Chapter XLI: Part 41

In 1658, Bontius for the first time took up in a precise manner the subject of the introduction of air into the pleural cavity. He declared there was no danger from it. Bartholin maintained the opposite opinion. The indications for the operation were laid down, but they were necessarily very imperfect. In proportion as attention was directed to the question of the admission of air, the manner of operating was modified. In 1669, Scultetus discussed thoracentesis in his work _Armamentarium Chirurgicum_. He made use of a trocar, with a bladder at the external orifice, principally to prevent the introduction of air, as Reybard later used a piece of cat's intestine and a bladder of gold-beater's skin. Scultetus used the sypho, a common syringe, for injecting the chest, and also the [Greek: pyoulchon] ([Greek: pyon], pus; [Greek: elchô], to draw out), or pyulcon, for drawing out matter, as its name indicates. This was practically the syphon. Scultetus describes the operation by incision with his gladeolo salicet longo, and by puncture with the canula et acus, both figured in his plates; so also his drainage-tubes, with directions for shortening them as the cavity heals, and the long tubes, which probably acted by gravitation after the manner of the syphon. Aspiration was made by the mouth, by cups, and by syringes affixed to a canula or catheter.[272]

[Footnote 272: These facts were kindly furnished me by Morrill Wyman, who carefully examined Scultetus' work (edition 1672) in the Harvard Library.]

It is thus evident that more than two hundred years ago aspiration was used to evacuate fluid from the pleural cavity. Trousseau says that "at that period aspiration and suction were used for this purpose--timidly pursued, in accordance with Scultetus' example; and that it became afterward in vogue with the masters of surgical art."

Palfin preferred the trocar to incision for treatment of hydrothorax. In 1707, Anel wrote a book on the art of sucking wounds without using the mouth. Bourdelin (1742) rejected the trocar for fear of injuring the lung. That Scultetus' practice was continued is evident from the work of Laurence Heister (1742), who described puncture of the chest, with drawings of exhausting syringes for the removal of pus or serum.

In 1765, one hundred years after Druin's use of the trocar, when perforation by actual cautery was abandoned, Lurde timidly advocated it on account of his fear of wounding the lung. He advised the operator to close the canula with the finger at each inspiration, leaving it open during expiration, so as to prevent the entrance of air. Chopart and Desault opposed the use of the trocar as a coarse mode of operation, involving the risk of wounding the intercostal artery and lung (Trousseau). Van Swieten at the end of the last century questioned the advisability of using the trocar. Later, in 1796, Benj. Bell,[273] in cases of thoracentesis, used india-rubber bottles fitted to the opening for the same purpose, first compressing them and then allowing them to expand by their elasticity. He strongly recommended paracentesis {589} of the pericardium when the amount was so excessive as to cause death. He gives exact directions how and where to operate.

[Footnote 273: Vol. v.]

Isbrand de Diéonerbrock[274] plunged a bistoury between the fifth and sixth ribs, and introduced into the wound a silver canula large enough to fit the orifice, and stopped the canula with a tent which he withdrew each day. Jean Scultetus[275] recommended several different canulas, some of silver, some of gold. He also invented syringes, straight and curved, to absorb the pus or make injections into the chest. Scultetus operated in the sixth intercostal space; he raised a piece of skin, so that it might lap over the orifice after the operation. He used a tent until the eleventh day, when he inserted a canula. After Scultetus, Lamzweerden[276] used suction, and contended that it was very successful. Paul Barbette[277] considered thoracentesis as indispensable in empyema and hydrothorax. He maintained that it was less dangerous than the puncture for ascites. F. Hoffmann at the commencement of the eighteenth century[278] gave his full and complete approbation to the operation performed according to the accepted rules. Dominique Anel[279] was an avowed partisan of the suction of the effused fluids in the chest. He had seen soldiers very successfully suck, with the mouth, wounds of the chest. He invented different syringes and other machines to pump out the effused fluids, some of which were very large, with canulæ whose orifices were very wide and of different shapes.

[Footnote 274: _Medic. Morb. Pectoris Hist._, 2.]

[Footnote 275: _Armam. Chir._, Paris, vol. i. p. 20, quoted by Sprengel.]

[Footnote 276: _Appendix ad Sculpt. Armen_, 1671, quoted by Sprengel.]

[Footnote 277: _Chirurgia_, lib. iii. cap. 2, Geneva, 1688, quoted by Sprengel.]

[Footnote 278: _Medicina consultatoma_, vol. i., 1721.]

[Footnote 279: _L'art de Sucer les plaies sans se servir de la bouche d'un Homme_, Amst., 1707.]

Laurence Heister[280] (1742) acknowledged that Anel's syringes were valuable in pumping out the fluid from the middle or lower part of the chest, but not when paracentesis was performed in the higher portions between the second and third ribs. Heister gives[281] drawings of exhausting syringes for the removal of pus or serum. C. G. Ludwig published[282] a new apparatus invented by a surgeon named Bucer to pump out the fluids contained in the chest. This machine was composed of canulæ, to which was adapted a bowl to receive the liquid as it was withdrawn. Ludwig claimed that the especial advantage of this instrument was that it pumped all the fluid out at one time, without the operator being annoyed by any disagreeable odor. Leber[283] proposed a similar instrument which was easier of application. A. T. Richter demonstrated the inutility of all these inventions; the blood, he said, would be drawn out with the fluid and by coagula stop up the canula. Valentin (1772) objected to the use of these pumps as applied to chest fluids.

[Footnote 280: _Chirurgie_, Th. i. Buch. i. Kap. 10, p. 89.]

[Footnote 281: _Ibid._, p. 72.]

[Footnote 282: _Diss. de Vul. Pectoris_, Leip., 1768.]

[Footnote 283: Quoted by Sprengel, p. 60, vol. ix.]

