used to evacuate fluid from the pleural cavity. Trousseau says that "at
that period aspiration and suction were used for this purpose--timidly
pursued, in accordance with Scultetus' example; and that it became
afterward in vogue with the masters of surgical art."
Palfin preferred the trocar to incision for treatment of hydrothorax.
In 1707, Anel wrote a book on the art of sucking wounds without using
the mouth. Bourdelin (1742) rejected the trocar for fear of injuring
the lung. That Scultetus' practice was continued is evident from the
work of Laurence Heister (1742), who described puncture of the chest,
with drawings of exhausting syringes for the removal of pus or serum.
In 1765, one hundred years after Druin's use of the trocar, when
perforation by actual cautery was abandoned, Lurde timidly advocated it
on account of his fear of wounding the lung. He advised the operator to
close the canula with the finger at each inspiration, leaving it open
during expiration, so as to prevent the entrance of air. Chopart and
Desault opposed the use of the trocar as a coarse mode of operation,
involving the risk of wounding the intercostal artery and lung
(Trousseau). Van Swieten at the end of the last century questioned the
advisability of using the trocar. Later, in 1796, Benj. Bell,[273] in
cases of thoracentesis, used india-rubber bottles fitted to the opening
for the same purpose, first compressing them and then allowing them to
expand by their elasticity. He strongly recommended paracentesis {589}
of the pericardium when the amount was so excessive as to cause death.
He gives exact directions how and where to operate.
[Footnote 273: Vol. v.]
Isbrand de Diéonerbrock[274] plunged a bistoury between the fifth and
sixth ribs, and introduced into the wound a silver canula large enough
to fit the orifice, and stopped the canula with a tent which he
withdrew each day. Jean Scultetus[275] recommended several different
canulas, some of silver, some of gold. He also invented syringes,
straight and curved, to absorb the pus or make injections into the
chest. Scultetus operated in the sixth intercostal space; he raised a
piece of skin, so that it might lap over the orifice after the
operation. He used a tent until the eleventh day, when he inserted a
canula. After Scultetus, Lamzweerden[276] used suction, and contended
that it was very successful. Paul Barbette[277] considered
thoracentesis as indispensable in empyema and hydrothorax. He
maintained that it was less dangerous than the puncture for ascites. F.
Hoffmann at the commencement of the eighteenth century[278] gave his
full and complete approbation to the operation performed according to
the accepted rules. Dominique Anel[279] was an avowed partisan of the
suction of the effused fluids in the chest. He had seen soldiers very
successfully suck, with the mouth, wounds of the chest. He invented
different syringes and other machines to pump out the effused fluids,
some of which were very large, with canulæ whose orifices were very
wide and of different shapes.
[Footnote 274: _Medic. Morb. Pectoris Hist._, 2.]
[Footnote 275: _Armam. Chir._, Paris, vol. i. p. 20, quoted by
Sprengel.]
[Footnote 276: _Appendix ad Sculpt. Armen_, 1671, quoted by Sprengel.]
[Footnote 277: _Chirurgia_, lib. iii. cap. 2, Geneva, 1688, quoted by
Sprengel.]
[Footnote 278: _Medicina consultatoma_, vol. i., 1721.]
[Footnote 279: _L'art de Sucer les plaies sans se servir de la bouche
d'un Homme_, Amst., 1707.]
Laurence Heister[280] (1742) acknowledged that Anel's syringes were
valuable in pumping out the fluid from the middle or lower part of the
chest, but not when paracentesis was performed in the higher portions
between the second and third ribs. Heister gives[281] drawings of
exhausting syringes for the removal of pus or serum. C. G. Ludwig
published[282] a new apparatus invented by a surgeon named Bucer to
pump out the fluids contained in the chest. This machine was composed
of canulæ, to which was adapted a bowl to receive the liquid as it was
withdrawn. Ludwig claimed that the especial advantage of this
instrument was that it pumped all the fluid out at one time, without
the operator being annoyed by any disagreeable odor. Leber[283]
proposed a similar instrument which was easier of application. A. T.
