bursting of an aneurism, from ulceration through the walls of the aorta
of the vena cava, or from the veins of the pleura. It may be caused by
laceration of the intercostal arteries in penetrating wounds. In very
rare cases a profuse bleeding takes place in caseous pneumonia or in
gangrene of the lungs, and bursts into the pleural cavity (Fraentzel).
Cancer of the lung or pleura may, by pressure, produce absorption and
destruction of the walls of the blood-vessels, and cause discharge of
their contents into the pleural cavity. Sir Thomas Watson[253] reports
a case where enormous hæmothorax caused enlargement of the left side,
pushing the heart to the right of the sternum from caries of two ribs
with ulceration through an intercostal artery. The blood never escapes
from the lung into the pleura when there is considerable pulmonary
apoplexy.
[Footnote 253: _Practice of Medicine_, vol. ii.]
PATHOLOGICAL ANATOMY.--Blood is found coagulated to a greater or less
degree in the pleural cavity, and the lesion producing the hæmothorax
can generally be found; the remains of blood may be found even after it
has been some time effused. If the hemorrhage does not prove fatal, it
may all be absorbed, or it may by its presence cause local inflammation
of the pleural membrane.
SYMPTOMS.--The symptoms are those of perforation into the chest--sudden
intense pain on the diseased side, with internal hemorrhage, great
pallor, feeble circulation, cold extremities, and syncope. Patients
often die in a few minutes. If the hemorrhage is moderate in quantity,
they revive and the circulation returns, but they complain of feelings
of suffocation and oppression. Slowly the general strength returns and
the patient recovers.
SEQUELÆ.--Most modern surgeons admit that serious hemorrhages into the
pleura come from the thoracic walls, or from the blood-vessels in the
neighborhood of the hilum, or from those which accompany the bronchial
diseases of the second or third order. Hæmothorax is always consecutive
to some primary lesion. Where it is caused by penetrating wounds or by
the bursting of blood-vessels in the lungs, air enters the cavity and
becomes mixed with the blood, producing a complication in the form of
hæmato-pneumothorax. This frequently gives rise to pyo-pneumothorax
with a collection of purulent and ichorous fluid.
DIAGNOSIS.--The previous history of the case, together with the
characteristic symptoms we have mentioned, enables us to diagnose
hæmothorax from {583} pneumothorax, which commences in a similar way.
The only other condition likely to be confounded with it is effusion in
pleurisy, the physical signs of which are somewhat the same. If the
blood remains uncoagulated we shall have absence of vesicular murmur,
with dulness on percussion, absence of fremitus, and no friction sound.
The introduction of a fine hypodermic needle enables us to be certain
of the nature of the fluid.
The PROGNOSIS is always serious. If the cause of the hemorrhage is the
bursting of an aneurism, death supervenes in a short time. Hæmothorax,
when caused by penetrating wounds, unless they produce hemorrhage, is
not necessarily serious. The blood may entirely disappear in a few
weeks. Entrance of air with the blood renders the prognosis more
serious. Secondary pleurisy is not ordinarily severe unless pus forms.
TREATMENT.--If time is allowed, every effort must be made by local and
general treatment to arrest the hemorrhage--ice-bags and hot-water bags
ought alternately to be applied to the chest and between the scapula;
the patient to be kept in the horizontal position and made to rest
quietly; ice taken by mouth; small doses of morphia and large doses of
ergotin must be given promptly hypodermically, as the stomach is in no
condition to absorb remedies readily. If the accumulation be excessive
and continues to embarrass the respiration very much, we recommend free
incisions to take out sufficient blood to relieve the pressure and
great dyspnoea. Unless danger is imminent, this is a hazardous
experiment, as letting in atmospheric air among blood-clots may
seriously complicate the condition. Should pleuritis or other
complications occur, they must be rationally treated.
Growths in the Pleural Cavity.
Some authors mention various tumors which are rarely met with in the
pleural cavity, and which are not peculiar to the serous membrane of
the pleura. Among them may be placed sarcomas, fibro-sarcomas, and
epithelioma. Their presence in other organs may assist in the
diagnosis. Other varieties exist more or less connected with chronic
pleurisies. Among these are fibromas, cartilaginous and osseous
formations. Rokitansky speaks of lipomas as deposited on the costal
pleura. The only varieties which we think it necessary to call
attention to are cancer and hydatids.