In the latter part of the eighteenth century there were numerous English and continental writers on the subject of paracentesis. Among them were J. W. Belquer, Sharp Mohrenheim, Richter, Ponteau, Callisen, Pierre Cooper, Allemoth, Zellar, and Audouard. Some of these preferred the trocar to the bistoury. Some were in favor of prompt action, and others objected to the operation unless there were threatening symptoms. Valentin urged that the presence, on the surface of the chest, of oedema and ecchymosed spots was a certain indication of fluid effusion.

During the first twelve years of this century the operation seems to have fallen into disuse. In 1808, Audouard objected to the Hippocratian method, which had been practised for centuries, of drawing out small quantities at a time, for fear that the sudden withdrawal of a large quantity would produce a vacuum in the chest. He maintained, and proved, that sudden and {590} complete evacuation had no such result. In 1811, Corvisart[284] drew attention to thoracentesis. In 1812, Larrey discussed its merits. Charles Bell[285] preferred the trocar to the other methods in hydrothorax when he could be positive of the presence of fluid, but he stated that he preferred first to introduce the bistoury. He operated in the sixth intercostal space, but in empyema he preferred to make the puncture higher up. Samuel Cooper[286] recommended as small an orifice as possible for the evacuation of serum, but larger and wider ones for pus and blood.

[Footnote 284: _Maladies du Coeur_, 1811.]

[Footnote 285: _System of Operative Surgery_, vol. ii. p. 194.]

[Footnote 286: _Dictionary of Surgery_, p. 749.]

In tracing the history of this important operation we have shown that it has been performed from the time of Hippocrates, and that it has been held in different degrees of estimation by the numerous authors who have discussed it--that sometimes it has been popular, and again regarded unfavorably.

Récamier operated, but unsuccessfully. Up to the period we have now reached (1816) great difficulty of accurate diagnosis existed, and crude notions of physiology prevailed. Errors of diagnosis as to the character of the fluid when present, and still more as to its existence in the chest, frequently led to unpleasant results. Laennec's genius so completely cleared up the differential diagnosis of all diseases of the chest, including pleurisy, that men grew less timid. Laennec[287] himself was a strong advocate of the operation; he advised it in acute pleurisy where dyspnoea, threatening life, supervened, and in chronic cases where other remedies failed. He proposed to apply a piston cupping-glass over the wound after the discharge of liquid, and to produce a vacuum in the chest more or less quickly, continuously, and completely according to effects.

[Footnote 287: _Traité d'Auscultation mediate_, 1818.]

As Bowditch[288] states, "We should be groping in the same dark way, and perhaps getting into the chest by caustic pastes or by actual cautery, had not Laennec discovered for us auscultation, with all its admirable powers of diagnosis of thoracic affections."

[Footnote 288: Unpublished communication to the writer, 1882.]

In 1815, Blondel practised puncture of the chest with a bistoury. Gendrin performed the same operation in acute pleurisy in 1831, but with only bad results. Townsend[289] (1833) acknowledged that the operation had fallen into disuse, as much from uncertainty of diagnosis as from any experience of its general danger. He gives the results of Thomas Davies's operations--8 out of 10 successful cases in empyema, with 9 fatal cases in pneumothorax with effusion (probably tubercular), and 3 fatal cases in hydrothorax. Davies used a grooved needle to determine the presence of the liquid, its quality, and the thickness of the walls. After the operation his practice was to inject a weak solution of chloride of lime, which he found to have the effect of diminishing the discharge and correcting its character. Crompton[290] (1834) had 3 successful cases out of 10.

[Footnote 289: _Cyc. Prac. Med._, vol. ii. p. 43.]

[Footnote 290: _Ibid._, vol. iii. p. 400.]

Robert Law[291] pronounced paracentesis more successful in chronic than in acute pleurisy. Townsend doubts whether the admission of air was hurtful; he quotes Nysten and Spies's experiment, showing that air introduced into healthy pleuræ was invariably absorbed in a few days.

[Footnote 291: _Ibid._, 1834.]

Townsend[292] and Law, as well as C. I. B. Williams,[293] speak of the different kinds of syringes that have been proposed to draw off the fluids.[294] Dupuytren proposed (1814) the introduction of a small canula with a very flexible substance at its outward extremity, such as the bladder of some domestic animal, which would allow fluid to escape, and at the same time would oppose the entrance of air into the chest. Becker (1834) published a work in which he investigated the nature of the false membranes in pleurisy, and showed that the {591} access of air did not produce unpleasant results. He reported 2 successful cases out of 3 of operation.

[Footnote 292: _Ibid._]

[Footnote 293: _Library of Pract. Med._, 1841.]

[Footnote 294: Boyson, _Thèse de Paris_, 1814.]

R. Townsend[295] wrote an elaborate paper in 1833 on empyema, in which he applied the principles of physical diagnosis. He cites numerous cases of thoracentesis, and speaks of the operation as easy of execution, productive of little pain to the patient, generally followed by immediate relief, and as having been in numerous instances crowned with complete success. Robert Law[296] (1834) speaks discouragingly of the operation in consequence of the "unavoidable admission of air into the inflamed cavity." He considered the operation of tapping the chest more likely to be successful in chronic than in acute pleurisy.

[Footnote 295: _Cyclop. Prac. Med._, vol. ii., 1833, London.]

[Footnote 296: _Ibid._, vol. iii., 1834.]

