favorable, unless it is complicated with other diseases or occurs in
enfeebled persons. The intrinsic tendency of the disease is to
recovery. Laennec considered that the prognosis in acute pleurisy was
always favorable. Pleurisy with scanty sero-fibrinous effusion is not
in itself serious. Dry pleurisy is free from danger. Subacute pleurisy
with large effusions, where the course of the disease is insidious and
slow, is more apt to be followed by tuberculosis than the more acute
cases. Louis's law, deduced from 150 cases, that patients never died
from the effusion in acute pleurisies, was long since disproved by
Trousseau. Lacaze du Thiers published in 1873, in his thesis, a number
of cases of sudden death from large accumulation of fluid. These deaths
were caused by a large amount of effusion being thrown out rapidly, and
suddenly compressing the lung before the system had time to accommodate
itself to the presence of the effusion. These cases, termed foudroyant,
should be very carefully watched. There is danger of death from
orthopnoea when the pleural cavity is completely filled, especially in
latent pleurisies, where the patient, unaware of the risk, makes,
perhaps, unusual physical exertions. Some deaths have been caused by
oedema of the lungs and some by syncope; others, again, from thrombosis
of the pulmonary artery. We must bear in mind the grave prognostic
value of attacks of orthopnoea and severe dyspnoea, because they, more
than the mere quantity of the fluid, show the want of tolerance in the
organism. These cases demand prompt mechanical interference with the
aspirator. The very rapid accumulation of the effused liquid, even if
unattended by dyspnoea, is an unfavorable sign, for observation has
proved that in such a case its absorption is attended with more
difficulty. Bilateral pleurisies attended with considerable effusion
are commonly fatal.
If there are complications with other acute diseases, such as
pericarditis or pneumonia, the prognosis may be far from favorable,
more particularly if pleurisies supervene when the organism has been
exhausted by a long continuance of the primary disease.
If absorption begins soon after the acute symptoms subside (and we
expect it to do so where the general health and strength are good), and
goes on vigorously, we can with confidence predict a favorable result,
especially if there be no contraction of the walls. The earlier the
reabsorption takes place the more favorable the prognosis. If, however,
four or five weeks pass without any perceptible diminution in the
extent of the effusion, there is cause for uneasiness. Especially is it
dangerous if, in addition, we have those ugly symptoms, emaciation,
weakness, and hectic fever, which point to the conversion of the fluid
into pus. There is the prospect of protracted formation of pus with its
dangerous sequelæ, including tuberculosis from infective absorption.
{519} That these dangers can in a great measure be obviated by prompt
thoracentesis ought now to be universally admitted. Anstie predicts
that the experience of the next twenty years will enable us to ensure
an absolute immunity from fatal results from either of these serious
complications. Symptoms of oedema of the lungs or of cyanosis are bad
prognostic signs; so is diminution in the amount of urine secreted,
which indicates that the arteries are incompletely filled. Still worse
are the symptoms of over-distension of the veins, dropsy, and the
appearance of albumen, casts, and blood in the urine.
The prognosis in secondary pleurisies is much more serious. In cases
where the effusion is purulent at their commencement, the prognosis is
graver than when it becomes purulent after remaining some time in the
cavity. This is because they are often pyæmic in their origin.
With modern treatment, however, the percentage of recovery is greater
than it formerly was. When we have to contend with chronic purulent
cases occurring in cachectic constitutions or in those debilitated by
other illnesses, especially tubercular, the prognosis is necessarily
unfavorable. The most fatal of all secondary pleurisies are those
supervening in the course of pyæmia or puerperal infection. Here death
is the rule, recovery the rare exception.
Pleurisies supervening on Bright's disease or nephritis, following
scarlatina and idiopathic fevers, have a high rate of mortality. The
modern employment of the thermometer is of the greatest assistance to
us in forming our prognosis. Marked variations of temperature, whether
they be below the normal or constantly high or advancingly high, have
grave significance. Anstie's valuable results from the use of the
sphygmograph, as giving us the favorable and the unfavorable pyrexial
pulse-forms, cannot be over-estimated. We fully concur with him, "that
in the dangerous secondary pleurisies the combined use, for prognostic
purposes, of the thermometer and the sphygmograph is more valuable than
all the other modes of observation put together." It is so because they
give us accurate physical data by which we can estimate the exact
condition of the patients.
Relapses, with a rapid increase in the amount of fluid after
reabsorption has been active and convalescence apparent, are frequently
attended with danger, because they often denote a tubercular or
hemorrhagic development. A very unfavorable sign is the rapid increase
in the effusion after spontaneous or artificial discharges, especially
if the fluid has become fetid in its character and has the dark
appearance of unhealthy, purulent matter.
TREATMENT.--The study of the natural history of acute fibrino-genic
pleurisy teaches us that there is always in it a tendency toward
recovery unless there is some constitutional weakness behind the
disease or a large fibro-serous effusion resulting from it. We have all
met with cases where patients have recovered in the course of a month
or six weeks spontaneously, without any treatment. Of A. L. Mason's 200
cases, 132 recovered without having to resort to thoracentesis. It is
often a harmless disease when left, as far as medical treatment is
concerned, entirely to itself. Of course the body-temperature and the
physical evidence of the effusion ought always to be carefully
observed. The hygienic treatment ought never to be neglected. We should
insist upon rest in bed in the most comfortable position to the
patient. The temperature of the room should be from 65° F. to 68° F.,
the approximate in-door winter degree for healthy adults.[53] The body,
especially the chest, should be kept quiet; all unnecessary movement
should be avoided. The food ought to be nourishing in quality, easy of
digestion, and in quantity sufficient to keep up healthy nutrition.
