Chapter XXXVI: Part 36

The value of counter-irritants has been frequently questioned of late years. Fly blisters give relief in limited dry pleurisy. Many practitioners have great confidence in large blisters used over the chest after the febrile stage has subsided. Woillez, in tabulating the results of the various means of promoting absorption, puts purgatives first in utility, and blisters last. Blisters, he claims, had no effect in 90 per cent. of cases. The iodide of iron, in pills, or the compound syrup of the iodide of iron and manganese, with improved digestive powers, are the best means of promoting absorption. At this period of the disease it is an advantage to lessen, within certain limits, the amount of fluid taken into the stomach, forcing the blood to abstract water by absorption from the chest. Jaborandi has the same effect by withdrawing water from the blood.

There are cases of excessive quantity of fluid, and others which resist all drugs given to promote absorption. Among these are some acute cases, but many of a subacute and chronic nature, where the effusion remains stationary, injuring respiration and often mechanically endangering life. This occurred in nearly one-third of Mason's cases.

Thoracentesis.--In studying the history of this operation we have seen how frequently, since the time of Hippocrates, it has been in favor with practitioners, and then has fallen into discredit. During the past thirty years, thanks especially to Bowditch and Trousseau, its unquestionable value has been established, and is now universally recognized. Improved knowledge of pathology, safe and easily-applied instruments, together with the discovery, by Lister, of the means of securing the operation from septic dangers, have perfected this surgical treatment. Observation in hundreds of cases has proved that, properly used, it is almost without risk. As a means of diagnosis it is the most accurate we possess; as a treatment for affording positive relief it is a boon to suffering humanity; as a method of cure it has been most successful.

Such being the estimate of its value, let us study, 1st, the indications for its use; 2d, the manner of operating; 3d, and finally, the objections founded upon the accidents that have followed its application.