CANCER OF THE PLEURA.--Cancer of the pleura is not a very rare disease,
but ordinarily it is a secondary formation, coming from cancerous
disease of the mediastinum, of the lung, or of some abdominal organ.
Some authors doubt whether it is primary even in the lungs and
mediastinum. It certainly is not often met with as a primary disease of
those organs. Lebert[254] had only seen 6 observations, in 447 cases of
cancer, involving the mediastinum, the pleura, and the lungs.
Walshe[255] reported 29 cases of primitive cancer of the respiratory
organs; in 18 cases one lung was diseased with its pleura, and in 13
the right lung. Lépine[256] in 1869 communicated a very curious case of
primary cancer of the pleura in a child ten years of age. The right
pleural cavity was filled by a white scirrhous tumor. Darolles[257]
(1874) reported another example of primary cancer of the pleura, which
afterward spread to the lung. Andral, Vidal, and Lebert reported cases
where the tumors appeared to develop simultaneously in the pleura and
other organs. Primary cancer of the pleura may exceptionally occur, but
ordinarily the disease results from its extension step by step, or else
distant propagation, from lungs, breast, mediastinum, or the abdominal
organs. Most frequently the secondary {584} cancer appears more or less
independently of the primitive tumor, and is seen in the form of
disseminated points on the surface of one or both folds of the pleura.
This propagation of cancer is now generally admitted to be through the
intermediary of the lymphatic system; in fact, the lymphatics are
themselves attacked by the degeneration, and they are seen,
particularly on the surface of the pleura, in the form of white small
cords. Some modern pathologists consider that the serous cavities are
lymphatic cavities, which can, just as the vessels themselves, serve as
ways of generalizing the disease (Cornil and Ranvier, Charcot, Lépine,
and Virchow).
[Footnote 254: _Traité Prac. Mal. des Cancereuses_, Paris, 1851.]
[Footnote 255: _Nature and Treatment of Cancer_, London, 1846.]
[Footnote 256: _Bull. de la Soc. Anat._, 1869.]
[Footnote 257: Quoted by Fernet, _Nouveau Dict. Méd._, vol. xxviii.]
PATHOLOGICAL ANATOMY.--Primary cancer of the pleura is ordinarily
encephaloid and multiple. Extended infiltration is very rarely found.
Lebert reports one case in an infant of seven months. The multiple
masses are ordinarily soft and pulpy, varying in volume from the size
of a grain of millet-seed to that of a small nut. The aspect is
yellowish-white. The juice is rarely pressed out of them. Under the
microscope we see large cells and multiple cells with their nuclei. The
small granulations or the lenticular masses are flat, resembling drops
of wax. We may have solid bodies possessing all the characters of
scirrhous, encephaloid, and colloid, grayish, or gelatinous structure.
These cancerous productions are generally vascular, especially in the
encephaloid variety. Their rupture frequently produces hæmothorax and
hemorrhagic pleurisies. The bronchial glands, and finally the cervical
glands, often become involved.
SYMPTOMS.--The symptoms of pleural cancer, especially of the smaller
and secondary deposits, are often obscure and indefinite. They are not
sufficiently definite to attract attention during life. If the masses
are scirrhous and large, they press upon the lungs, impede respiration,
and give rise to dyspnoea. If the disease is propagated from the lungs
or breast, we may suspect cancer where we have a dull pain with some
cough. Pain, indeed, is constant, but not violent, unless the nodules
excite local inflammation. When scirrhous tumors press upon the
intercostal nerves, the pain is very persistent. External pressure over
the points gives rise to pain. The dyspnoea increases as the size of
the tumor increases. The expectoration is occasionally bloody. The
physical signs are sometimes characteristic--dulness on percussion,
absence of respiratory murmurs, friction sounds, no vocal fremitus.
DIAGNOSIS.--Generally very difficult. The progress of the disease is
ordinarily slow, and follows its development in other portions of the
body. Cancerous cachexia, degeneration of the glands above the
clavicle, hæmothorax, and hemorrhagic pleurisy, together with dry cough
and persistent intercostal neuralgia, are, when present, valuable aids
to diagnosis. Extensive caseous pneumonia and pleuritic effusions may
be confounded with cancer of the pleura. These tumors may not be at the
base, but in the middle of the thorax; dulness may not exist at the
base as is invariably the case in pleurisy. The position of the body
does not affect the limit of dulness in cancer.
