what produce this serious condition. The view sustained by Hérard[87]
is the one generally admitted to be correct--viz. that it is from rapid
congestion and acute oedema of the lung, and not from the passage of
serous effusions of the pleura through the bronchi. Foucart[88] relates
a similar case of albuminous expectoration occurring in heart disease.
This condition could not be produced by perforation of the lung, for
the pre-existing vacuum renders the aspirator-needles the safest to
introduce, because if there is fluid present it at once flows out and
warns the operator not to push the implement farther in. In no autopsy
has the orifice made by the needle been found, nor has it ever been
known to produce pneumothorax. The quantity of albuminous sputa is out
of all proportion to the orifice made. In several cases of reported
perforation these symptoms did not occur. After the lung has been a
long time compressed by an effusion, and when, in consequence of the
expulsion of the liquid, it retakes its normal proportions, there
occurs a rush of serum which is expelled by the bronchi. Hérard has
seen patients in whom he could not find more than traces of liquid
after the puncture, and who at the end of a half hour or an hour
expectorated 500 to 1000 grammes of fluid which did not come from the
pleura. That oedema of the lungs, or serous exudation from the
capillaries into the walls and on the free surface of the alveoli, is a
result of hyperæmia and pulmonary congestion is admitted by Robin,
Bernard, Niemeyer, Jaccoud, and others. We have first congestion of the
lung, then oedema resulting from it, ending in free albuminous
expectoration, {536} which comes not only sometimes from the diseased
side, but from the healthy side, owing to pressure against the
mediastinum and the other lung. This is an accident the possibility of
which should be always before us in operating. No precaution ought to
be neglected which will ward it off. It is instructive to analyze
Terrillon's cases as to the cause of the oedema. As he considers that
the aspirator, by draining out the lung, is likely to produce this
unfortunate result, it is satisfactory to find that of the 16 cases
where this unpleasant symptom was found, 12 were where the old trocar
(Reybard's) was used without aspiration, and 4 where aspirators were
used. Of the 6 fatal cases collected by Terrillon, 3 were with the
trocar and 3 with the aspirator. Five out of the 6 fatal cases are
found to have been not simple pleurisies, but pleurisies with
complications, such as heart disease, bronchitis, tuberculosis,
numerous adhesions, double pleurisy. The same may be said of the benign
cases. In addition to these complications, large quantities of fluid
had been drawn out at one time. Dieulafoy challenges his confrères to
produce an instance of death from this cause when the fluid removed did
not exceed 1200 grammes. His rule now is never to withdraw more than
1000 grammes of liquid at one time, and in large effusions to empty the
sac by several operations. The older and more complicated the effusion,
the more rigorous should be the rule, because there is great danger in
thoracentesis when the fluid has existed long enough to have compressed
the lung to a serious extent by bands. All careful operators now follow
this rule. It is dangerous, and withal unnecessary, to draw off large
quantities at a time. The gradual removal of fluid diminishes the risk
of syncope where a sudden withdrawal may be serious in its effects. The
effect is to suddenly deprive the lung of pressure which has for weeks
perhaps made it anæmic. The blood rushes into the empty vessels, the
air into the alveoli, and violent congestion and consequent oedema
result. If, on the contrary, we draw out moderate quantities at
different times with the capillary needle, which is so small that its
introduction is harmless, the lung resumes progressively the functions
it has lost, and the circulation gradually enters. Thus there is no
risk of congestion.
[Footnote 87: _Acad. Méd._, 30 Juillet, 1872.]
[Footnote 88: _Thèse de Paris_, 1875.]
In examining the fatal cases reported by different authors, Foucart,
Dieulafoy, Mercier, Lerebenthel, and Gagnet, we find other modes of
death in addition to those by oedema of the lung, such as asphyxia and
pulmonary emboli, and, as connected with the heart, syncope and cardiac
thrombosis. In most of the cases these accidents resulted indirectly
from the operation in twenty-four hours or a longer time. In a case
reported by Guyot it occurred three days afterward. Congestion by
itself may cause sudden and rapid death by determining asphyxia.