The indications are met with in two conditions--that of excessive accumulation of fluid, and where there is non-absorption of the effused liquid. In going over the symptoms we have seen the effects of large collections of fluid in the pleura--how the heart is pushed out of its normal position, and how the large blood-vessels are distorted. We have called attention to the retraction and compression of the lung until in many cases it is airless, and thus not able to perform its functions. We have shown that all the adjoining organs and cavities are sometimes forcibly thrown out of the position nature placed them in. The liver is pressed forward into the abdominal cavity, and {522} the diaphragm is unable, from mechanical pressure, to ascend and contract. The mediastinum, with its contents, is materially interfered with. Observation has shown that such a state is a very dangerous one. Not only does it cause great dyspnoea, pain, and oppression, but the risk to life is imminent. In a number of instances it has caused death. Trousseau tells us of 3 deaths; Lacaze reports others. Bowditch, having seen several fatal cases produced by the quantity of fluid, worked with energy and perseverance until he was furnished by Wyman with his ingenious aspirator, of which he promptly availed himself, notwithstanding the objections he met with from others. "Ridicule," he says, "was pointed at me by some high in surgery: at first the whole medical profession was against me." He could not stand still and see men die whose lives could be saved. Chew had a patient die suddenly from this cause. Many authors mention cases of death from the large amount of fluid. Wilson Fox summed up from the records between 50 and 60 deaths from effusion in the pleural sac. Moreover, many patients have died where the disease was not recognized. The condition of the circulatory apparatus is such that we can readily understand that emboli would form in the heart, in the large blood-vessels, and in the parenchyma of the lung itself. These clots produce grave results. If they form in the pulmonary veins or in the left heart, they determine an embolic obstruction of the central artery, with all its consequences--apoplexy, hemiplegia, etc. If it forms in the right heart or in the pulmonary artery, it may produce rapid aphasia and death (Paget). Louis was certainly wrong when from his 150 cases of pleurisy he deduced the law that none died of this disease per se. It is thus a matter of the utmost importance that we should be able to recognize that there is a quantity of fluid capable of producing such serious results. The call for relief and diminution of the amount of fluid by thoracentesis is urgent. What amount is dangerous to life, and how can we arrive at an accurate estimate? To what extent can we judge by the subjective symptoms, especially by the dyspnoea? Andral and Trousseau both speak of it as a very fallacious and uncertain symptom, and by itself may be unimportant as an indication. In the beginning of the disease we find suffocating dyspnoea for a time when there is very little fluid. Diffusible stimulants and anodynes give relief. On the other hand, there are patients who with large amounts of fluid, even two quarts, walk about with but little difficulty in breathing, and attend to their pursuits unconscious of being in danger of sudden death. Bowditch[58] speaks of several fatal cases in simple pleurisy from excessive amounts, "from sudden failure of the power of the heart, with or without more or less dyspnoea." This is especially the case where the fluid forms insidiously, without marked general symptoms. When, however, we meet with dyspnoea, together with other and more reliable symptoms, it is very significant of danger, and ought to force us to resort to thoracentesis to afford mechanical relief. If we rely upon general symptoms, we may be deceived as to the amount of fluid, and serious results may follow. However, we must bear in mind that the most imperative reasons for thoracentesis are the signs of threatened failure of cardiac power. Bowditch lays down the rule that "if the dyspnoea is excessive, so as to amount to permanent orthopnoea, or if I learn that within a few hours previous to my visit there has been even one attack of momentary orthopnoea during which the patient felt as if the breath would be wholly lost, I tap immediately, provided I am sure that there is even a small quantity of fluid in the pleural cavity, and that it is apparently the chief or perhaps only cause of the orthopnoea. I fear," he says, "death may occur before my next visit." This eminent American authority on this subject lays down as the result of his vast experience the rule that "when a patient comes under {523} notice in whom a large quantity of fluid has been long effused, I advise thoracentesis as the first remedy." The author ventures to assert that where the amount is excessive there is imminent danger to life from the mechanical results of the presence of the fluid, even during the febrile stages; consequently thoracentesis is urgently necessary. I am confirmed in this view by Dieulafoy, Fernet, Clifford Allbutt, Marshall, and Cross. Barnes[59] says in all cases where the effusion is large and where dyspnoea is urgent it is better to operate at once. "It is my practice to operate at once when the chest is two parts filled with water, without waiting for urgent dyspnoea." Dieulafoy, in discussing these questions, states,[60] after consulting all the authorities accessible to him, that death has never been caused by less than two liters (equivalent to 62½ fluidounces), except in one instance reported by Blackey, where after death there was found 1500 grammes (47 fluidounces). In adults with well-formed chests he considers 1800 or 2000 grammes as the amount demanding surgical interference. He candidly acknowledges that he cannot make this an absolute rule, because the capacity of the pleural sacs must necessarily vary in different individuals according to their height, breadth, development of thoracic muscles, sex, etc.; consequently, the inconveniences and functional disturbances produced by a given quantity of fluid in the chest must be different in different persons. But how can we arrive at an accurate estimate of the amount in the chest? Dieulafoy,[61] in calculating the quantity, states that if it amounts to 1200 grammes when it reaches the sixth intercostal space, it ought to be valued at 2000 grammes when it is found at the third intercostal space. This is only approximative and unreliable. The height of liquid is not always proportional to quantity. It varies with size of chest, resistance of organs and walls, and condition of lungs. Potain insisted upon the difficulties that the pulmonary hyperæmia caused in the diagnosis, the abundance of fluid, the variable degree of yielding of the lung, and the adhesions which have drawn the walls to the lung. The true way of judging of the necessity for the operation is from the grave functional disturbances and by the definite positive physical signs which give us unmistakable indications which we dare not neglect. We can calculate the amount of the effusion by the level of the flatness on percussion, by mensuration with the cyrtometer, and of the impaired thoracic movements by the stethometer. Physical examination reveals the extent of the displacement of the heart and other viscera. The displacement of the abdominal viscera, the liver, the spleen, and the stomach shows that there must be excessive amount of effused fluid in pleura--enough to produce serious intra-thoracic pressure. This is a condition demanding surgical interference. The Skodaic resonance under the clavicle, the complete flatness being horizontal instead of giving us the Ellis curve, impaired resonance over the posterior triangle becoming absolute dulness, the presence of cavernous or amphoric respiration near the sternal-clavicular articulation, and, in rare instances, subclavian murmur from pressure upon the subclavian artery,--all these signs give unmistakable evidences that the pleural cavity is full of fluid. It is important, in considering the treatment, to form a correct estimate of the degree of intra-thoracic pressure, for Erichson has shown that the mere collapse of a lung affects but little the facility of the circulation through it; its compression or forcible collapse necessarily retards the circulation and throws extra work upon the already overburdened heart. The more precise our physical diagnosis, the more appropriate will be our treatment. Douglass Powell found the intra-thoracic pressure to vary from a -- pressure to ½ and 1½ inches of mercury at the commencement, and from -1/8 to -½, and even -1, inch mercury at the termination of paracentesis, there being in all cases a more or less considerable amount of fluid still remaining in the pleura. He states, {524} as the result of his own observations, that in recent cases the period of effusion at which the intra-thoracic pressure is converted from a -- pressure or zero to a positive pressure upon the lung and heart is marked clinically (1) by the flatness mounting up above the third cartilage (patient in sitting position), and (2) by the Skodaic resonance becoming changed from the full note to a more tubular quality. The extent of Skodaic resonance is a very valuable indication of the amount of fluid, and consequently of the propriety of operating. If this tympanitic resonance be down to the third rib, and the cyrtometer shows no decided enlargement, we had better not interfere. On the other hand, if the Skodaic sign is not heard, and instead there is flatness, we will be sure to find decided increased measurements and tubular breathing behind. Under such circumstances we may feel confident of positive intra-thoracic pressure of from one inch to one inch and a half of mercury--an amount sufficient to compress the lung and interfere with the heart's action. There is some danger of syncope, even if the patient remains motionless in bed, but if he moves about he is in imminent danger. The subject is annoyed by a straining retching cough with frothy, viscid sputa with perhaps some discolored points. The heart and the lung of the healthy side give warning of the danger, which ought never to pass unheeded. A murmur may be heard over the displaced heart, and over the lung on the unaffected side we may hear a fine crepitant râle, showing pulmonary hyperæmia and resulting oedema. The syphon or aspirator will afford, by withdrawing perhaps a quart, the necessary relief. Nature will do the rest in a large proportion of cases.

[Footnote 58: Unpublished MSS.]

[Footnote 59: _Brit. Med. Journal_, Dec., 1877.]

[Footnote 60: _Nouveau Dict. Méd._, vol. xxviii., art. "Thoracentesis."]

