wait over three weeks before operating. As he shall show in the study
of the dangers and objections, he considers the operation a perfectly
safe one if the simple rules now generally observed by operators are
faithfully carried out.
In studying the advisability of operating where there are not urgent
indications we must ever bear in mind that while it takes a large
quantity of {530} fluid to compress the lung, the retracted lung may,
by neo-membranes, be kept to its diminished volume. As long as the lung
is able to lift up the fluid and the diaphragm it is in no danger of
atelectasis. It is in a state of physiological rest. In a subject of
bad constitution interstitial changes may indicate an earlier
operation, but, if an effusion exists on the side on which there is
already lung disease of a phthisical nature, we should be loath to
interfere; for "experience has shown that an effusion checks, and
sometimes arrests, the tubercular process" (Powell).
Contraindications.--These are principally in connection with the
general condition of the patient. If it is such that there is no hope
of his rallying, if he is very old, or if he has intervening croupal
pneumonia, the operation is not justifiable. If the quantity of fluid
is not large and does not interfere with organic functions, we can wait
for some time.
Mode of Operating.--The old trocar method of operation is now
abandoned. It was not always an easy one, was painful, and there was
more or less danger of cutting the intercostal artery, of introducing
air, and of establishing, by the size of the puncture, a fistulous
orifice. If, perchance, the lung was perforated by the trocar,
pneumothorax was established. In some cases of sacculated and limited
effusions, and in chronic cases where the membranes were thick, it was
not effectual, and if the fluid was not reached, the operator hesitated
to introduce the trocar elsewhere. When the fluid flowed through the
trocar, it came frequently in jets with painful coughs. The above
operation was quite a formidable one. Now thoracentesis is always
performed with very fine perforated needles attached to aspirators of
some modern pattern, and guarded by Fitch's dome-trocar or Castiaux's
protected point. We employ Dieulafoy's Potain's bottle-aspirator,
Castiaux's of Paris, or Raumussen's of Copenhagen. Flint recommends the
use of Davison's syringe. We fear it would be found too rough an
instrument for so delicate an operation. The points of attachment of
the bulb with the tubing are not sufficiently air-tight. The valves are
very imperfect, and easily get out of order. In our efforts to pump out
the fluid we might throw air in, and with it particles of organic
matter.
The operator has his choice among no less than thirty-odd instruments
similar to Dieulafoy's. They all work upon the same principle--the
close operation, the withdrawal of the fluid by aspiration. The needle
or trocar must be capillary: the smallest that is effective is the
best--say a half millimeter in diameter--in order to make the orifice
as minute as possible.
If we prefer the syphon, we must use a larger canula than we employ for
aspiration--one of four millimeters in diameter. It should have two
outlets--one straight, for the trocar, and one at an angle, for the
attachment of the tubing. It should also be guarded by an air-tight
collar. Into the syphon tubing a T-tube may be inserted for the purpose
of attaching a side tube to be connected with a mercurial manometer, by
means of which the exact intra-thoracic pressure may be observed during
the operation. The syphon tube should be long enough to provide a fall
of one, two, or three feet, as may be necessary. A fall of twelve to
eighteen inches is usually enough, as we wish to remove the fluid
slowly. We can easily increase the force by lengthening the tube. If
the canula should become obstructed, lowering the basin suddenly will
probably remove the piece of lymph. The trocar can be pushed again
through the canula if necessary. In case the aspirator should be
needed, the end should have a metallic joint affixed to it. In all the
instruments used, absolute cleanliness should be observed. The tubing
previous to operation should be filled with a solution of carbolic acid
(1:40).