There are other lung causes which produce sudden death following
thoracentesis, such as atelectasis, consecutive to effusion; secondary
pneumonia, caseous or not; pulmonary tubercles. Besnier reports a case
of gangrene of the lung following paracentesis. Of the 8 cases
collected by Dieulafoy which may be put into this category, we find
death from pericarditis, cardiac clot, and from thrombosis of the
pulmonary artery. Death from the heart may be due to old lesions, to
syncope, or to the presence of clots in the heart or small circulation.
Stokes has given fatty degeneration of the heart as a cause of death in
simple pleurisy without operation. Syncope, with death after operation,
is caused by the sudden return of the heart to its normal position. The
heart being pushed out of position, the larger blood-vessels are
distorted, and the course of the circulation is severely interfered
with. A very slight cause will arrest the circulation. By aspiration
the mechanical cause is removed, but a small embolus, may, by the
increased force of blood, be carried into the pulmonary circulation.
Death by emboli in the capillaries of the lungs is very similar to
death {537} from clots in the right side of the heart and at the origin
of the pulmonary artery. These clots may be formed in the pulmonary
vessels, or may be transported in the small circulation to points more
or less distant. Potain in 1861, and Vallin in 1869, reported sudden
deaths from effusion in the pleural sac, causing embolism of the
cerebral artery. How far aspiration is responsible for accidents of
this kind it is difficult to decide. Were they caused by thoracentesis
or notwithstanding the operation? They are unquestionably the cause of
death without the operation in excessive effusions. The conditions
which produce these results ought to be well considered previous to
operation. We notice that in most of these cases large quantities of
fluid were withdrawn--2000 grammes (Legroux), 3 liters (Vallin), 3500
grammes (Guyot), 1500 grammes (Chaillon and Goquel). The withdrawal in
cases of long standing of such large quantities had, beyond a doubt,
considerable influence in producing the fatal result. Bowditch[89]
addressed letters to 60 physicians, living in 31 of the States and 2 in
Canada--representative men--asking if they had ever seen or heard of
fatal results following thoracentesis by aspiration. Of this number, 53
replied in the negative, and 7 in the affirmative. "Upon an analysis,
however," he states,[89] "of the circumstances under which death
occurred in these last, I found nothing to shake my confidence in the
operation, provided it be performed with proper precautions during and
subsequent to the tapping. In no one of these cases had the operation
been the sole cause of the fatal result." "In 4 there was extra motion
on the part of the patient after operation, and in the other 3 the
disease had been allowed to continue without aid from a surgeon long
after the operation was needed. In 1 the operation was a forlorn hope.
One patient died on the table from anæsthetics." Bowditch adds: "These
cases should not lessen our confidence in the operation, but simply
teach us caution on three points--namely: do not delay too long; be
very careful to direct the patient not to move, if possible, for
twenty-four hours after operation; be cautious of using anæsthetics."
Bowditch, from 29 fatal cases collected from Otto Leichtenstein,[90]
from his own knowledge, and from European literature, tabulates the
causes of death in American and European practice: 7 of these cases
were caused by extra-exertion after operation; 3 from cyanosis and
coma; 4 from spray injections; only 1 from syncope; and 2 from
albuminoid sputa. He quotes the final remark of Leichtenstein: "Death
or any serious symptoms are so rare that they ought not to have the
least influence upon our estimate of this most benign and blessed
operation." Bowditch states that there were only 7 deaths in this
country (as far as he could ascertain), and 29, or four times as many,
in Europe, although the operation has been done much more frequently
here and for a much longer time. Does not this show that in this
country, in following Bowditch's precepts of great care and
deliberation, the operation has been more successful? He never ceased
in his lectures and writings to caution us to suspend the withdrawal of
fluid the moment the patient begins to suffer in breathing, even in the
slightest degree. Of course there may have been other cases occurring
in American practice of fatal results, of which no reports were made to
Bowditch.
[Footnote 89: Unpublished MSS., 1882.]
[Footnote 90: _Deutsches Arch. für klin. Med._, vol. xxv., 1880.]