[Footnote 61: _Loc. cit._]

We cannot always estimate accurately the quantity of fluid by the displacement of the heart and other organs. The retractile energy of the lung is a very important factor in producing this result. A very large effusion, associated with a very powerful lung, will produce but slight displacements, while small effusions, when the lung of the affected side has lost its elasticity, will cause relatively great displacements (Garland). If there be no adhesions present, the letter _S_ curve of flatness becomes a sign of the greatest value. It marks accurately the height of the effusion. Knowing this, as well as the position of the heart and diaphragm, and the capacity of the chest, we can estimate the quantity of fluid in the pleural cavity. If in left pleurisies the heart be so pressed out of position that its apex beats to the right of sternum it is very diagnostic. With these signs, whether accompanied by dyspnoea or not, we must regard thoracentesis as imperatively called for. The presence of the febrile movement is not a counter-indication under these circumstances. The presence of a basic murmur, caused by the heart or aorta displacement, is an urgent indication for surgical interference.

There are attacks of fainting and syncope, suffocative paroxysms, with irregular and painful palpitations of the heart, with sometimes alarming threatenings of asphyxia--especially in pleurisy of the left side. These symptoms are probably due to the twisting of the inferior cava as it passes through the quadrilateral foramen of the diaphragm. The danger is necessarily increased by long continuance of the effusion. Prompt surgical treatment is indicated when we detect evidences of embarrassed circulation in the opposite lung, with a blowing quality of respiration and subcrepitant and oedemic râles.

In all cases of double pleurisy, where the total amount is sufficient to fill one whole cavity, we ought not to postpone operating. Even when the effusion is not very large, if there are other diseases of the respiratory or circulatory systems to cause grave complications, and danger of increased impairment of their functions, thoracentesis is rendered necessary. That these conditions justify thoracentesis we believe no one who has any practical experience will question. But two conditions exist where there is considerable {525} difference of opinion in regard to the propriety of operating: 1st, during the febrile stage, and, 2d, where moderate effusion remains unabsorbed.

In regard to the first of these, many authorities, even among the most enthusiastic advocates of the operation, have contended that unless there is imminent danger to life from the excessive collection of fluid, it should not be withdrawn, as it would at once re-form, and additional inflammatory action might be excited by surgical treatment. Castiaux,[62] however, strongly advocates the view that the operation by aspiration will hasten the cure of acute pleurisy and prevent the formation of the fibrinous deposits and bands which to a greater or less degree, even in moderate effusions, impair the expansion of the lungs. He relates 37 cases, almost all of which were operated upon by himself. He was successful in all of them, and the patients suffered no inconvenience or discomfort in consequence. In most of his cases the pulse and body-temperature fell (perhaps the same day, certainly the next morning), and even became normal after the operation, and the patients improved rapidly. He aspirated as soon as he detected the presence of fluid by exploratory punctures, believing that from the moment we have at our disposition sure means of relief which are harmless, it is useless to leave to nature the duty of removal--useless to leave to untrustworthy medication the relief which we can promptly give. He operated at the height of the first or inflammatory stage of the disease. He assigned as reasons for operating that he thereby relieved the lung of the compression which impairs expansion; that he removed a liquid rich in fibrin and capable of increasing the thickness of the neo-membranes; that by restoring the power to dilate he further prevented the lung from being compressed by the false membranes. These membranes cannot become organized unless they are separated by fluid. He states that he removed the fluid as completely as possible. As soon as the cavity was emptied respiration was made easy and the patient was relieved. Auscultation showed, by the vesicular murmur, that the lung had resumed its place without difficulty from top to bottom. The effusion returned, only in a few cases, with high temperature and frequent pulse, but another operation effectually arrested them. The pleurisy was cut short and puncture was considered the means of aborting the disease. The duration of the disease treated by this means was much shorter. Thus the patients were not forced to retain for months the liquid and false membranes in their chest. He states emphatically that there never supervened any accident, and especially that he never witnessed as a result the transformation of the serosity into pus, although it might appear theoretically likely to occur, as the serous membranes, already inflamed, ought to be more sensitive to injury.

[Footnote 62: _Thèse de Paris_, 1873.]

This testimony is very strong. Moutard-Martin operated upon 12 patients with fibro-serous effusions where they had existed less than ten days, and where there was more or less of fever. Out of this number, 8 had no reproduction whatever of fluid, and in 4 there was only a slight re-formation, and there was no degeneration into purulent fluid in any of them. In the other cases operated upon, where the effusions dated from twenty to sixty days, the fluid was almost always reproduced, though ordinarily to a moderate extent. He urges the prompt withdrawal of the fluid as the most successful method, especially if there is reason to suspect the formation of false membranes.

Wedal's[63] results confirm this view of the harmlessness of punctures during the febrile stage; and, more than this, they show that they hasten the cure. He operated on 17 patients from the second to the fifth day, and three times from the eighth to the tenth day. In cases of acute disease, where the patients were exempt from pulmonary or bronchial complications, the cure was not protracted beyond the twelfth day. Some were cured by the sixth day. His patients were, for the most part, vigorous men, young {526} soldiers--very favorable subjects. Ordinarily, however, as shown by J. L. Mason's[64] report of 132 cases where the operation was not performed, the duration of the attacks was weeks, and in some cases months. He considers the operation more apt to be successful if performed early in the disease, and that the existence of fever is no contraindication. The author has always pursued a more conservative course, and abstained from operating in the febrile stage unless, as in three instances, the effusion was so rapid in its formation that there was danger of serious consequences from the amount of the fluid. In these three instances the result was successful and without unpleasant sequelæ. Moutard-Martin[65] states that aspiration made during the febrile stage is in no way prejudicial to the patient. Dieulafoy[66] advises us to wait until the fever falls.