In cases of rapid effusion, especially during the febrile stage and
when the intra-thoracic pressure of fluid is great, some prefer using
the feeblest form of aspiration. Southey's capillary trocar, with
drainage-tubes attached, is used as a syphon for this purpose. The
fluid is drained off {531} through a narrow india-rubber tubing which
is placed under water to prevent air being drawn into it. Ordinarily,
the use of the fine aspirating-needle without much force, and slowly
drawing off the fluid, answers the same purpose. The fear some have
expressed, of the danger of injuring the lung by the force of the
rarefied space, is more theoretical than real. Even with a canula of
the size that Southey employs there is some danger of leaving a
fistulous orifice, for it has to be kept in for hours. If the smallest
tube is used, from which the fluid simply comes in drops, the operation
consumes five or even ten hours. Southey speaks of cases where the flow
was kept up for twenty-four hours. Unless aspiration is resorted to,
flocculi may easily stop up the canula, and then we are compelled to
reintroduce the trocar, and afterward to reattach the tubing. Oxley,
who thinks that the best results are obtained by the use of these
tubes, acknowledges that so much time was consumed that he inserts four
canulas, drawing off 44 fluidounces of fluid in one hour and ten
minutes, thus defeating the object of using this method, which was to
draw off the fluid very slowly, so as to enable the lung to expand
gradually and healthfully.
There are cases where, to withdraw the fluid, more suction force than
is usually employed with the syphon has to be used in order to
antagonize the negative force exercised by the traction of the lung and
the passive tension of the diaphragm. The author recently had a case
where, notwithstanding the presence within the right pleural sac of a
quantity of fluid large enough to obliterate the Skodaic resonance
under the clavicle, not a drop could be drawn out by a syphon attached
to a canula of 2 mm. in diameter. Having no additional tubing to
increase the force of the syphon at hand, he used Dieulafoy's rack
aspirator, ½ mm. in diameter, and drew off a quart of fluid--enough to
relieve the symptoms of oppression. Stone reports a case of the kind
where, although there were two quarts of fluid in the pleural sac, no
fluid could be drawn out with a syphon exerting a force of 1½ pounds to
the square inch, or one-tenth of an atmosphere. In the same case there
was actually, in inspiration, a negative pressure exercised by the lung
of two inches of water. Stone mentions another case where a boy fifteen
years of age died from the quantity of fluid, which would not flow out
when tapped. If he had had an instrument by which he could have used
aspiration he would have saved the life.
The value of this syphon method has within a few years grown much in
favor. It is simple and inexpensive. It allows the fluid to be drawn
out with a uniform and feeble aspiratory force. The flow is very slow,
which gives the lung time to expand gently, and the displaced organs to
return gradually to their normal position. With the manometer attached
we can judge accurately as to the intra-thoracic pressure. The size of
the canula has to be larger than when we employ the aspirator--4
mm.--whereas with the latter we use ½ mm. or 1 mm. in diameter. If by
any accident the lung should be perforated, the larger orifice would
not be as harmless and insignificant as the smaller one. It must be
borne in mind, especially in cases of long standing, that the
neo-membranes are very vascular, and that with a 4 mm. perforator we
may rupture the blood-vessels and complicate matters by the escape of
blood into the pleural cavity. It is claimed that when the canula and
syphon tubes have been introduced the patient can be left in charge of
the nurse. This, the author thinks, should never be done, for nurses
are rarely competent to judge whether a sufficient amount has been
withdrawn, nor are they fit to assume the responsibility of acting in
cases where promptness of treatment may be of the utmost importance.
The operator or a competent substitute must remain until the operation
is over. The withdrawal of fluid must, moreover, be slow, for slowness
contributes in a great degree to lessen the dangers. Fraentzel
recommends testing the force of the {532} aspirator in the palm of the
hand. Garland[80] employs needles which are 1-2 mm. in diameter and
remove only 50 to 100 grammes per minute. The thoracic pressure must be
relieved by the withdrawal of only enough fluid to effect that purpose.
It has been objected that the negative force of the aspirator is
uncertain. It is a well-founded objection, yet we can employ with it a
feeble force by exhausting only a portion of the air from the cylinder
or bottle, and thus remove the fluid cautiously and very deliberately.
It is admitted that if there is no intra-thoracic pressure the fluid
will not flow out unless we introduce air or negative force. We claim
that the syphon and the aspirator with capillary needles, employed with
the precautions dictated by modern experience, are both safe and
effective. Ordinarily, we prefer the bottle aspirator of Potain, or
Dieulafoy's instrument with the manometer attachment.