In 1835, Faure[297] read his paper on thoracentesis before the Academy of Medicine of Paris, which attracted a great deal of attention. Contradictory opinions were given by prominent members as to the value of the operation. The debate was prolonged, and no definite conclusion was reached. Laennec, although he had recommended the operation in excessive effusions and in chronic cases, was yet timid, and his advice had not the overwhelming influence that it should have had. Becker of Berlin in 1834 wrote his paper on chronic pleurisy, in which he also laid down the principles of diagnosis by means of auscultation and percussion. He detailed 5 cases which he had operated upon. To Thomas Davies is due the credit of having in 1835 recommended the use of the exploring-groove needle to ascertain the nature of the pleuritic effusions, but Powell claims that Sir Benj. Brodie first suggested it. Ringer first recommended the use of the hypodermic syringe for that purpose. Stokes[298] insisted upon the evils attending paracentesis, among which he mentions the converting of serous into purulent effusions.

[Footnote 297: _Bullétin de l'Académie de Médecine_, 1838, tome i. p. 62.]

[Footnote 298: _Dis. of Chest_, Dublin.]

Watson's lectures on practice, delivered in 1836-37, show that while he was much interested in the operation, the necessity of which he discusses with his characteristic ability, yet his conservatism led him to put prominently forward the dangers and evils connected with it. According to these two prominent English practitioners, only imminent peril to life justified the operation. Guérin[299] in 1841 applied his subcutaneous method of operation to empyema. He drew fluids from the chest by a suction-pump applied to a canula, using a curved trocar and canula to prevent injury to the lung.[300]

[Footnote 299: _Essai sur la Méthode Sous-cutanée_, Paris, 1841.]

[Footnote 300: Drawings of the trocar and canula, with the aspirators, are shown in Jacob and Bongeré, _Med. operatoire_.]

Reybard in 1837 took up Dupuytren's suggestion, and used gold-beater's skin as a valvular means of excluding air at the mouth of the canula; this is now known as Reybard's canula apparatus, and was the one used and highly recommended by Trousseau. Stanski in 1839 invented an apparatus for drawing off air from the chest, working on the principle of aspiration. Bowditch states[301] that while in Paris from 1832 to 1835 he never saw a case of pleurisy in Louis's, Chomel's, Andral's, or Trousseau's wards where thoracotomy was performed or even suggested. Medical opinion was either indifferent or in actual opposition at that time. H. I. Bowditch of Boston relates[302] that he saw 2 cases of effusion in the pleural cavity in 1839, in which he proposed thoracentesis, but the surgeons would not operate: both of these patients died. He was convinced at the time that their lives might have been saved. Schuh of Vienna published his work on the _Influence of Auscultation and Percussion on Practical Surgery_, in which he boldly maintained that paracentesis was a radical cure in cases of chronic thoracic effusion, no matter how originating. This work had a great influence in advancing {592} the popularity of the operation of thoracentesis. Subsequently, Schuh and Skoda, both professors at Vienna, published[303] a monograph on the treatment of pleurisies, especially by surgical means, which, as Trousseau acknowledged, has become a classical work in Germany, and occupies a distinguished place in the history of paracentesis of the chest. They admitted that when the effusion is not excessive in quantity, and there are no complications, recovery generally takes place. When the effusion is excessive even, it may in time disappear, but it may prove a matter of months or years. They advised that the operation should be performed when there was no marked improvement for three weeks. These authors refuted the arguments urged against the operation, and gave details as to the mode of operating. The Germans were the first to consider the puncture as a means of radical cure in pleuritic effusions: Becker, Schuh, and Skoda gave it a decided impulse. Hope's[304] paper endeavored to prove that pleuritic effusions did not require surgical interference, but would yield to general treatment.

[Footnote 301: Unpublished MS., 1883.]

[Footnote 302: _American Journal Med. Sciences_, April, 1852.]

[Footnote 303: _Medicinische Jahrbücher der K. K. Oesterreich Staates_, 1841.]

[Footnote 304: "Notes on the Treatment of Chronic Pleurisy," in _Medico-Chir. Review_, London, 1841.]

Thus we see that up to 1841 these unsettled controversies over the dangers and advantages of the operation were still going on. Fred. Bird's results in 1843 proved the possibility of its successful employment, doubted up to that time in England. Trousseau's attention was strongly drawn to the necessity of the operation of thoracentesis as early as 1832, when he attended a case at the Hôtel Dieu that died from excessive pleuritic serous effusion. Louis, from the observation of 150 cases of simple pleurisies that had recovered, had enunciated the law that pleurisy is never the immediate cause of death. This fact, together with Récamier's want of success, had so prejudiced the minds of French practitioners against the operation that it was loudly condemned in acute cases of effusion and in all cases of hydrothorax. Having no fears of fatal termination in pleurisy, they saw naturally no necessity for surgical interference. Trousseau states that it was not until after he had witnessed three patients die from acute pleurisy that he ventured to operate (Sept. 11, 1843). He did not summon a consultation, for fear of being thwarted. It was so successful that he was emboldened to operate without hesitation. After his third operation he read his memoir to the Academy of Medicine in 1843. Trousseau in these memoirs maintained the proposition which extensive observation has now after forty years fully sustained, that dyspnoea and orthopnoea may occur when the effusion is in moderate quantity, and that they may be absent when the effusion is considerable, especially if it has formed slowly. Furthermore, that the signs that constantly indicate the gravity and imminent danger of effusions, and which consequently demand the operation, are the displacement of the heart (whence results syncope), displacement of the mediastinum, depression of the spleen and of the liver, acceleration and feebleness of the pulse, and an anxious countenance.