The PROGNOSIS is always very serious, the disease being invariably
fatal. In Walshe's cases the duration of the disease was from three and
one-half months to twenty-seven months; average duration, thirteen and
one-fifth months. One-fourth of his cases occurred between the ages of
fifty and sixty years.
The TREATMENT is palliative--opium and other narcotics, and locally
chloroform and aconite for the intercostal pains. When effusion results
from cancerous inflammation the aspirator may be used to relieve the
great oppression caused by the quantity of fluid.
{585} Hydatids of the Pleura.
Trousseau[258] considered hydatids of the pleura a comparatively rare
disease. He believed that when found in the cavity it was frequently
caused by cysts of the lung which had fallen into the pleural cavity.
Vigla[259] mentions 3 cases. Davaine[260] met with 25 cases of
hydatids, only 1 of which he believed originated in the pleural cavity.
The acknowledged greater frequency of these hydatids in the right
inferior lobe of the lung, gives probability to Dolbeau's[261] view
that "they frequently proceed from cysts on the convex surface of the
liver." Hearn[262] reports 75 cases collected from various observers as
intra-thoracic, 15 of which were in the pleura, in the subserous
tissue, between the parietal pleura and thoracic wall.
[Footnote 258: _Clin. Med._, vol. i., Philada. ed.]
[Footnote 259: "Des Hydàtides intrathor.," _Arch. gén._, 1855.]
[Footnote 260: _Traité des Entozoaires, etc._, Paris, 1860.]
[Footnote 261: _Thèse de Paris_, 1856.]
[Footnote 262: _Thèse de Paris_, 1875.]
PATHOLOGICAL ANATOMY.--In the greater number of cases, as examined at
autopsies in Hearn's reports, the tumor was formed by a voluminous
pocket occupying a large part or the whole of the cavity of the pleura.
The walls of the envelope were formed of a transparent or slightly
opaline and whitish membrane composed of numerous thin layers,
containing on its interior surface the echinococci. In the interior of
the cyst there was a limpid hyaline liquid with living parasites.
Nothing different was noticed in cysts from those found elsewhere,
except the absence of the usual adventitious membrane--a fact
previously noticed by Davaine. When the cysts are very large they press
upon the lung and adjoining organs just as is the case with large
effusions in the pleural cavity. The heart, moreover, is pushed to one
side, out of its normal position; the lung is compressed and diaphragm
depressed.
SYMPTOMS.--The first appearance of cysts of the pleura causes but
little disturbance of the functions of the lung. It is scarcely
appreciable until it interferes with the play of the other organs. The
three prominent symptoms are the pain, the dyspnoea, and the cough. The
pain occupies the exact point where the tumor is situated, and radiates
from that point. Once developed, it persists with tenacity throughout
the duration of the disease. This persistence of the pain is indeed an
important characteristic of the disease, and is a sign of value in the
diagnosis between hydatids and pleuritic effusions. The dyspnoea
increases progressively with the volume of the tumor. The cough is not
heard as frequently as when the cysts occur in the lungs. It is dry,
and does not cause hæmoptysis.
DIAGNOSIS.--Physical signs must be marked to enable us to distinguish
fluid cysts of the pleura from cysts in the lung or effusions in the
pleural cavity. When the hydatid tumor has attained sufficient size to
cause pain and dyspnoea it generally presses outward the walls of the
chest after the lung has been compressed. It does not occupy the base
of the cavity, as the effusions do, and the dilatation has a globular
form. Trousseau[263] has given several examples in which this shape
determined the diagnosis. With this arching of the chest the immobility
of the chest is an important sign. Vocal fremitus is diminished or
totally abolished, and percussion elicits absolute flatness. These two
physical signs assist us in making the diagnosis between hydatids and
pleurisy. The auscultatory phenomena, from similar physical conditions,
closely resemble those of pleuritic effusions. It must be borne in mind
that sometimes hydatid cysts are complicated by pleuritic
inflammations, caused by their presence. The diagnosis is
unquestionably complicated by difficulties that are not removed unless
the cysts burst through a bronchial tube and discharge a transparent
and clear fluid in which the microscope shows the presence of
echinococci. Such hydatid expectoration is a pathognomonic {586} sign
of the existence of an intra-thoracic cyst. Hydatids of the liver may
press the diaphragm far up into the pleural cavity without bursting
through it. Trousseau maintained that without bursting they may make a
passage for themselves through the distended, attenuated fibres of the
muscular portion of the diaphragm, for the progress of these cysts is
necessarily slow. We must not hesitate to make an exploratory
aspiration to determine with certainty the nature of the fluid.