[Footnote 63: _Étude clin. des épanchments pleurit._, 1877.]

[Footnote 64: _Boston City Hospital Reports_, 3d Series, 1882.]

[Footnote 65: _Loc. cit._]

[Footnote 66: _De la Thoracéntèse dans la Pleur. Aigue_, 1878.]

To remove the effusion during the inflammatory stage does not appear to be rational treatment unless the quantity is so excessive as to endanger the life of the patient. The fluid remains limpid unless exposed to air or contact with foreign substance. When, after a time, there is some coagulation, it is only of a thin layer which covers and protects the roughened surface of the pleura. A certain amount of effusion is useful; it separates and bathes in a bland fluid the tender and inflamed surfaces, and keeps at rest the affected portion of the lung. The lung in health exercises a constant traction upon the pleural sac, the vessels of which have therefore to sustain a negative or aspiratory pressure: this being so, it is physiological that if these vessels become temporarily weakened and congested by the inflammatory process, increased exudation proceeds from them. The effect of this exudation is to neutralize lung-traction, and therefore to lessen the afflux of blood to the weakened vessels. "Fluid effusion being thus both natural and salutary, in acute pleurisy we must be watchful, but not meddlesome" (Powell). We must not hurry, but we must try if nature will not by spontaneous absorption cause it to subside. We can ordinarily do this up to the end of two or even three weeks before resorting to artificial means.

The defervescence in pleurisy, we have seen, has no fixed period, as in pneumonia. In favorable acute cases the absorption begins as soon as the temperature begins to fall. Moreover, the liquid may be absorbed, notwithstanding the continuance of fever, and the effusion may continue notwithstanding the defervescence. In the subacute form the febrile period passes by unnoticed, although the effusion is often in large quantity.

When not urgent, how long should we wait for absorption of fluid? This is a question much discussed, and not yet settled. What becomes of the effusion in the acute pleurisies?

In the first days of its formation the liquid portions of the effusion are reabsorbed by the normal vessels of the serous membranes at the points left intact and the recent vessels of the neo-membranes, but the organization of these last demands, to be complete, from two to three weeks; it is not until the end of that time that they will be most favorable to reabsorption. Dybkowsky points to the anatomical fact that the lymph-vessels are found only in those parts of the costal pleura which cover the intercostal muscles, while the portions which are reflected over the ribs are destitute of such vessels.

On the other hand, the eccentric pressure made by a considerable effusion on the pleuræ may retard their vascularization and lengthen out the work of absorption. Moreover, during the time necessary for that organization a certain quantity of coagulable fibrin is deposited on the surface of the serous membranes. The pseudo-membranous bridles are not slow in forming, and cause the adhesions which press the lung against the costal wall, the {527} vertebral gutter, and the superior parts of the thoracic cage, toward which the effusion tends to force them.

In very favorable cases the effusion may disappear by the twentieth day of the disease. In many cases, however, it lasts with the false membranes for several weeks, and not infrequently for many months. Cases are recorded by Powell and others where the effusion remained of a sero-fibrinous character for eighteen months and two years. Flint mentions two cases where the effusion was permanent, having lasted for years. Wilson Fox[67] thinks that there is but slight danger of the fluid becoming purulent from mere lapse of time unless the patient should have another fresh inflammatory attack. It must be noted, however, that such is not the case in children. Voyet[68] says that simple pleurisy in infants is transformed into purulent pleurisy with facility and extreme rapidity--so much so that when with these a serous effusion is slowly absorbed there is great danger of suppuration taking place. M. Vertiac[69] states that chronic serous pleurisy may not exist among children. In 13,000 sick children in eleven years Barthez did not have a single case. Pathological anatomy has demonstrated to us that this fluid in separating these neo-membranes on the parietal and pulmonary pleuræ increases their development. The plastic rugosities collect the fibrils of fibrin on their surface, in the same manner as they are found on the twigs in whipping the blood, and as the atheromatous deposits on the interior of blood-vessels favor the formation of emboli. These false membranes may cause a number of complications by surrounding the lung with a thick, inelastic shell. The collapse of one part of the lung diminishes necessarily the field of hæmatosis, and consequently causes a compensatory congestion of that lung, and even of the lung of the other side. This occurring in an individual predisposed to tuberculosis or in a condition to develop and cultivate the bacillus tuberculosis may start the disease. Formad[70] maintains that pleurisy is a very frequent cause of pulmonary tuberculosis. These imperfectly organized embryonic membranes cause deformities of the thorax; they are good ground for the growth of pathological products, such as cancer or tubercle; their fragile capillary vessels are the principal cause of a most troublesome form of hemorrhagic pleurisy. (See HEMORRHAGIC PLEURISY.) If the lung be compressed but a short time, it does not undergo irreparable injury, but if for a considerable time, the thickened organized membrane, with the effusion, causes a more or less considerable atelectasis, binding down the lung and preventing its expansion. The author holds that the effusion, after the fever has subsided, is, in itself, a foreign and troublesome element; for even with a medium effusion we are not exempt from unpleasant results.

[Footnote 67: _Brit. Med. Journ._, Dec., 1877.]

[Footnote 68: _Thèse de Paris_, 1870.]

[Footnote 69: _Ibid._, 1865.]

[Footnote 70: Paper read before the Baltimore Clinical Society, February, 1883.]