The next year (1844) Trousseau read another memoir on the same subject. He used the trocar with Reybard's gold-beater's skin at the orifice. While he was popularizing the operation and laying down the indications which called for its performance, several English observers[305] were turning their attention in the same direction. The paper by Hughes and Cock[306] showed that they had been operating in Guy's Hospital for four or five years, and with great success, using a simple trocar and canula of the diameter of one-twelfth of an inch. They imputed their success to the small size of the instrument used, which allowed the fluid to flow slowly and never permitted air to enter the chest during respiration. They gave a tabular account of 20 operations. Hamilton Roe[307] at that time was operating successfully with the trocar. {593} Roe's paper was replete with information and with practical suggestions. He tabulated 39 cases where syncope (one great objection which had been urged against the operation) did not occur even once. He disproved another popular objection, that there was great danger of the admission of air into the pleural sac. Owing to the size of his trocar, a considerable quantity of air entered the pleura during his operations, and in some of them so freely as to produce all the physical signs of pneumothorax, but in none of them did it produce any permanently evil effects. In one instance only was even temporary inconvenience caused. When the fluid was ascertained by the exploring-needle to be purulent, he advised the immediate performance of the operation. In acute cases he recommended a delay of three weeks as the time for testing nature's powers of absorbing the fluid. He advised the closing of the orifice after operation. This author gave an account of his 24 cases. He concluded by stating that the operation is not more dangerous than any other which is performed upon the human body, and that the evil consequences supposed to attend it are imaginary rather than real, inasmuch as it was only fatal in 1 out of 24 cases, and does not produce even temporary inconvenience. Thompson in the same year justly condemns the practice of leaving the canula in the orifice--a proceeding he considers as capable of converting a serous into a purulent fluid. In 1848,[308] at the request of H. I. Bowditch of Boston, J. M. Warren operated by the usual method recommended in the works on surgery. Partial relief was obtained, but the amount of suffering undergone by the patient during the operation, and the fact that an aperture was usually left open by this method, decided Bowditch that he would never recommend it unless under very urgent circumstances. Soon after this, Stone operated with the common trocar and canula, by the advice, in consultation, of Bowditch. In 1849, Bowditch saw another death resulting from effusion where he had advised the operation, but the consulting surgeon would not consent.

[Footnote 305: _London Medical Gazette_, 1847.]

[Footnote 306: _Guy's Hospital Reports_, vol. ii., 1844.]

[Footnote 307: _London Lancet_, 1844, copied into _Amer. Journal Med. Sciences_, Oct., 1845.]

[Footnote 308: Bowditch, _Amer. Journal Med. Sciences_, April, 1852.]

To illustrate the opposition Bowditch found in the United States, he quotes[309] a remark of W. W. Gerhard, the distinguished auscultator of Philadelphia, "that he should be as willing to have a bullet shot through his chest as to have paracentesis performed on one of his patients."

[Footnote 309: Unpublished MS., 1882.]

About 1850,[310] Bowditch saw the paper published by Hughes and Cock, and it determined him in future to try the trocar they had used or something like it.[311] "Fortunately, a few weeks before (April 10, 1850) M. Wyman had a sudden and severe case with large effusion and intense orthopnoea. Death was threatening, yet Wyman felt called upon by public opinion, medical and lay, to summon a prominent practitioner from Boston. They both agreed that the patient was in extreme danger, and Wyman urged tapping with an exploring-trocar. It was decided to postpone surgical interference until next day, when another meeting would be held, the consulting physician returning to Boston to advise with the ablest men of the faculty and render their decision the following forenoon. That was done, and it was found that no prominent practitioner in Boston would consent to the idea of tapping. Nevertheless, the oppression was so severe, and death so imminent unless the patient could be relieved by some means, that the country physician agreed to Wyman's proposal that an exploring-trocar should be introduced. The fluid flowed out imperfectly, but some relief and no harm resulted" (Bowditch). Two days after this, Wyman operated again with the exploring-trocar and a suction-pump. Wyman[312] demonstrated to John Homans on the 23d of February, 1850, that the chest could be safely punctured with his instrument and the serum evacuated in acute pleurisy.

[Footnote 310: _Ibid._]

[Footnote 311: _Ibid._]

[Footnote 312: Private letter to author, 1883.]

Although suction, as we have shown, was used as far back, probably, as Galen (second century), by Scultetus in 1662, and was in use in 1707, as {594} shown in Anel's work, in 1742 in Laurence Heister's work, by Ludwig and Lehren in 1768, again in 1796 (Benj. Bell), yet it had been abandoned and lost sight of, with the exception of Laennec's suggestion of its application in the form of a cupping-glass over the orifice of puncture, until Guérin (1841) used it. The author followed Trousseau's clinics in 1849 and 1850, and saw him repeatedly operate with Reybard's canula guarded by gold-beater's skin, but never with Guérin's suction apparatus. The French seemed to have lost sight of it until 1865, when Guérin, at the French Academy, recalled attention to it, showing how he aspirated liquids, instead of allowing them to flow outward after the puncture. His apparatus consisted of a curved trocar, the end of which was made tapering and sharp enough to puncture the thorax through the skin and the muscles; of a pump, the piston of which was perfectly adjusted to produce a vacuum; and of an adjuster at the extremity of the pump, consisting of a stopcock which enabled the operator alternately, without removing the instrument, to aspirate the fluid and evacuate it into a basin. Wyman's pump, invented in 1850, was arranged very much in the same way, only it contained valves which were opened and closed by the movement of the barrel, to enable the operator to suck out the fluid and then force it out of the pump. After the operation the skin, being drawn over and closing the orifice, acted as a valve which prevented at the same time the entrance of air and the escape of fluid. Dieulafoy, in November, 1869, invented his aspirator, which is based upon the same principles as those used by Guérin (1841) and by Wyman and Bowditch (1850)--namely, pneumatic aspiration, which the vacuum of the air-pump supplies. Guérin's instrument was large and costly. Wyman's trocar was of a very small diameter, being only one-twenty-fourth of an inch, and the canula but little larger. This was attached, at first, directly to the aspirating syringe, afterward by means of a flexible tube. With this apparatus Wyman demonstrated that tissues could be safely punctured and cavities evacuated without the admission of atmospheric air, that the wound, causing but a drop or two of blood, was followed by no inflammation, and that no dressing was required. The smallest trocar used previously to Wyman's was that of Roe, which was one-twelfth of an inch in diameter. From 1850, Bowditch appreciated the great value of Wyman's invention, as shown in one of the first operations on a patient of his. He adopted and practised it. His position as professor of diseases of the chest, and his great reputation in that branch, gave him an extensive practice and brought him many cases of pleurisy. He met with great opposition from the surgeons and prominent practitioners of the country, but his results were so favorable that he forced an unwilling and an unbelieving profession to accept, as he expresses it, "the beautiful thought of Wyman of thoracentesis or aspiration with a fine needle." "I considered the operation so simple, and yet so effectual, and never harmful, that I deemed it my duty to print cases illustrative of its value." Bowditch had been for eight or ten years endeavoring to get some effective plan of opening the chest without risk. He readily caught at Wyman's plan, and he operated so frequently and successfully as to demonstrate its value to the medical public both of this country and of Europe. As he states,[313] it was, in fact, what he had been for years longing for--viz. a simple and painless, or almost painless, operation for removing fluids from the thorax--one that could be done without danger and leave no open wound. Bowditch relates[314] that when he visited Europe, nine years after his first publication of cases, he showed the instrument in England, Scotland, France, and Germany, and that he met with very indifferent recognition of its value. Only W. T. Gardner of Edinburgh and Budd of London seemed to appreciate the plan. They had instruments made after the American pattern. All others had no faith in the operation. In Paris his old master, Louis, smiled {595} incredulously at his enthusiasm for it and doubted its necessity. At Vienna Skoda turned with apparent scorn and left the room as Bowditch was demonstrating its employment. The Parisian authors, Woillez, Peter, Moutard-Martin, Peyrot, and others, do not even mention Bowditch, but give Trousseau alone the credit of popularizing thoracentesis.