The author has carefully gone over Leichtenstein's collected cases, and
he finds a number of deaths mentioned by other European authors which
are not included in his list. (The reader is referred to the theses of
Terrillon,[91] Foucart,[92] Foster,[93] Dieulafoy,[94] Mercier,[95]
Pinault,[96] Wilson Fox,[97] and others.) Terrillon alone reports 6
deaths with symptoms of oedema of the lungs following thoracentesis.
Leichtenstein does not mention any deaths from embolism, {538} such as
are quoted by Goquel, Chaillon, and Woillez. In his collection he gives
only 1 death by syncope, whereas Dieulafoy comments upon 4 as found
recorded by Trousseau and other French authorities. Toussaint's[98]
statistical tables of 300 cases, collected from other sources, give 14
deaths. Wilson Fox collected between 30 and 40 deaths connected with
thoracentesis. Besnier stated in 1876 that the mortality from pleurisy
in the French hospitals had greatly increased since the practice of
thoracentesis had been largely followed. It is difficult to account for
this in the face of the statements made by so many of its innocuousness
when properly guarded: it may be explained by the fact that suppurative
pleurisies are often confounded with those of a fibro-serous nature and
treated by simple aspiration. Many fatal cases of empyema are
complicated with phthisis; formerly these were added to the mortality
for phthisis; where paracentesis was performed upon them they were
added to the pleurisy column. Bearing in mind that chronic pleurisies,
serous and purulent, are frequently consecutive to diabetes, Bright's
disease, chronic alcoholism, cirrhosis of the liver, and other organic
diseases, patients die of the primary lesions, though they have been
relieved of the secondary ones. These statistics may record the deaths
as resulting from pleurisy, for which there was operative interference,
instead of from the organic diseases.
[Footnote 91: _Loc. cit._]
[Footnote 92: _Loc. cit._]
[Footnote 93: _Clin. Obs._]
[Footnote 94: _Loc. cit._]
[Footnote 95: _Thèse de Paris_, 1876.]
[Footnote 96: _Ibid._, 1855.]
[Footnote 97: _Brit. Med. Journ._, Dec., 1877.]
[Footnote 98: _Thèse de Paris_, 1878.]
Formerly, when trocars and canulas of considerable diameters were used,
only extreme necessity from peril to life made surgeons consent to
operate. We claim that by capillary needles, gentle force, and
protected points all the old objections are obviated. As Anstie says,
there is no opposition to the modern operation by men who have fairly
tried Bowditch's practice. Only theorists who are afraid of its
imaginary results and men too timid to act hesitate to make use of it.
We have discussed elsewhere (Purulent Pleurisy) the danger of admitting
air into the pleural cavity, but we insist that in the close method,
with capillary needles, there is no danger whatever of air entering.
The puncture is so very small that it closes at once by the elasticity
of the structure of the chest, just as the knuckle of the intestine in
hernia closes after the needle has drawn gases and fluid out of it.
Another objection urged against puncture of the pleura in such cases is
the possibility of perforating the lung by fine needles, thus letting
air into the cavity and causing cough.[99] Marotte read a memoir on the
subject to the Academy in 1872. He reported 4 cases, in all of which
there were only temporary effects, no serious ones. Dieulafoy[100]
says: "I have been witness to the puncturing of the lung several times,
and I have never seen any accident supervene under any circumstances. I
have thoroughly convinced myself that punctures performed with a No. 1
needle, diameter half a millimeter, are harmless, and experiments on
animals have given me the same results." He even suggests aspirating a
few grammes of blood from a congested lung in the first stage of
pneumonia, and thus practising local bloodletting. The author has 3
times pricked the lung in aspirating--twice with a No. 2 needle,
diameter 1 millimeter, where a few drops of blood were drawn into the
instrument, and they did not even produce a cough or the slightest
inconvenience. The third time was with a No. 4 needle (2 millimeters).
From this puncture some air escaped into the pleura, and for a few days
there was evidence of pneumothorax. It then disappeared entirely, the
air being absorbed. The case was a circumscribed empyema, which
entirely recovered.
[Footnote 99: Allbutt, _Quain's Dict. Med._, 1883.]
[Footnote 100: _Treatise on Pneumatic Aspiration_, Eng. trans., p.