Although, in moderate effusions, there is no compression of the lung, yet there is necessarily collapse of it pari passu with the amount of fluid. This interferes with its retractive power--the aspiration force, as it has been called--by which the venous blood is drawn into the right side of the heart. T. B. Curtis of Boston calls attention to this very important fact, and shows that the result must be disturbance of circulation, with imperfect blood-supply to the heart, interrupted cardiac action, feeble arterial tension, together with venous repletion and stagnation. In consequence of this condition there is a diminution of the quantity of urine, and, as generally occurs where there is venous congestion, a small quantity of albumen, cyanosis, etc. Fraentzel, Traube, and Lichtheim attribute the venous stagnation, etc. to obstruction in the pulmonary circulation resulting from pressure exercised by the effusion. Curtis and Garland hold that these bad symptoms are not caused by pressure, but by the diminished pulmonic retractility which exercises the negative pressure of emptying the large venous trunks.

{528} Such being the ill-effects of the retracted lungs, is it well to allow even a moderate amount of fluid to remain in the pleural sac after Nature has failed to remove it? Besides, the presence of liquid alone displaces the organs, especially the heart and lungs; adhesions form and keep them in an abnormal condition. The retracted lung, bound down by bands, becomes enfeebled, loses its suppleness, and is rendered rigid, seriously impairing respiration. There exist three factors--false membranes, adhesions,[71] and interstitial pneumonia--which tend to seriously disable the lung and even to produce complete atelectasis pulmonum. We must bear in mind that there is some danger of the fluid becoming purulent, especially if a fresh inflammatory attack should occur. The less time a pleurisitic effusion lasts, the sooner the patient will be placed beyond the probability of these serious injuries to the process of hæmatosis. It is but right to give Nature an opportunity, assisted by iron, salines, diuretics, iodine, and even blisters, in cases of moderate effusion. The rapidity of Nature's work in many cases in removing large quantities of fluid here and elsewhere is wonderful. But if she does not act, we ought not to let our patient become feeble and depressed in his nutrition, or perhaps maimed for life, by not withdrawing the fluid. Sometimes the absorbents only half do their work of removing the fluid, and leave a quantity in the chest. Under these circumstances tonics, good diet, and change of air will complete the absorption.

[Footnote 71: According to Wilson Fox, the density of the adhesions and false membranes is determined within the first fortnight of the effusion.]

The question arises, How long shall we wait for absorption? Test first, by exploratory puncture, the nature of the fluid: if it is fibro-serous day after day, try by the cyrtometer the size of chest and by percussion the exact amount of flatness. If there is no evidence of any decline of the effusion in two weeks, slowly withdraw some of the fluid. This will start the absorbents into activity, for the natural absorbing power of the pleura is diminished when it has been unduly stretched for some time. The layer of lymphatics subjacent to the pleura and communicating by stomata with the pulmonary lymphatics, together with the other absorbent vessels, appear to be unable to remove the fluid. We maintain that the pressure on the orifices of the lymphatics is often too great for absorption to take place, and that by removing the pressure we can start the absorbents into activity. Aspiration under these circumstances shortens the duration by several weeks and hastens convalescence. J. W. Hunt[72] advises that we should wait two or three weeks before operating. Loomis[73] says if the fluid remains stationary for one week, or is increasing when the cavity is half filled, we must operate. Barnes[74] would only wait a few days if the chest is half full, to see if absorption will begin to remove it. When the chest is two-thirds full, he advises immediate surgical interference. Oxley[75] advises a delay of three or four weeks before operating. Anstie's[76] rule is to postpone operating for one month. T. Clifford Allbutt's[77] general rule is, if an effusion rises above the angle of the scapula, and abides in that quantity or increases for two or three weeks in spite of adequate treatment, it must be drawn off, whether the patient be embarrassed by it or not. Bowditch[78] says: "If the effusion does not subside under the medical treatment, and the symptoms have not lessened after two or at the utmost four weeks, I have, after long experience, been led to the following general rules for my own guidance: 1st. I never allow any time to elapse before performing thoracentesis after a decided and prominent dyspnoea appears, or if a sudden and very threatening orthopnoea occur, or if I find the chest has become full or more than half full of fluid in a perfectly latent manner {529} during a month of illness. 2d. After there is dulness to the angle of the scapula, with the other rational and physical signs of pleuritic effusions, I tap within four weeks, even if the patient seems quite comfortable, if the line of dulness does not get lower and seem to subside under the treatment. I think fatal mistakes are made by delaying too long before tapping." The author prefers ordinarily to wait for the subsidence of the fever in acute cases, unless the effusion is in dangerous quantity. The practitioner must continually use the thermometer as well as observe physical phenomena and general symptoms. Cyrtometric tracings give very valuable indications as to the activity or non-activity of the absorbent vessels. After the fever subsides the fluid may be regarded as a foreign body doing harm to the two principal organic functions upon which the nutrition of the animal frame is dependent--respiration and circulation. It is from this standpoint that Dieulafoy[79] advises, if absorption is slow or difficult after two or three days, that the fluid should be aspirated. The greatest success has been obtained in cases where the fluid has been present but a short time. The number of fatal cases is increased by delay of operation. Toussaint's cases show this:

4 deaths in 176 cases operated upon between 1st and 20th day.
6 " 80 " " " " 20th and 60th "
1 " 7 " " " " 60th and 120th "

In the quiet kind of pleurisy, formerly designated the subacute or latent, thoracentesis is especially applicable. Ordinarily, when the practitioner is consulted, there is considerable fluid, without any febrile movement. Here we are in duty bound to assist nature. Iron in the form of the tincture of the chloride and the syrup of the iodide are our best remedies. We cannot give the patients the tonic influence of outdoor air with exercise, because there is danger in their moving about; but they should have an abundant supply of nourishing food, with light wines. Absorption is very inactive and sluggish. Even with moderate effusion to the extent of one-third of the pleural cavity, we cannot let the fluid remain too long. Pidoux designated this form of pleurisy as the thoracentesis variety.