[Footnote 313: Unpublished MSS., 1883.]

[Footnote 314: _Ibid._]

Trousseau's first publication was in 1843, and yet in 1859 there was no general adoption of the operation, nor was there until 1869, when Dieulafoy rediscovered Wyman's wonderful improvement of the application of negative force to draw out fluids from the chest.

In estimating the value of the substitution of aspiration for the trocar-and-canula method, we must bear in mind that with the latter there was danger of the introduction of air into the thoracic cavity, of the production of fistulous orifices, and the too rapid, and therefore dangerous, evacuation of the fluid. Moreover, there are cases where the trocar and canula is not effectual, although the quantity effused be considerable--where, indeed, the fluid cannot flow out, although the canula be pushed in actual contact with the fluid. The explanation of this is now understood. The fluid is kept in the pleural sac by a negative pressure of from 4 to 5 inches of water (Stone), 6 millimeters mercury (Donders), 5 millimeters mercury (M. Foster), exercised by the lung in its elastic contraction, and by the passive tension of the arched diaphragm. The fluid has no tendency to flow out, and this suctional pulmonary force must be antagonized by an external suctional force, that of aspiration, before the fluid can be withdrawn.

The invention can best be appreciated from the standpoint reached by modern investigations of the physics of the living mechanism of the chest. The principle of applying suctional force in pleurisy is in imitation of nature's gentle methods in connection with respiration. We have shown that most of the dangers connected with aspiration are caused by not taking into consideration the adjustment of lung-tension with thoracic resilience, and consequently of using too great negative force and withdrawing the fluid too rapidly and in too great quantity.

Thoracentesis by aspiration, with greater or less force as may be necessary, is now placed upon a scientific basis. We claim that this modern method is an American invention--that Morrill Wyman was the discoverer and H. I. Bowditch the utilizer of the discovery. As such they may be regarded as benefactors of the human race.

It is extraordinary that Trousseau never alluded to Bowditch's operations, and that Dieulafoy should never have heard of them. Fraentzel acknowledges that Bowditch was the first to introduce aspiration into practice. The Germans have been very slow in appreciating its value. Fraentzel states that he did not use it until 1871, and that it was not until 1879 that it had in Germany any ardent supporters. Bowditch[315] has now operated 387 times upon 246 patients without any unpleasant result.[316] The distinctive points in Dieulafoy's ingenious modification of the aspirator are that the needles are very fine, even one-half of a millimeter in diameter; that the barrel of the exhausting pump is of glass; that there is a pre-existing vacuum; that we are not compelled to jar the side of the patient by the process of pumping, and moreover by turning the cock we produce at once a vacuum in the needle itself, and know with certainty the moment the fluid is reached, and can see it flow through the glass index in the tubing, even if it be in drops. We can judge of the nature of the fluid, whether it be serum, pus, or blood. The minuteness of the needle is a great cause of safety, because it allows the fluid to flow so gradually that the lung has time to expand slowly. We can in an instant arrest the flow of the fluid by turning the stopcock, and if necessary by drawing out the needle. By giving the needle a downward direction after it {596} enters the cavity, we prevent the point from pricking the lung. So small an orifice is made that even if the needle does touch the lung, there is no danger, for the orifice closes over at once. As Dieulafoy claims, "the fineness of the needle guarantees the harmlessness of the puncture." Castraux's concealed point (invented in 1873), and Fitch's (of Nova Scotia) protected canula (invented in 1873), are valuable additions to the aspirator-needle. These dome-trocars, as they are called, prevent the possibility of injuring the lung, for the sharp-pointed needle, after it has penetrated the pleural cavity, is at once, by a slight movement, converted into a blunt-pointed needle with an orifice near the end. With these very fine needles the force is sufficient to draw up the thickest fluids. We are compelled to admit that Dieulafoy's instrument is a great advance on any other that has been invented. Its simplicity, its easy application, its safety, have rendered paracentesis a harmless operation and one of great value in serous effusions. While Guérin and Wyman may both claim priority of invention, all must admit that Dieulafoy has improved upon their ideas and given us a beautiful and effective instrument. There have been proposed, since Dieulafoy showed his instrument in 1869, no less than forty other aspirators, modifications in form or dimensions of his apparatus. Of these, to us the most valuable is Potain's bottle aspirator, with which aspiration can be so easily and effectually employed. It is simple and cheap. An india-rubber cork accurately fitting a strong bottle is perforated for two tubes each having a stopcock. One of the tubes fits on the end at the exit in the basin, and the other is adapted to an aspirating syringe.