[Footnote 80: "Dis. of Pleura," in _Ziemmsen's Appendix_.]
Modern aspirators, if in perfectly good order, completely prevent the
possibility of septic contamination by admission of air. Unclean
needles and canulæ can--and we fear formerly often did--convert
sero-fibrinous into purulent pleurisies. A case came under Powell's
observation in which carelessness in this respect apparently led to
decomposition of the fluid, suppurative pleurisy, and ultimately to the
death of the patient. Before operating we ought always to test the
instrument, and see that it works well by passing carbolized water
through it. The points should be put in the flame of a spirit-lamp, and
then dipped in carbolized water and glycerin--not in oil, which may be
rancid. The hands and clothes of the operator should not be overlooked
in this regard. The atmosphere of the room should previously be
completely cleansed by ventilation, and afterward purified by
atomization of disinfectants. We must not, in a word, incur the
slightest risk of converting a simple inflammatory effusion of
fibro-serous fluid, a mild disease, into a suppurative inflammation, a
very troublesome, dangerous one.
A needle of not larger diameter than 1 millimeter (No. 2) should be
connected with the end of the tubing. Next turn the stopcocks which
shut off the barrel from the tubing on both sides, producing a vacuum
in the receiver. The patient should then be placed in the recumbent
position in bed, with his head and chest raised. We prefer this
position, as the easiest for the patient at the time of operation and
less apt to produce syncope or faintness. He can, without being moved,
lie down in the horizontal position, which he should maintain for at
least two hours. Bowditch has, without any accident, had his patients
to sit during operation sidewise in a chair, with one arm resting upon
a pillow placed upon the top of the back. The operation is accompanied
with so little pain that it is not necessary to use either general or
local anæsthesia. Some surgeons advise before operating the
administration of a small dose of morphia hypodermically, or a
stimulating drink of whiskey. We are not in the habit of using either.
We have generally allowed patients to take a good meal of
easily-digested food (milk if they consent) about two hours previous to
the operation. Whiskey and ammonia we have ready in case of need. If we
find it necessary to use a 4-mm. canula for syphon, it may be best to
spare the pain of its introduction by local anæsthesia by ether, or by
rhigoline in Richardson's spray, or by applying a piece of ice
surrounded by salt, as suggested by Powell.
The point of puncture should vary according to the quantity of fluid.
If the fluid is excessive, we can operate as high up as the fifth
intercostal space on the right side and the seventh on the left. We can
choose a lower intercostal, but as it is not proposed to draw off all
the fluid, the higher operation is preferable. If the chest is
two-thirds full, we can take the seventh or sixth intercostal space on
the right side and eighth on the left. If only one-third of the cavity
is occupied by fluid, we can go as low as the eighth intercostal {533}
on right and left sides, on a level with the angle of the scapula in
the axillary line. If the quantity of liquid is so great as to force
the abdominal viscera, especially the liver and the spleen, below their
normal position, we may be safe in puncturing below the seventh
intercostal space. But if such is not the case, the diaphragm may
easily be touched on a level with even the seventh intercostal space.
Aran plunged a trocar into the liver when operating through the seventh
intercostal space. Ch. Bernard impinged upon the peritoneum at the same
point. Woillez and Paul Barbille recommend the fifth intercostal space.
Cruveilhier advises the third or fourth as being the point of the
spontaneous openings. The author usually inserts the needle in the
sixth intercostal space in the mid-axillary line: it is out of reach of
the diaphragm and is accessible when the patient lies in the position
in which he prefers placing him. The space is sufficiently wide and the
parietes thin. Before operating the point must be examined carefully by
percussion, auscultation, and palpation, so as to be accurate in the
diagnosis that there is fluid at that point, and that nothing can be
injured--lung, heart, or diaphragm.