256.]
It will be noted that throughout the discussion of this important
subject liberal use has been made of a valuable communication specially
prepared by Henry I. Bowditch for this purpose, and embodying the
mature results of his study and experience of thoracentesis. It seems
not only to establish conclusively the claim that to him, in
conjunction with Wyman, is due the {539} great credit of introducing
the principle of aspiration, but also to how great an extent it was
through his persevering and skilful advocacy and performance of the
operation that it became so firmly established in America upon a true
scientific basis.
Purulent Pleurisy.
DEFINITION.--Purulent pleurisy is that disease in which the pleura
secretes pus instead of fibro-serous fluid, as in simple pleurisy.
SYNONYMS.--Pyothorax; Empyema; Suppurative pleurisy.
HISTORY.--The term empyema was applied originally to any internal
collection of pus--[Greek: en] and [Greek: pyon]. It is now restricted
to pus in the pleural sac. The ancients, from the time of Hippocrates,
diagnosed and treated empyema by thoracentesis and pleurotomy. They
were familiar with the fact that it would sometimes discharge through
the bronchi and make an orifice through the walls of the chest, and
discharge outwardly. Their views of its pathology and its connection
with other forms of pleurisy were necessarily crude and indefinite. Of
late years, owing to the aids given by exploratory punctures, purulent
pleurisies have been thoroughly investigated. Townsend[101] divided the
disease into four varieties, all of which are from degenerations of
acute serous pleurisies, from increase of intensity of the inflammatory
phenomena, or from modification of the secretion of the serous
membrane. More modern researches have shown that frequently such is the
case, and that purulent pleurisies often succeed serous pleurisies. The
liquid when first thrown out is serous and limpid in character, and
afterward becomes cloudy, opaline, then more and more opaque and
purulent, owing to the pus being freely secreted and mixing with the
fibro-serous effusion. In a certain number of cases, however, the
effused liquid has from the first the appearance and anatomical
composition of purulent fluid--d'emblée purulente. This has been shown
by autopsies in cases of women who died in childbed from suppurating
pleurisies, and in persons attacked with pyogenic fever, not simply
from deposits of pus, but where an inflammatory period, of longer or
shorter duration, preceded the deposit.[102] Dieulafoy[103] showed that
in all effused liquids in the pleural sac there were present red
globules and leucocytes.[104] Laboulbène[105] has established the fact
that the exuded fluid in all pleurisies, even those apparently serous,
contained, from the time of their formation, purulent globules. All
cases, then, are historically purulent; but clinically serous and
purulent pleurisies are distinct in their progress, termination, and
treatment. Purulence is not always the sign of chronicity of pleural
inflammation. It may, and does, show itself in many instances from the
very commencement of the attack. Wilson Fox[106] shows there is but
little natural tendency in serous effusions to undergo purulent
transformations. He thinks in the vast majority of cases suppurative
pleurisies are so at early periods of disease. He states the proportion
of primary suppurative pleurisies as from 14 to 20 per cent. It is when
the number of leucocytes, from the intensity of the inflammation or
modification of the process, discolors the fluid and gives to it its
distinctive properties, that we use the name of purulent pleurisy.
Verliac[107] states that all chronic cases in infants become purulent.
[Footnote 101: Article "Empyema," _Cyc. Prac. Med._, vol. ii.]
[Footnote 102: _Pleurisie purulente_, (Moutard-Martin), Paris, 1872.]
[Footnote 103: "De l'Examen histologique des Liquides, etc.," _Soc.
Méd. des Hôp._, 1878.]
[Footnote 104: See section on Hemorrhagic Pleurisies.]
[Footnote 105: _Traité d'Anatomie path._, Paris, 1872.]
[Footnote 106: _Brit. Med. Journ._, Dec., 1877.]
[Footnote 107: _Thèse de Paris_, 1865.]