[Footnote 315: _London Lancet_, vol. ii., 1879.]

[Footnote 316: Letter to author, 1883.]

One of the most important of the improvements to the aspirator-canula is the addition--first suggested in 1858 by Charles Thompson,[317] and afterward adopted by Potain, Powell, and Fraentzel--of a lateral tube for the outflow connected with the main canula through which the trocar passes. By this improvement, in case the canula is clogged up, the trocar can be pushed down to remove the obstruction without danger.

[Footnote 317: _Med. Times and Gazette_, 1858.]

The principle of aspiration is now well established, and the indications for its use are becoming more defined and more accurate. New applications as a means of diagnosis, as well as of treatment, daily render it more valuable.

To guard against the dangers shown by modern experience to be sometimes attendant upon the operation of aspirating the pleura (see Dangers of Thoracentesis), it is now generally admitted that the removal of the contents of the chest should be slow and gradual; and that, ordinarily, it is safest at one operation to remove only a portion of the effused liquid. Our object should be to remove pressure and allow nature by absorption to take away the remainder, for positive pressure is an urgent indication for thoracentesis. It is therefore of primary importance to properly estimate the quantity present, and thus to test the intra-thoracic pressure. Great care and caution must be used, because if we extract too much the operation may be followed by serious results.[318] Large-sized canulæ should never be used, for fear of too rapid withdrawal of fluid. It has been demonstrated that even with a capillary perforated needle we can exercise more negative pressure than is safe, especially toward the close of the operation, when there supervenes a negative pressure exerted by the fluid remaining in the pleural cavity. It is from these well-known facts that we recognize the great value of Potain's ingenious addition to the aspirator of a manometer of extreme simplicity, a kind of barometer or cuvette, which is placed along the tube which withdraws the fluid. If we are not satisfied with this new safety improvement of the aspirator, we may adopt Douglass Powell's suggestion (_On Consumption, etc._) {597} of fitting into the bottle a pressure-gauge, so as to know at any moment what degree of aspiration is being used.

[Footnote 318: _Trans. de l'Assoc. pour l'Adv. des Sciences_, 6th Session, 1877.]

The syphon method has been of late years very extensively used, especially by Southey, W. H. Stone, and Garland, A. T. H. Waters, Wilks, Oxley, and habitually by Douglass Powell. It is a feeble aspirating force, which has very decided advantages. It is effective, and acts slowly and uninterruptedly with a gentle and uniform negative pressure. Its action allows the lung gradually to expand and the displaced organs slowly to resume their normal position. It thus in many cases furnishes us with a safe means of thoracentesis. (See Surgical Treatment, in Pleurisy.)

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DISEASES OF THE CIRCULATORY SYSTEM.

DISEASES OF THE SUBSTANCE OF THE HEART.

ENDOCARDITIS AND CARDIAC VALVULAR DISEASES.

CYANOSIS AND CONGENITAL ANOMALIES OF THE HEART AND GREAT VESSELS.

CARDIAC THROMBOSIS.

NEUROSES OF THE HEART.

DISEASES OF THE PERICARDIUM.

THE OPERATIVE TREATMENT OF PERICARDIAL EFFUSIONS.

DISEASES OF THE AORTA.

DISEASES OF THE CORONARY, PULMONARY, SUPERIOR MESENTERIC, INFERIOR MESENTERIC, AND HEPATIC ARTERIES, AND OF THE COELIAC AXIS.

DISEASES OF THE VEINS.

THE CAISSON DISEASE.

DISEASES OF THE MEDIASTINUM.

DISEASES OF THE BLOOD, AND OF THE HÆMATOPOIETIC SYSTEM.

DISEASES OF THE BLOOD AND BLOOD-GLANDULAR SYSTEM.

DISEASES OF THE SPLEEN.

DISEASES OF THE THYROID GLAND.

SIMPLE LYMPHANGITIS.

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{601}

DISEASES OF THE SUBSTANCE OF THE HEART.

BY WILLIAM OSLER, M.D.

Malpositions of the Heart.

We shall consider only such alterations as affect the whole organ; faulty position of individual parts comes under the section upon Malformations. It may, however, be mentioned that cases are known of complete transposition of the chambers, the pulmonary artery and cavæ being connected with the left, the aorta and pulmonary veins with the right side, the valves being also transposed.[1]

[Footnote 1: Pazannuzzi, _London Med. Record_, 1877.]

Malpositions of the heart result either from errors of development, or, more commonly, from changes in contiguous organs, usually the effect of disease.

Of the congenital anomalies only a few are of practical interest. The heart may be placed vertically in the chest, as in the foetus, the apex beating at the lower end of the sternum; or, more rarely, the organ lies transversely. Dextrocardia, the condition in which the heart is on the right side of the body, is much more important, and is usually associated with the transposition of the abdominal viscera--situs inversus viscerum. In these cases the apex-beat is in the region of the right nipple; a distinct area of dulness can be obtained to the right of the sternum, in which situation the heart sounds are loudest; and, lastly, there is pulmonary resonance in the place of normal cardiac dulness. In the great majority of cases--70 out of 78[2]--the abdominal organs are also transposed, the liver on the left side, the spleen on the right; but in a few instances the heart alone has been misplaced, and under such circumstances care is needed to diagnose the condition from dislocation of the organ due to old-standing lung disease with retraction.