[Footnote 72: _Loc. cit._]

[Footnote 73: _Dis. Resp. Org., etc._, 1875.]

[Footnote 74: _Loc. cit._]

[Footnote 75: _N.Y. Med. Ex._, Sept., 1882.]

[Footnote 76: _Syst. Med._]

[Footnote 77: Quain's _Dict. Med._]

[Footnote 78: Unpublished MSS.]

[Footnote 79: _La Thoracent. par Asp. dans les Pleur. Aigues_, 1878.]

Conclusions.--1st. The author wishes to be distinctly understood as not advocating aspiration simply because there is an effusion, as a mere matter of routine, for its indiscriminate employment is undoubtedly attended with risk. He does claim that its performance is imperatively called for when the pleural cavity is full or nearly so; when there is much displacement of the heart or other viscera; when the patient is suffering from serious dyspnoea and danger of syncope, and when there are complications of disease of any kind of the other side or of the heart; finally, when there is double pleurisy. Bowditch states that he has seen thoracentesis give great relief in effusions following Bright's disease and cardiac diseases.

2d. He thinks that in acute cases, after the subsidence of the fever, if the pleura is one-third full of fibro-serous fluid, Nature will probably do her work of removal promptly. If she shows no sign of doing so, we should come to her assistance in about ten days or two weeks, and draw off a portion of the fluid--enough to relieve pressure and to encourage the absorption of what is left in the sac.

3d. In the subacute or chronic fibro-serous effusions it is not well to wait over three weeks before operating. As he shall show in the study of the dangers and objections, he considers the operation a perfectly safe one if the simple rules now generally observed by operators are faithfully carried out.

In studying the advisability of operating where there are not urgent indications we must ever bear in mind that while it takes a large quantity of {530} fluid to compress the lung, the retracted lung may, by neo-membranes, be kept to its diminished volume. As long as the lung is able to lift up the fluid and the diaphragm it is in no danger of atelectasis. It is in a state of physiological rest. In a subject of bad constitution interstitial changes may indicate an earlier operation, but, if an effusion exists on the side on which there is already lung disease of a phthisical nature, we should be loath to interfere; for "experience has shown that an effusion checks, and sometimes arrests, the tubercular process" (Powell).

Contraindications.--These are principally in connection with the general condition of the patient. If it is such that there is no hope of his rallying, if he is very old, or if he has intervening croupal pneumonia, the operation is not justifiable. If the quantity of fluid is not large and does not interfere with organic functions, we can wait for some time.

Mode of Operating.--The old trocar method of operation is now abandoned. It was not always an easy one, was painful, and there was more or less danger of cutting the intercostal artery, of introducing air, and of establishing, by the size of the puncture, a fistulous orifice. If, perchance, the lung was perforated by the trocar, pneumothorax was established. In some cases of sacculated and limited effusions, and in chronic cases where the membranes were thick, it was not effectual, and if the fluid was not reached, the operator hesitated to introduce the trocar elsewhere. When the fluid flowed through the trocar, it came frequently in jets with painful coughs. The above operation was quite a formidable one. Now thoracentesis is always performed with very fine perforated needles attached to aspirators of some modern pattern, and guarded by Fitch's dome-trocar or Castiaux's protected point. We employ Dieulafoy's Potain's bottle-aspirator, Castiaux's of Paris, or Raumussen's of Copenhagen. Flint recommends the use of Davison's syringe. We fear it would be found too rough an instrument for so delicate an operation. The points of attachment of the bulb with the tubing are not sufficiently air-tight. The valves are very imperfect, and easily get out of order. In our efforts to pump out the fluid we might throw air in, and with it particles of organic matter.

The operator has his choice among no less than thirty-odd instruments similar to Dieulafoy's. They all work upon the same principle--the close operation, the withdrawal of the fluid by aspiration. The needle or trocar must be capillary: the smallest that is effective is the best--say a half millimeter in diameter--in order to make the orifice as minute as possible.

If we prefer the syphon, we must use a larger canula than we employ for aspiration--one of four millimeters in diameter. It should have two outlets--one straight, for the trocar, and one at an angle, for the attachment of the tubing. It should also be guarded by an air-tight collar. Into the syphon tubing a T-tube may be inserted for the purpose of attaching a side tube to be connected with a mercurial manometer, by means of which the exact intra-thoracic pressure may be observed during the operation. The syphon tube should be long enough to provide a fall of one, two, or three feet, as may be necessary. A fall of twelve to eighteen inches is usually enough, as we wish to remove the fluid slowly. We can easily increase the force by lengthening the tube. If the canula should become obstructed, lowering the basin suddenly will probably remove the piece of lymph. The trocar can be pushed again through the canula if necessary. In case the aspirator should be needed, the end should have a metallic joint affixed to it. In all the instruments used, absolute cleanliness should be observed. The tubing previous to operation should be filled with a solution of carbolic acid (1:40).