[Footnote 263: _Loc. cit._]
PROGNOSIS.--The prognosis is certainly very serious, but not so bad as
when cysts of the same nature are situated in the lungs. Their
spontaneous cure may be effected by bursting through a bronchus or even
through the walls of the chest. The patient may, however, die from
asphyxia during the discharge through the lungs. When not evacuated
they may produce death by compression of the lungs.
TREATMENT.--If the disease is recognized previous to its making an
opening through a bronchus, it can be treated safely and effectively by
aspiration. Bird[264] reports a number of cures by this operation in
Australia. Trousseau advises extreme caution, even in regard to
exploratory punctures, unless adhesions have taken place between the
tumor and the walls of the chest, for he fears the escape of fluid into
the cavity of the chest and consequent purulent pleurisy. It is well to
remember that this great practitioner was not aware of the
innocuousness of capillary punctures and aspiration. If the bronchus
has been perforated, we must hope for spontaneous cure. If empyema be
caused by the tumor pleurotomy must be used as recommended by
Moutard-Martin[265] and Vigla,[266] and constant washing of the pleuræ
must be used. This treatment gives us reasonable assurance of success.
[Footnote 264: Quoted by Hearn.]
[Footnote 265: _Purulent Pleurisy_.]
[Footnote 266: _Loc. cit._]
History of Thoracentesis.
Thoracentesis ([Greek: thôrax], chest, and [Greek: chentein], to
pierce) is the operation for the evacuation of collections of fluid,
serum, pus, or blood from the pleural cavity.
Among the ancients, dating back to the time of Hippocrates, it was
practised, and was known as the operatio empyematis. Hippocrates uses
the word [Greek: empyon], signifying, literally, an internal collection
of pus just above the cavity of the peritoneum, above the diaphragm.
Subsequently he speaks of empyema of blood, empyema of serum, empyema
of gas, but not of pus, applying the term to the operation, which he
employed principally for empyema necessitatis. Subsequently the name
empyema was used, as now, to designate a purulent collection in the
pleural cavity.
If we may credit the story which has descended from mythological times,
the operation for empyema had its origin in an accident. It is related
that a certain Phalereus, who was attacked with what was denominated an
ulcer on the lungs, was pronounced by all his physicians to have an
incurable disease. In his despair he exposed himself in battle so that
he might be slain; the enemy's weapon, however, pierced his side,
making an opening through which the pus escaped, and he recovered.[267]
[Footnote 267: Cicero, _De Naturâ Deorum_, lib. iii. cap. 28.]
It is certain that from the most remote periods the chest was opened
when collections of pus were formed. Galen states that the ancients
employed actual cautery for that purpose. He reports that Euryphon de
Cinde by this means saved the life of Cinesias, son of Evagoras.[268]
The details into which Hippocrates and his school entered in regard to
the operation show that it was frequently performed in their day. It is
very remarkable that many of the more important precautions in the
operation were observed by {587} Hippocrates. We find from the
_Aphorisms_ that the operation was considered the only means of
cure,[269] and that when these precautions were observed, and the fluid
was white and of good quality, the patients recovered.[270] The
principal precautions were not to delay the operation after the
existence of pus was recognized, and to draw off the liquid. He further
states that if the serous fluid in dropsy of the chest or pus in
empyema should be drawn off too rapidly the patient would die. So
impressed were the disciples of Hippocrates by this view that they
adopted the operation of perforating a rib instead of cutting through
the intercostal space, because they could with more ease stop up the
orifice and regulate the outward flow of the fluid. The later
Hippocratians preferred cutting instruments to actual cautery.
Hippocrates, if unable to discover the locality of the fluid in the
thorax by succussion, applied over the walls of the chest a linen
compress which he soaked in earth of Eretria and warm water, and
concluded that the collection existed at the points where the earth
commenced to dry!
[Footnote 268: _Comm. in Aphor. Hipp._, lib. vii.]
[Footnote 269: _Aphorisms_, lib. vii., Aph. 44.]
[Footnote 270: _Ibid._, lib. vi., Aph. 27.]
When these signs failed, he cut through the most prominent rib at the
base of the chest and toward the back. He made a large incision through
the rib, but only a small one the size of a thumb-nail through the
tissue beneath the rib. After allowing a small quantity of pus to
escape, he introduced a tent of undressed flax, with a piece of thread
attached to it. This he withdrew twice daily, to allow the pus to flow.
