia, it is sufficient that the vast surfaces of the pleura produce certain prurient secretions, which, when absorbed and carried into the circulation, cause hectic fever with its results. ”

“ But if the fever continue beyond sixty days, without any subsidence of the swelling, it indicates that empyema is about to take place; and a swelling in any other part of the cavity will terminate in like manner. Such, then, as are painful, hard, and large, indicate danger of speedy death; but such as are soft, free of pain, and yield when pressed with the finger, are more chronic than these. Swellings in the belly less frequently form abscesses than those in the hypochondrium; and seldomest of all, those below the navel are converted into suppuration ”

“ Suppuration often is the result of the incited action; and purulent matter forms in the cavity of the pleura, generally without breach of surface. The membrane is covered with lymph, more or less extensively organised. Empyema is established. Suppuration may take place in the substance of the lungs, and from ulceration the matter may escape, in small quantity at a time, into the bronchial tubes, giving relief to the patient ”

“ If a sinus passes through a muscle, the repeated contractions tend to prevent healing until the muscle is kept at rest by a splint, or put out of action by division of its fibres. The sinuses associated with empyema are prevented from healing by the rigidity of the chest wall, and will only close after an operation which admits of the cavity being obliterated. ”

“ The symptoms of entrance of air into the pleural cavity may not occur for some time. The patient who has had empyema is made more uncomfortable; the discharge through the mouth is offensive, and its quantity and its character call attention to the chest, in which percussion shows the presence of air; auscultation gives amphoric breathing, and succussion demonstrates the presence of air and fluid in the pleural cavity. Very soon, however, the presence of air produces putridity of the secretion, with loss of appetite, fever, diarrhoea, and the other alarming symptoms of pyo-pneumothorax. ”

“ The symptoms of a confirmed empyema are weight in the chest, an intense dry cough, with pain, and sometimes with a fluid, in which case they seem to experience an alleviation. At the commencement the attacks of fever are weak, irregular, and difficult to perceive; but when the abscess is about to burst, they have more violent fever, attended with rigor, and in speaking their breathing is obstructed. When the abscess bursts, matter is brought up, sometimes pure and sometimes feculent: sometimes it is discharged upwards, when it is attended with more danger ”

“ Young persons, who become affected with empyema from determination (metastasis?) , or fistula, or from any other similar cause, or from the retrocession of an abscess, do not recover unless many of the favorable symptoms combine in the case. They die, most commonly, in autumn, which proves peculiarly fatal in protracted diseases. Of all others, virgins, and women suffering from amenorrhœa, seldomest recover; and in their cases there is no hope unless menstruation be restored. ”

“ Afterward, pneumonia and pleurisy are most circumstantially described, and the treatment of them laid down with a degree of prolixity very unlike the usual manner of Hippocrates. Thus, to promote the expectoration in pleurisy, he recommends the flos æris, asafœtida, trefoil, pepper, etc. [219] I am not aware that any other ancient authority recommends these medicines for the cure of this disease. The symptoms and diagnosis of empyema as the consequence of pleurisy, are given in much the same terms as in the preceding book. Succussion is particularly alluded to. ”

“ If any man would measure one very small part of the lives that are saved by this method, let him contrast the treatment of empyema fifty years ago with its treatment now. If he would measure the saving, not of lives but of limbs, let him take the treatment of compound fractures. If he would measure the saving of patients from pain, fever, and long confinement to bed, let him take the ordinary run of surgical cases, not only the major operations but all abscesses, lacerated wounds, foul sores, and so forth. ”

“ With regard to consumptive patients, he says, he has the same observations to make with regard to the sputa and cough as he had written with regard to empyema. [522] If the patient is to recover, the sputa should be white, equable, of one color, without phlegm; the defluxion from the head should be determined to the nose; there should be no fever, nor anorexia, nor thirst; the alvine discharges firm, proportionate to the ingesta, and the patient should not get thin. The best form of the chest is when it is quadrangular and hairy, and when the cartilage is small, and covered with flesh. ”