In cases of rapid effusion, especially during the febrile stage and when the intra-thoracic pressure of fluid is great, some prefer using the feeblest form of aspiration. Southey's capillary trocar, with drainage-tubes attached, is used as a syphon for this purpose. The fluid is drained off {531} through a narrow india-rubber tubing which is placed under water to prevent air being drawn into it. Ordinarily, the use of the fine aspirating-needle without much force, and slowly drawing off the fluid, answers the same purpose. The fear some have expressed, of the danger of injuring the lung by the force of the rarefied space, is more theoretical than real. Even with a canula of the size that Southey employs there is some danger of leaving a fistulous orifice, for it has to be kept in for hours. If the smallest tube is used, from which the fluid simply comes in drops, the operation consumes five or even ten hours. Southey speaks of cases where the flow was kept up for twenty-four hours. Unless aspiration is resorted to, flocculi may easily stop up the canula, and then we are compelled to reintroduce the trocar, and afterward to reattach the tubing. Oxley, who thinks that the best results are obtained by the use of these tubes, acknowledges that so much time was consumed that he inserts four canulas, drawing off 44 fluidounces of fluid in one hour and ten minutes, thus defeating the object of using this method, which was to draw off the fluid very slowly, so as to enable the lung to expand gradually and healthfully.

There are cases where, to withdraw the fluid, more suction force than is usually employed with the syphon has to be used in order to antagonize the negative force exercised by the traction of the lung and the passive tension of the diaphragm. The author recently had a case where, notwithstanding the presence within the right pleural sac of a quantity of fluid large enough to obliterate the Skodaic resonance under the clavicle, not a drop could be drawn out by a syphon attached to a canula of 2 mm. in diameter. Having no additional tubing to increase the force of the syphon at hand, he used Dieulafoy's rack aspirator, ½ mm. in diameter, and drew off a quart of fluid--enough to relieve the symptoms of oppression. Stone reports a case of the kind where, although there were two quarts of fluid in the pleural sac, no fluid could be drawn out with a syphon exerting a force of 1½ pounds to the square inch, or one-tenth of an atmosphere. In the same case there was actually, in inspiration, a negative pressure exercised by the lung of two inches of water. Stone mentions another case where a boy fifteen years of age died from the quantity of fluid, which would not flow out when tapped. If he had had an instrument by which he could have used aspiration he would have saved the life.

The value of this syphon method has within a few years grown much in favor. It is simple and inexpensive. It allows the fluid to be drawn out with a uniform and feeble aspiratory force. The flow is very slow, which gives the lung time to expand gently, and the displaced organs to return gradually to their normal position. With the manometer attached we can judge accurately as to the intra-thoracic pressure. The size of the canula has to be larger than when we employ the aspirator--4 mm.--whereas with the latter we use ½ mm. or 1 mm. in diameter. If by any accident the lung should be perforated, the larger orifice would not be as harmless and insignificant as the smaller one. It must be borne in mind, especially in cases of long standing, that the neo-membranes are very vascular, and that with a 4 mm. perforator we may rupture the blood-vessels and complicate matters by the escape of blood into the pleural cavity. It is claimed that when the canula and syphon tubes have been introduced the patient can be left in charge of the nurse. This, the author thinks, should never be done, for nurses are rarely competent to judge whether a sufficient amount has been withdrawn, nor are they fit to assume the responsibility of acting in cases where promptness of treatment may be of the utmost importance. The operator or a competent substitute must remain until the operation is over. The withdrawal of fluid must, moreover, be slow, for slowness contributes in a great degree to lessen the dangers. Fraentzel recommends testing the force of the {532} aspirator in the palm of the hand. Garland[80] employs needles which are 1-2 mm. in diameter and remove only 50 to 100 grammes per minute. The thoracic pressure must be relieved by the withdrawal of only enough fluid to effect that purpose. It has been objected that the negative force of the aspirator is uncertain. It is a well-founded objection, yet we can employ with it a feeble force by exhausting only a portion of the air from the cylinder or bottle, and thus remove the fluid cautiously and very deliberately. It is admitted that if there is no intra-thoracic pressure the fluid will not flow out unless we introduce air or negative force. We claim that the syphon and the aspirator with capillary needles, employed with the precautions dictated by modern experience, are both safe and effective. Ordinarily, we prefer the bottle aspirator of Potain, or Dieulafoy's instrument with the manometer attachment.

[Footnote 80: "Dis. of Pleura," in _Ziemmsen's Appendix_.]

Modern aspirators, if in perfectly good order, completely prevent the possibility of septic contamination by admission of air. Unclean needles and canulæ can--and we fear formerly often did--convert sero-fibrinous into purulent pleurisies. A case came under Powell's observation in which carelessness in this respect apparently led to decomposition of the fluid, suppurative pleurisy, and ultimately to the death of the patient. Before operating we ought always to test the instrument, and see that it works well by passing carbolized water through it. The points should be put in the flame of a spirit-lamp, and then dipped in carbolized water and glycerin--not in oil, which may be rancid. The hands and clothes of the operator should not be overlooked in this regard. The atmosphere of the room should previously be completely cleansed by ventilation, and afterward purified by atomization of disinfectants. We must not, in a word, incur the slightest risk of converting a simple inflammatory effusion of fibro-serous fluid, a mild disease, into a suppurative inflammation, a very troublesome, dangerous one.