At the end of two days he permitted the remaining pus to be discharged,
and inserted a tent of linen. To prevent the lung, habituated to the
presence of fluid, from drying too rapidly he injected wine and oil
through a canula. When the excavated fluid was thin (serous?) he
replaced the tent by a tube of tin, and when it ceased to secrete fluid
he shortened each day the length of the tube, so that the cicatrization
of the wound extended from the inner end of the orifice.[271] The
genius of Hippocrates cannot but excite our admiration, as it did
Laennec's, who selected as the subject of his thesis "The Doctrines of
Hippocrates as applicable to the Practice of Medicine." Can it have
been Hippocrates's modes of physical explanation that suggested to
Laennec the idea that led to his great discovery of auscultation?
[Footnote 271: _De Morbis_, lib. i. p. 448.]
Hippocrates's operations were made by boring through the rib or with a
red-hot iron or a bistoury cutting through the intercostal space. Galen
(A.D. 150) had his pyulcon with which to draw out the fluid. Galen and
Roger of Parma bored through the sternum. Many of the ancient surgeons,
such as Eumphon of Cnidos, Paul of Ægina, Celsus, Solinger, divided the
soft parts by caustics and the knife after laying bare the pleura.
Blunt instruments were sometimes used, such as sounds. Celsus in his
latter years lost confidence in the operation, and it fell into
discredit among the Greeks and the Romans, by whom it seems to have
been nearly abandoned. In the Middle Ages the question was discussed
whether it was better to open the chest by steel or by fire in
traumatic pleurisies. Trousseau states that about the sixteenth century
the operation of trepanning the ribs was revived. About the same time
the detersive injections which had been recommended by Galen were again
advocated, especially by Fabrice d'Aquapendente. The operation was
unpopular among the greatest surgeons, and but seldom resorted to
except in extreme cases. Notwithstanding the servile obedience to
tradition in those days, some important points were advocated in regard
to the propriety of allowing the openings for empyema to remain
unclosed for an indefinite period. From the seventeenth to the
eighteenth century the operation of paracentesis was the topic of many
surgical treatises.
Early in the seventeenth century practitioners became less distrustful
of {588} puncturing the chest, and were led to believe in the
harmlessness of the operation (Trousseau). As a consequence of this
tendency, physicians began to study the question of puncturing the
chest in hydrothorax. In 1624, Gérome Goulée alleged that he succeeded
more frequently in hydrothorax than in abdominal paracentesis. Twenty
years later, Zacutus Lucitanus asserted that paracentesis was as
necessary in cases of serous effusion into the chest as incision in
empyema. In 1663, Robin and Duval recommended thoracentesis as the best
treatment for hydrothorax. Some time afterward this practice was put in
force by Willis. Lower also mentions a case, and subsequent authors
quoted these cases as an encouragement to the performance of
paracentesis of the chest for the removal of serous effusions. Jean de
Vigo brought out again the pyulcon. Druin about the year 1665 proposed
the use of the trocar as a substitute for the actual cautery in opening
the chest.
In 1658, Bontius for the first time took up in a precise manner the
subject of the introduction of air into the pleural cavity. He declared
there was no danger from it. Bartholin maintained the opposite opinion.
The indications for the operation were laid down, but they were
necessarily very imperfect. In proportion as attention was directed to
the question of the admission of air, the manner of operating was
modified. In 1669, Scultetus discussed thoracentesis in his work
_Armamentarium Chirurgicum_. He made use of a trocar, with a bladder at
the external orifice, principally to prevent the introduction of air,
as Reybard later used a piece of cat's intestine and a bladder of
gold-beater's skin. Scultetus used the sypho, a common syringe, for
injecting the chest, and also the [Greek: pyoulchon] ([Greek: pyon],
pus; [Greek: elchô], to draw out), or pyulcon, for drawing out matter,
as its name indicates. This was practically the syphon. Scultetus
describes the operation by incision with his gladeolo salicet longo,
and by puncture with the canula et acus, both figured in his plates; so
also his drainage-tubes, with directions for shortening them as the
cavity heals, and the long tubes, which probably acted by gravitation
after the manner of the syphon. Aspiration was made by the mouth, by
cups, and by syringes affixed to a canula or catheter.[272]
[Footnote 272: These facts were kindly furnished me by Morrill Wyman,
who carefully examined Scultetus' work (edition 1672) in the Harvard
Library.]