“ Rupture into pleura may occur and produce empyema. Rupture of hepatic abscess and discharge through the lungs is also a clinical form shown by this antecedent event, pointing to hepatic inflammation. The egress of the pus is sometimes through a narrow track, and not by a reservoir within the pulmonary tissue; at other times the lung is really excavated. The discharge of pus is usually copious and paroxysmal. Leyden recognizes as his third class a form of chronic abscess, or one coming on during a case of chronic pneumonia and bearing great resemblance to a variety of phthisis. ”

“ The course to recovery was sometimes broken by signs of slight pleuritic inflammation, which, as affecting the amount of effusion, will be spoken of under the heading of symptoms. In some cases the amount of blood was so great as to necessitate means being taken for its removal; in these a reaccumulation often took place. Occasionally an empyema followed in cases thus treated.
The nature of the blood evacuated on tapping varied much. In very early aspirations unchanged blood was often met with, but clot sometimes made evacuation difficult and necessitated a second puncture. ”

“ In the latter case, the abscess is liable to be mistaken for one associated with tuberculous disease of the rib, particularly as the rib is usually found to be bare. In rare cases the pus opens into the pleura, giving rise to empyema. When the disease is on the anterior surface of the bodies of the lower thoracic vertebræ, the pus may spread down through the pillars of the diaphragm and reach the sheath of the psoas muscle. ”

“ It occurs in all severe cases, and the fluid either is again absorbed, if in small quantity, or is the immediate cause of death, if in very large quantity, or a lesser amount may 100remain for a long time, impeding respiration, and forming an empyema or dropsy of the chest. When it exists, the breathing is always labored, and there is œdema or tumid swelling of some external part, generally the abdomen, chest, or point of the breast. ”

“ At first this mode of evacuation, empyema necessitatis, is a great relief, but cures rarely result from it. Most frequently, owing to the imperfect evacuation through the tortuous canal and the entrance of air mingling with the pus, death supervenes unless the surgeon enlarges the orifice or produces a new one, and thoroughly empties the sac and persistently washes it out. From statistics collected by Wilson Fox, the mortality is not so great from spontaneous parietal openings as was formerly supposed. Of Andral's cases there were 2 deaths in 25. Goodhart had 11 cases, all of which recovered. ”

“ The syringing should at first be daily, even twice a day if necessary, and then gradually diminished in frequency, until after the lapse of a week it is found that the maxillary sinus is quite free of any pus or flocculent mucus. By changing the obturator daily the patient can readily tell whether a washing out is required. When three to six months have passed without any trace of secretion, the empyema may be considered cured. This is the more likely if a formerly obscure sinus becomes translucent, and if the patient passes through a ‘cold’ without suppuration beginning in it again. ”

“ It seemed as if the box were bewitched, and as if the cottage were not big enough to hold it, without Pandora's continually stumbling over it, and making Epimetheus stumble over it likewise, and bruising all four of their shins.
Well, it was really hard that poor Epimetheus should have a box in his ears from morning till night; especially as the little people of the earth were so unaccustomed to vexations, in those happy days, that they knew not how to deal with them. Thus, a small vexation made as much disturbance, then, as a far bigger one would in our own times. ”

“ Anaximenes (c. 610-c. 545 B. C.) , an Ionian predecessor of Empedocles, may be said to have defined for us these functions of the pneuma; ὁιον ἡ ψυχη ἡ ἡμετερα αηρ ουσα συγκρατει ἡμας, ὁλον τον κοσμον πνευμα και αηρ περιεχει {hoion hê psychê hê hêmetera aêr ousa synkratei hêmas, holon ton kosmon pneuma kai aêr periechei}, ‘As our soul, being air, sustains us, so pneuma and air pervade the whole universe’; [63] but it is the speculation of Empedocles himself that came to be regarded as the basis of the Pneumatic School in Medicine which had later very important developments. ”

“ For some time Epimetheus and Pandora lived happily in the gardens of the earth, and every day Epimetheus thanked the gods for their last and best gift to man. He never tired of watching Pandora chasing butterflies through the tall meadow grass, or making cups out of broad leaves, that she and Epimetheus might drink from the clear, cool spring. One day as they were resting under the trees and eating their simple meal of dates and wild honey, they saw a traveler coming toward them. ”