A needle of not larger diameter than 1 millimeter (No. 2) should be connected with the end of the tubing. Next turn the stopcocks which shut off the barrel from the tubing on both sides, producing a vacuum in the receiver. The patient should then be placed in the recumbent position in bed, with his head and chest raised. We prefer this position, as the easiest for the patient at the time of operation and less apt to produce syncope or faintness. He can, without being moved, lie down in the horizontal position, which he should maintain for at least two hours. Bowditch has, without any accident, had his patients to sit during operation sidewise in a chair, with one arm resting upon a pillow placed upon the top of the back. The operation is accompanied with so little pain that it is not necessary to use either general or local anæsthesia. Some surgeons advise before operating the administration of a small dose of morphia hypodermically, or a stimulating drink of whiskey. We are not in the habit of using either. We have generally allowed patients to take a good meal of easily-digested food (milk if they consent) about two hours previous to the operation. Whiskey and ammonia we have ready in case of need. If we find it necessary to use a 4-mm. canula for syphon, it may be best to spare the pain of its introduction by local anæsthesia by ether, or by rhigoline in Richardson's spray, or by applying a piece of ice surrounded by salt, as suggested by Powell.

The point of puncture should vary according to the quantity of fluid. If the fluid is excessive, we can operate as high up as the fifth intercostal space on the right side and the seventh on the left. We can choose a lower intercostal, but as it is not proposed to draw off all the fluid, the higher operation is preferable. If the chest is two-thirds full, we can take the seventh or sixth intercostal space on the right side and eighth on the left. If only one-third of the cavity is occupied by fluid, we can go as low as the eighth intercostal {533} on right and left sides, on a level with the angle of the scapula in the axillary line. If the quantity of liquid is so great as to force the abdominal viscera, especially the liver and the spleen, below their normal position, we may be safe in puncturing below the seventh intercostal space. But if such is not the case, the diaphragm may easily be touched on a level with even the seventh intercostal space. Aran plunged a trocar into the liver when operating through the seventh intercostal space. Ch. Bernard impinged upon the peritoneum at the same point. Woillez and Paul Barbille recommend the fifth intercostal space. Cruveilhier advises the third or fourth as being the point of the spontaneous openings. The author usually inserts the needle in the sixth intercostal space in the mid-axillary line: it is out of reach of the diaphragm and is accessible when the patient lies in the position in which he prefers placing him. The space is sufficiently wide and the parietes thin. Before operating the point must be examined carefully by percussion, auscultation, and palpation, so as to be accurate in the diagnosis that there is fluid at that point, and that nothing can be injured--lung, heart, or diaphragm.

Before inserting the needle the skin should be wiped over with an antiseptic solution. The skin being drawn up, the nail of the left index finger serving as a director, the point, having been first made aseptic, is introduced along the upper margin of the lower rib, taking care not to injure the periosteum--not by a boring motion, but by a sharp push, giving it a downward direction instead of a perfectly straight one, so as to avoid striking the lung. When the fluid is reached the stopcock is turned, so as to convert the needle into an aspirator. The index tells us whether we have struck the fluid, and its nature is shown. In chronic cases, where the bands are thick and partitions are firm, we may not find the fluid the first time. In such cases the needle is withdrawn and another point selected. The author had a case where he made no less than eight punctures before getting the fluid. At the last insertion of the needle he found it, and drew off a large quantity. The patient feels relieved in a very short time. As the fluid flows out the aspirating force should be only sufficient to draw it out slowly and gently. It is well to stop for a few minutes after aspirating about 4 fluidounces to watch the effects. The fluid running in a very small stream, we give the lung time to accommodate itself to its altered condition. The lung by this process is led, rather than forced, to resume its normal position. It is a difficult matter to fix the quantity that ought to be drawn off at one time. This must vary according to the circumstances of each case. Our rule has been to draw off more when the pleurisy is acute than when it is chronic. The long continuance of the fluid in the cavity has so impaired the lung's capability of expansion by the adhesive bands or compresses that the sudden withdrawal of a large quantity is attended with risk. If the patient bears the operation well, we may remove much more than if the contrary is the case. The amount withdrawn at the first operation should vary from 8 fluidounces to 16 fluidounces in a child, and 12 fluidounces to 24 fluidounces for an adult. We must bear in mind, as to the quantity to be removed, that ordinarily there is more or less danger of producing fresh engorgement of the capillaries and hyperæmia of the lung in removing a large quantity; and, moreover, it is unnecessary. We wish to remove the intra-thoracic pressure upon the lung and to promote the absorption of the fluid. The manometer will tell us accurately whether it is necessary to take out one, two, or three pints. If nature does not in due time remove what is left, the operation can be again resorted to. Slowness in the withdrawal of the fluid, as well as the small quantity drawn, lessens the probability of any unpleasant effects. Bowditch says: "I always draw with great deliberation. I pull so lightly upon the handle of the piston that it seems as if the fluid itself were pressing out from the chest and pushed the piston upward, my hand simply following that impulse. The instant that the patient becomes {534} restless, especially if he have any constriction or sharp pain in the chest, I withdraw the tube, even if a large quantity of fluid remains. If I do this, I find the patient is soon relieved, and in most cases nature appears stimulated even by the withdrawal of a very small part of the effusion. The absorbents begin to act well, and the fluid that is left is speedily removed."

One point is of the utmost importance: the needle should be instantly withdrawn at the onset of dyspnoea, constriction, much cough, or any tendency to syncope. These symptoms are warnings we should never neglect. This is the time to administer stimulants, and ordinarily the patient soon recovers from these effects. We must not, especially in cases of long duration, expect to find much expansion of the lung until next day. The greatest success has followed cases treated by early operation and partial removals, repeated, if necessary, every day or two until absorption is commenced.