Stimulants are unnecessary, but it is a mistake to withdraw water,
which contributes so much to the comfort of the patient and {520}
cannot injure him in the first stage. We should take care that the
patient has enough sleep. If necessary, mild hypnotics should be used.
The effusion results from the inflammatory process, and not from simple
transudation. If the pain is very severe, we must resort to the
administration of opium by mouth or to hypodermics of from one-eighth
to one-sixth of a grain of morphia; this, however, should be avoided
when possible, as preparations of opium impair the appetite and depress
the patient. The pain ordinarily passes off in 48 hours, and can often
be relieved by application of hot-water bags, turpentine stupes, or
anodyne liniments. Bloodletting, general or local, is rarely necessary.
Leeches will give relief to the acute pain, but opium does that more
effectively. Depletory remedies are hurtful and retard convalescence,
and do not control the amount of the effusion, which in itself is
depletory. If the patient is seen at the initiation of the disease, a
large dose of quinia (from ten to fifteen grains), especially if the
temperature goes to 101° F., often has a marked effect in controlling
the temperature and also the tendency to effusion. Smaller doses may be
repeated every few hours. Liq. ammonii acetatis, in fluidrachm j to
fluidrachm ij doses every two hours, and Apollinaris or other alkaline
drinks, relieve vascular tension and promote the action of the skin and
kidneys. During the pyrexia, with the effusion increasing, we endeavor
to lower arterial pressure within the pleural vessels by aconite,
diaphoretics, mild salines, diuretics, with complete rest of the body.
Hot applications (not heavy poultices, however) may sometimes be used
at short intervals, with a view of dilating the superficial vessels and
thus relieving those of the interior.
[Footnote 53: _Boston City Hosp. Reports_, 3d Series, 1882.]
Under this simple treatment many patients are sufficiently well in a
few weeks' time to sit up. They ought not to be permitted to move about
unless there is a very small amount of effusion. Roberts[54] of
University College Hospital applies adhesive strips over the chest in
all cases from the beginning. Mason prefers Martin's india-rubber
bandage, three or four inches wide, extending from the lower border of
the ribs to the axilla, as it adapts itself better to the chest-walls
and supplies an easily-regulated elastic pressure. He considers it also
useful in promoting absorption after tapping. Generally in three or
four weeks, in favorable cases, the effusion has been absorbed and the
patient is able to resume his ordinary duties. The writer cordially
endorses Anstie and Bartholow's protests against the employment of
mercury for any supposed aplastic properties. It really exhausts the
recuperative forces of the organism, and probably injures instead of
benefiting in pleurisy.
[Footnote 54: Quain's _Medical Dictionary_.]
If the exudation be in considerable quantity, three or four weeks may
be required for its absorption. If this process is sluggish, can we by
medicines promote it? Mercury has lost its old reputation as a remedy
for this purpose. Iodine externally, and iodide of potassium in decided
doses, still retain, to a limited extent, the confidence of
practitioners. Preparations of iron, especially the muriatic tincture,
have had better effects in the hands of the writer than any other
remedy. Large blisters cause great discomfort, and their utility is
very questionable. Alkalies possess the power of dissolving exudation,
and of these the most efficient is ammonia, especially carbonate of
ammonium in doses of from five to ten grains. Saline laxatives, by
producing watery stools, have some power in reducing the amount of
fluid. Some authors recommend highly the acetate and citrate of
potassium dissolved in a decoction of scoparium. J. W. Hunt[55] places
most reliance upon pilocarpus pinnatus, which has given him most marked
and successful results, even where other remedies have failed. He
pushes it to the extent of producing extreme diaphoresis. He commences
with thirty minims of the fluid extract four times daily, rapidly
increasing {521} the quantity and the frequency of the doses to the
extent of fluidrachm j every two hours. The one-eighth of a grain of
its alkaloid, pilocarpine, given hypodermically, acts very promptly. He
admits that the vital forces are so exhausted by this treatment as to
require at once the administration of tonics, especially of iron with
strong food. Grasset[56] reported 5 cases of effusion treated by
jaborandi. They were cases of pleurisy without fever or sign of
inflammation--cases which ordinarily require several blisters to
produce an effect.
[Footnote 55: _Dublin Journal Med. Sci._, Dec., 1882.]
[Footnote 56: _Journal de Thérapeutique_, Avril, 1876.]
Ernest Wernaere[57] reported 7 cases of acute pleurisy where there was
considerable febrile reaction. Jaborandi was effectual in every case,
and the effusion rapidly disappeared after two doses of the infusion.
The fever at the same time was diminished, and there was no return of
it, as frequently occurs in non-inflammatory cases. It has less effect
upon children than upon adults. In a case of Wernaere's only one dose
was given.
[Footnote 57: _Thèse de Paris_, 1876.]
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.