Before inserting the needle the skin should be wiped over with an
antiseptic solution. The skin being drawn up, the nail of the left
index finger serving as a director, the point, having been first made
aseptic, is introduced along the upper margin of the lower rib, taking
care not to injure the periosteum--not by a boring motion, but by a
sharp push, giving it a downward direction instead of a perfectly
straight one, so as to avoid striking the lung. When the fluid is
reached the stopcock is turned, so as to convert the needle into an
aspirator. The index tells us whether we have struck the fluid, and its
nature is shown. In chronic cases, where the bands are thick and
partitions are firm, we may not find the fluid the first time. In such
cases the needle is withdrawn and another point selected. The author
had a case where he made no less than eight punctures before getting
the fluid. At the last insertion of the needle he found it, and drew
off a large quantity. The patient feels relieved in a very short time.
As the fluid flows out the aspirating force should be only sufficient
to draw it out slowly and gently. It is well to stop for a few minutes
after aspirating about 4 fluidounces to watch the effects. The fluid
running in a very small stream, we give the lung time to accommodate
itself to its altered condition. The lung by this process is led,
rather than forced, to resume its normal position. It is a difficult
matter to fix the quantity that ought to be drawn off at one time. This
must vary according to the circumstances of each case. Our rule has
been to draw off more when the pleurisy is acute than when it is
chronic. The long continuance of the fluid in the cavity has so
impaired the lung's capability of expansion by the adhesive bands or
compresses that the sudden withdrawal of a large quantity is attended
with risk. If the patient bears the operation well, we may remove much
more than if the contrary is the case. The amount withdrawn at the
first operation should vary from 8 fluidounces to 16 fluidounces in a
child, and 12 fluidounces to 24 fluidounces for an adult. We must bear
in mind, as to the quantity to be removed, that ordinarily there is
more or less danger of producing fresh engorgement of the capillaries
and hyperæmia of the lung in removing a large quantity; and, moreover,
it is unnecessary. We wish to remove the intra-thoracic pressure upon
the lung and to promote the absorption of the fluid. The manometer will
tell us accurately whether it is necessary to take out one, two, or
three pints. If nature does not in due time remove what is left, the
operation can be again resorted to. Slowness in the withdrawal of the
fluid, as well as the small quantity drawn, lessens the probability of
any unpleasant effects. Bowditch says: "I always draw with great
deliberation. I pull so lightly upon the handle of the piston that it
seems as if the fluid itself were pressing out from the chest and
pushed the piston upward, my hand simply following that impulse. The
instant that the patient becomes {534} restless, especially if he have
any constriction or sharp pain in the chest, I withdraw the tube, even
if a large quantity of fluid remains. If I do this, I find the patient
is soon relieved, and in most cases nature appears stimulated even by
the withdrawal of a very small part of the effusion. The absorbents
begin to act well, and the fluid that is left is speedily removed."
One point is of the utmost importance: the needle should be instantly
withdrawn at the onset of dyspnoea, constriction, much cough, or any
tendency to syncope. These symptoms are warnings we should never
neglect. This is the time to administer stimulants, and ordinarily the
patient soon recovers from these effects. We must not, especially in
cases of long duration, expect to find much expansion of the lung until
next day. The greatest success has followed cases treated by early
operation and partial removals, repeated, if necessary, every day or
two until absorption is commenced.
The needle should be taken out suddenly, the operator having previously
turned the stopcock, and the skin allowed at once to fall over the
orifice, which is so small that no air can enter. It is indeed
obliterated at once. It may be well, however, to put some collodion
over it, with a small compress. The patient ought not to be permitted
to move for twenty-four hours after the operation. He should lie
quietly in bed and partake of simple nourishment. The removal of fluid
causes the return of friction sounds and of pleuritic pain. Nature
slowly does her work of absorbing the fibrinous bands. The
breath-sounds in some cases are not heard for weeks, or even months,
after the operation. Complete recovery being slow, and the shock to the
organism very serious, the patient should thoroughly re-establish his
health and strength before reassuming his active duties. A protracted
rest in an invigorating climate or a sea-voyage should be advised. If
the lung is slow to expand, the patient should frequently practise
long, deep inspirations.