ETIOLOGY.--The causes of purulent pleurisies are divided into local or
traumatic, which are well ascertained and defined; and the general, the
{540} action of which is uncertain. Among the first are wounds of the
chest, fractures or caries of the ribs, phlegmonous abscesses of the
walls of the chest, effusions of blood, pathological liquids, pulmonary
gangrene, rupture of tubercular cavities, and other injuries from
adjacent organs, especially of those where pus is discharged into the
cavity, for the presence of pus engenders pus. Thoracentesis has been
accused of converting serous into purulent pleurisies by the admission
of air into the pleural cavity. If the atmosphere admitted is
contaminated by germs, we must acknowledge that such a result is
possible. By the older methods, previous to the adoption of Reybard's
protected canula, such a result may have been produced. We can thus, in
a measure at least, account for the great mortality in cases operated
upon. But since the adoption of the protected orifices of the small
aspirating trocar of Wyman and the capillary perforating needles of
Dieulafoy, we question whether, with such an insignificant puncture and
the complete exclusion of air, thoracentesis can be justly accused of
producing such serious mischief. Trousseau[108] earnestly denied such a
deleterious effect of the operation in his day. We have now not only
the results obtained by Demarquay, Leconte, and Manotte of injecting
air into the pleural cavities of inferior animals, but we have the bold
experiments of Matice, who, convinced that air could not have any bad
influence, actually had the audacity to perform the operation a number
of times, allowing the air to enter freely through the canula. From
numerous observations there resulted the fact, unsuspected by many,
that air, penetrating freely to replace the liquid extracted, never
gave rise to purulence in pleurisy; that, owing to its rapid
absorption, it did not in the least interfere with the expansion of the
lungs; in short, that it produced no accident whatever. While admitting
the force of Matice's conclusions, we think it preferable to avoid the
possibility of doing harm.
[Footnote 108: _Loc. cit._]
GENERAL CAUSES.--We have shown that secondary pleurisies frequently
occur in the course of convalescence from eruptive diseases, measles,
small-pox, and especially scarlet fever, and that they are purulent in
their nature. The puerperal condition predisposes to suppurative
inflammations of the serous membranes, and pleurisies in lying-in women
are almost always purulent. In rheumatism, gout, and delirium tremens,
and albuminuria as a rule, the pleuritic effusion is serous. It is
purulent in persons suffering from severe injuries and among men
exhausted by over-work or by alcoholic excesses, or protracted obscure
diseases, such as typhoid fever and pyæmia. Analyses of the cases in
which purulent transformation has occurred show that tubercles of the
lung have only a minor influence in its production--only 34 per cent.
of the whole number. Attimont's[109] observations were founded upon 130
cases, 80 of which recovered; of the remaining 50 that died, he found
tubercle in only 9 cases. Sometimes malhygienic conditions and
insufficient alimentation may account for them. Men are more subject to
this disease than women in the proportion of 8 to 1,[110] and young
children oftener suffer from purulent pleurisy than adults. It is not
easy to explain the transformation of serum into pus in pleuritic
effusions that have existed for some time where there have been no
grave symptoms. Imprudent exposure, affecting the general health, may
thus produce disastrous results. This occurs so frequently that
purulent pleurisies are generally called chronic pleurisies. There are
cases where neither local nor general conditions explain the
transformation of serous into purulent effusions in the chest.
[Footnote 109: _Thèse de Paris_, 1869.]
[Footnote 110: E. Moutard-Martin.]
PATHOLOGICAL ANATOMY.--This is shown by an examination of the effused
liquid, the different solid detritus that it contains, the false
membranes, the pleura, the lung, and the thoracic wall itself. The
liquid effused is purulent in character. It contains a greater or less
number of leucocytes, {541} some red globules, and voluminous granular
cells, besides crystals of the fatty acids and plates of cholesterin.
The pus is mixed with the serosity in varying quantities. The liquid
may be slightly opaline or greenish-yellow, and sometimes gray. It may
be thin or thick, with heavy flocculi, so as to pass with difficulty
through a canula. The liquid is, ordinarily, inodorous, but it may be
strong, and even fetid, where it has been in contact with air. In very
few cases of old standing can the pus be regarded as active, the
corpuscles being, as a rule, dead or having undergone fatty
degeneration. Active suppuration is also more readily set up in a
pleura which has already yielded pus.