[Footnote 2: Gruber, _Virchow's Archiv_, 1865.]

More serious congenital malpositions, but of less practical importance, are the cases of ectopia cordis, which may exist in all grades, from simple failure of closure in the sternum--fissura sterni--to the most extreme condition, in which the naked heart lies outside the chest-wall. Hodgen[3] and March[4] have each described remarkable examples of the latter condition. In other instances the heart lies free in the neighborhood of the neck, or it may be in a congenital umbilical hernia.

[Footnote 3: _American Practitioner_, xviii. p. 107.]

[Footnote 4: _Trans. of the New York State Medical Society_, 1859.]

The malpositions with which we are more immediately concerned arise from disease of the heart itself or its membranes, or from disease of contiguous organs.

We judge of the situation of the heart by the site of the apex-beat, by the position and extent of the area of dulness, and by the character of the sounds. So constant in health is the position of the apex-beat in the fifth intercostal {602} space that in our examination of the heart we seek first to determine its existence as affording the most important information of the normal situation of the organ. The area of dulness is a much more variable guide, depending as it does so greatly on the degree of distension of the lungs. When, as sometimes happens, neither apex-beat nor area of dulness can be obtained, the position of maximum intensity of the heart sounds becomes an important indication.

In regard to the effect of respiratory movements in the position of the heart, with each inspiration it is drawn down slightly by the descent of the diaphragm, and it is separated from the chest-wall by the inflation and descent of the left lobe of the lung--in deep inspiration to such a degree as to obliterate the area of dulness and to prevent the systolic impulse from reaching the intercostal space.

The effect of gravity on the position of the heart is well illustrated by the more forcible and extended beat when the chest is bent forward or when the person is turned toward the left side--procedures frequently resorted to when from any cause the apex-beat is obscure.

Of diseases of the heart itself, dilatation and hypertrophy are very common causes of displacement, and in general enlargement the organ may occupy a very considerable part of the left side of the chest, and the apex-beat in the seventh or eighth space in the axillary line. Hypertrophy of the left ventricle alone pushes out the apex-beat, while enlargement of the right ventricle gives a stronger impulse toward the left border of the sternum and a more marked pulsation below the ensiform cartilage. Hypertrophy and dilatation of the auricles increase the width of the cardiac dulness, and may cause marked pulsation in the second and third spaces on either side of the sternum.

In pericardial effusion the heart is pressed backward and the apex slightly raised.

To understand clearly the effects upon the position of the heart of disease of contiguous organs, we must bear in mind their mutual relations. Situated in the mediastinum between the lungs on either side, it is subject to the elastic traction of these organs, which counterbalance each other, but if from any cause the elastic tension of one lung is suppressed, as in pneumothorax or in pleural effusions, then the other lung may also collapse to a slight degree, and pull over the mediastinum and with it the heart. The pericardium is firmly fixed below to the diaphragm, chiefly to the central tendon, to a slight extent also to the muscular substance, but the union with the diaphragm is so intimate that there can be but little movement of the attached portion. The mobility of the heart is measured by that of the mediastinum and pericardium, and through these alone the displacing forces act. The limits of dislocation are determined by the attachments of the central tendon, of the inferior cava, and the great vessels at the root. Within the pericardium the heart has a certain degree of mobility, but this is confined, as regards pressure or traction effects, to rotation upon its axes.

Of the malpositions due to changes in contiguous organs, the following may be considered:

Changes in the Chest-wall.--The gradual incurvation of the ribs and costal cartilages in some cases of rickets may alter the position of the heart.

Curvature of the spine, particularly cases which narrow to a great extent the upper outlet of the thorax, may produce very considerable displacement of heart and great vessels. There may be areas of extensive pulsation on either side of the sternum, and the condition may simulate aneurism of the aorta, as in a case reported by Bramwell.[5]

[Footnote 5: _Lancet_, 1878, i.]

In certain affections of the lungs the position of the heart is much altered. {603} In emphysema, when extensive, the apex is directed more to the right, and the organ is somewhat lower than normal, on account of the depressed condition of the diaphragm. The heart may also occupy a more transverse position. The area of cardiac dulness may be greatly reduced by the distended left lung, and there is usually forcible epigastric pulsation, due to the lower position of the organ and the hypertrophy of the right ventricle which almost always accompanies emphysema.

The most marked displacement is produced by fibroid induration of the lung, with contraction--cirrhosis. As the process of condensation goes on, the chest-wall is gradually flattened, and the mediastinum, with the heart, drawn toward the affected side. When the left lung is involved, the heart may be completely to the left of the median line, and is usually drawn upward as well. There may in such cases be a very wide area of impulse, as the heart occupies the position of the left lung in front. In cirrhosis of the right lung the organ is drawn toward the right side, and the area of visible impulse may be in the third and fourth interspaces to the right of the sternum. In the process of slow traction the heart revolves upon itself and the left chambers come uppermost. In many cases of chronic phthisis, when the anterior margin of the left lung is involved, the retraction from induration may leave a large portion of the heart exposed and increase the area of visible pulsation; sometimes, when there is much contraction of the upper lobe, the organ is drawn up and to the left, and the apex-beat may be in the fourth interspace.

The pressure of a pneumonic lung may depress the diaphragm and draw down the heart.