Dangers of and Objections to the Operation.--Thoracentesis as a means
of relieving suffering humanity has from time to time been praised and
proscribed, even in this century. Boyer operated several times, and
never saved a single case. Dupuytren had only 2 successful cases in 50.
He said he preferred that his patients should die by the hand of God
rather than by the hand of man. Sir Astley Cooper had only 1 successful
case, Gendrin not 1 out of 20 cases. Davis saved two-thirds of his
cases. The eminent W. W. Gerhard of Philadelphia looked upon the
operation as nearly always attended by fatal results. What a contrast
to modern views and clinical results! Since Bowditch and Trousseau
popularized the operation, and Dieulafoy improved the aspirating
instruments, there is now no difference of opinion as to the imperative
necessity of operating in cases where there is, from the quantity of
fluid, imminent danger to life. Up to Nov., 1882, Bowditch[81] had
operated 386 times in 245 cases, without a single fatal result, and
with only 1 case in which alarming symptoms supervened. Dieulafoy's[82]
cases in 1878 amounted to 150, without the shadow of an accident. My
colleague, S. C. Chew, has never met with any unpleasant result from
his operations. The author has had 84 cases, with 138 operations,
without any unpleasant result beyond temporary cough and slight
dyspnoea. Fraentzel[83] had 85 different cases, with 164 operations. A.
L. Mason[84] performed 122 operations in 70 cases, with no unfavorable
result which could be attributed to the operation in any instance, but
usually with great and permanent relief. In 42 of his cases 1 operation
was all that was necessary. So common is the operation that cases are
not reported unless there is something to attract attention to them. As
illustrative of the great interest taken in the operation see the
number of writers on the subject and the numberless articles in medical
journals, and the modifications of instruments of all kinds connected
with aspiration {535} and drainage. Such being the case, we ought not
to be surprised that some operators may have used the aspirator-needle
when they ought not to have done so--that some should have neglected
the simple rules now insisted upon as the result of experience.
[Footnote 81: Unpublished MSS.]
[Footnote 82: _Tho. Pleu. Aig._, 1878.]
[Footnote 83: _Ziemssen's Cyc._, vol. iv.]
[Footnote 84: _Loc. cit._]
Although thoracentesis by aspiration is always a harmless operation in
itself, there are dangers and accidents which may follow. They may be
slight, serious, and sometimes even fatal. The number of deaths which
have been the result of the operation, however, is small compared to
that of persons dying from the effusion whose lives might have been
saved by the withdrawal of fluid. Thoracentesis was frequently made use
of without accident, and was considered a perfectly safe operation
until Terrillon[85] called attention to an accident which occurred
sometimes after operating, a complication which Pinault[86] had
mentioned in 1853--the albuminoid expectoration. Terrillon reported 2
cases of sudden and rapid death with that symptom. Several similar
cases, resulting in death, had been previously reported. Dieulafoy has
collected from different sources reports of 6 deaths with albuminous
expectoration, caused by acute oedema of the lungs brought on
apparently by the operation of thoracentesis in twenty-four to
thirty-six hours. In one of these cases (Gérard's) death occurred in
ten minutes; in another (Gombault's) in fifteen minutes; in another
(Bouveret's) in two hours; in Behier's in four hours. Terrillon's
cases, where there was this frothy, albuminoid, and sometimes bloody
expectoration, numbered 16, of which 6 were fatal. The patient is
attacked with cough and oppression, with the characteristic
expectoration. Auscultation shows the fine subcrepitant râles of oedema
of the lungs, mingled with tubular quality and ægophony. Gradually, in
favorable cases, the cough subsides, respiration is re-established, and
in one hour the danger has passed. In fatal cases the cough becomes
irregular and jerky, the agony increases, and the patient throws up the
yellowish and albuminous expectoration in quantity varying from 50
grammes to (in one case reported by Moutard-Martin) 1 liter. The
intensity of the dyspnoea and its duration vary very much--from twelve
to twenty-four hours.
[Footnote 85: _Thèse de Paris_, 1872.]
[Footnote 86: _Ibid._, 1853.]