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.