Abnormal conditions of the pleuræ are frequent causes of cardiac displacements. In pneumothorax there is collapse of the lung on the affected side, and the elastic traction of the sound lung draws over the mediastinum and heart. It is not that the heart is pushed over, as so often stated, but the tension of the other lung, being unopposed, pulls the mediastinum toward the sound side. Later, when, as usually happens, effusion takes place, the pressure assists in the displacement. In pleuritic effusion dislocation of the heart to one side is almost constant if the amount of fluid is at all considerable. Here pressure plays the most important part, and the heart is gradually pushed over by the effusion; but the elastic tension of the lung on the sound side is also concerned in the result. In right-sided effusion the whole organ may be to the left of the median line, and from the depression of the diaphragm it is usually lower in the chest, so that the apex-beat may be in the sixth, rarely the seventh, interspace in the axillary line. When the exudation is on the left side, the dislocation is more marked, and there may be a cardiac impulse at the right nipple or even beyond it. A common error is to regard the pulsation as due to the apex, but it is invariably caused by some portion of the right chambers, usually the ventricle. Even in the most extensive effusion the apex is probably never pushed beyond the right border of the sternum, and the relative position of apex and base is not changed. This I have carefully noted in several autopsies.[6]

[Footnote 6: Fig. 76 of Sibson's article on "Displacements of the Heart" in _Reynolds's System of Medicine_ gives an incorrect idea of the position of the organ in these cases, as the apex is represented as beating beneath the right nipple.]

In the gradual absorption of a pleuritic effusion, serous or purulent, the heart may not only regain its normal position, but is in many instances drawn toward the affected side by the contracting false membranes.

Of conditions of the mediastinum producing displacement, two only need be mentioned--aneurism and tumor. Very large aneurisms of the arch usually press the heart downward, and its axis may be transverse; but much depends on the direction of growth, and a slight lateral and downward dislocation is most frequently met with. Tumors do not necessarily {604} cause displacement, but when large there may be some dislocation in the direction of the growth of the mass. Most extensive masses of mediastinal cancer may occur without any disturbance of the position of the heart.

Diseases of the abdominal viscera not uncommonly produce dislocation of the heart, generally upward. Extensive peritoneal effusion, gaseous or fluid, forces up the diaphragm, and with it the heart, which may assume the transverse position, and the apex beat as high as the third interspace. Gas much more readily than fluid rapidly lifts the diaphragm and produces upward dislocation of the heart. Diaphragmatic hernia of intestines or stomach may push the heart up or to one side.

Conditions of the liver not infrequently affect the position of the heart. Abscess or hydatid cysts of the left lobe may push the organ up and to the left. More rarely large hepatic tumors drag the diaphragm down, and with it the heart. Very great splenic enlargement, as in leukæmia, may push up the diaphragm and lift the heart.

Other abdominal growths, as large retro-peritoneal and ovarian tumors or aneurism of the abdominal aorta, may occasionally produce the same effect. Knowsley Thornton has given in Fothergill's work on the _Heart_ an excellent account of the upward displacement of the heart in ovarian disease.

As a very rare circumstance, the heart is displaced by accidental injury to the chest-walls. The case which Stokes relates of this kind was probably, as he subsequently suggested, due rather to the effects of the pleuritic effusion which followed the accident.

The dislocations of the heart when gradually induced rarely disturb to any serious extent the functions of the organ.

Myocarditis.

Inflammation of the heart-muscle is rarely primary; usually it is associated with endo- or pericarditis, strain,[7] embolic processes, disease of the arteries, or the presence of certain poisons--diphtheritic, rheumatic, etc.--in the blood.

[Footnote 7: Some French writers refer specially to the occurrence of myocarditis from strain or prolonged muscular exercise--myocardite des surmenes. Peter (_Maladies du Coeur_, Paris, 1883) gives two cases (without autopsy), and quotes a case from Revilliod, whose work (_La Fatigue_, Lausanne, 1880) I have not been able to consult.]

We may recognize three forms--acute suppurative, acute interstitial, and chronic myocarditis. By many writers the parenchymatous degeneration so frequent in fevers is regarded as an inflammation, but it is the result of a process which we can scarcely term inflammatory.

Acute suppurative myocarditis is almost invariably associated with pyæmia or with malignant endocarditis, and in most instances may be regarded as embolic. In severe pyæmia from any cause foci of suppuration are not infrequently met with in the walls of the ventricles. There may be multiple abscesses or a single purulent collection varying in size from a pea to a walnut. Numerous miliary abscesses are not so often met with in ordinary pyæmia as in endocarditis. If large, the abscess may burst into the heart or into the pericardium and excite inflammation of this membrane; or, indeed, without perforation, as I saw in one instance. The calcareous nodules occasionally found in the muscle-substance have been regarded as healed abscesses. Suppurative myocarditis is a frequent result of malignant endocarditis, and we meet with it either in the form of miliary abscesses, scattered in numbers through the substance, or as large solitary abscesses at the bases of vegetative outgrowths or in connection with excavating ulcers of the endocardium, valvular or mural. The small embolic abscesses vary in size from {605} a pin's head to a pea, and may occur in extraordinary numbers in the muscle-substance of all the chambers. They present usually a central grayish-white focus of suppuration surrounded by a zone of deeply-congested and hemorrhagic tissue. Microscopically, there is a central infiltration of leucocytes with destruction of the muscle-fibres, and in every instance colonies of micrococci can be readily discovered. These abscesses are identical in character with those occurring in the kidneys, intestines, and brain. Sometimes at the base of large endocardial outgrowths, particularly of the aortic segments, abscesses are found extending deep into the muscle-substance, and even perforating the wall. These occur most often in the left ventricle, but occasionally in the right, as in a case of stenosis of the pulmonary valves at the Montreal General Hospital, in which there was an abscess cavity in the wall of the right ventricle the size of a marble, situated at the base of some endocardial vegetations. The acute ulcer of the heart is of the nature of a suppurative myocarditis, having its starting-point, in the great majority of cases, in the endocardium. It may perforate the wall of the ventricle, as in the cases of Mackenzie[8] and Keating.[9] The blood-pressure in the abscess-cavity may dilate the wall, and form what is known as acute aneurism of the heart.

[Footnote 8: _Path. Soc. Trans. London_, xxxiii.]

[Footnote 9: _Trans. of the College of Physicians of Philadelphia_, 1879.]