Richter demonstrated the inutility of all these inventions; the blood,
he said, would be drawn out with the fluid and by coagula stop up the
canula. Valentin (1772) objected to the use of these pumps as applied
to chest fluids.
[Footnote 280: _Chirurgie_, Th. i. Buch. i. Kap. 10, p. 89.]
[Footnote 281: _Ibid._, p. 72.]
[Footnote 282: _Diss. de Vul. Pectoris_, Leip., 1768.]
[Footnote 283: Quoted by Sprengel, p. 60, vol. ix.]
In the latter part of the eighteenth century there were numerous
English and continental writers on the subject of paracentesis. Among
them were J. W. Belquer, Sharp Mohrenheim, Richter, Ponteau, Callisen,
Pierre Cooper, Allemoth, Zellar, and Audouard. Some of these preferred
the trocar to the bistoury. Some were in favor of prompt action, and
others objected to the operation unless there were threatening
symptoms. Valentin urged that the presence, on the surface of the
chest, of oedema and ecchymosed spots was a certain indication of fluid
effusion.
During the first twelve years of this century the operation seems to
have fallen into disuse. In 1808, Audouard objected to the Hippocratian
method, which had been practised for centuries, of drawing out small
quantities at a time, for fear that the sudden withdrawal of a large
quantity would produce a vacuum in the chest. He maintained, and
proved, that sudden and {590} complete evacuation had no such result.
In 1811, Corvisart[284] drew attention to thoracentesis. In 1812,
Larrey discussed its merits. Charles Bell[285] preferred the trocar to
the other methods in hydrothorax when he could be positive of the
presence of fluid, but he stated that he preferred first to introduce
the bistoury. He operated in the sixth intercostal space, but in
empyema he preferred to make the puncture higher up. Samuel Cooper[286]
recommended as small an orifice as possible for the evacuation of
serum, but larger and wider ones for pus and blood.
[Footnote 284: _Maladies du Coeur_, 1811.]
[Footnote 285: _System of Operative Surgery_, vol. ii. p. 194.]
[Footnote 286: _Dictionary of Surgery_, p. 749.]
In tracing the history of this important operation we have shown that
it has been performed from the time of Hippocrates, and that it has
been held in different degrees of estimation by the numerous authors
who have discussed it--that sometimes it has been popular, and again
regarded unfavorably.
Récamier operated, but unsuccessfully. Up to the period we have now
reached (1816) great difficulty of accurate diagnosis existed, and
crude notions of physiology prevailed. Errors of diagnosis as to the
character of the fluid when present, and still more as to its existence
in the chest, frequently led to unpleasant results. Laennec's genius so
completely cleared up the differential diagnosis of all diseases of the
chest, including pleurisy, that men grew less timid. Laennec[287]
himself was a strong advocate of the operation; he advised it in acute
pleurisy where dyspnoea, threatening life, supervened, and in chronic
cases where other remedies failed. He proposed to apply a piston
cupping-glass over the wound after the discharge of liquid, and to
produce a vacuum in the chest more or less quickly, continuously, and
completely according to effects.
[Footnote 287: _Traité d'Auscultation mediate_, 1818.]
As Bowditch[288] states, "We should be groping in the same dark way,
and perhaps getting into the chest by caustic pastes or by actual
cautery, had not Laennec discovered for us auscultation, with all its
admirable powers of diagnosis of thoracic affections."
[Footnote 288: Unpublished communication to the writer, 1882.]
In 1815, Blondel practised puncture of the chest with a bistoury.
Gendrin performed the same operation in acute pleurisy in 1831, but
with only bad results. Townsend[289] (1833) acknowledged that the
operation had fallen into disuse, as much from uncertainty of diagnosis
as from any experience of its general danger. He gives the results of
Thomas Davies's operations--8 out of 10 successful cases in empyema,
with 9 fatal cases in pneumothorax with effusion (probably tubercular),
and 3 fatal cases in hydrothorax. Davies used a grooved needle to
determine the presence of the liquid, its quality, and the thickness of
the walls. After the operation his practice was to inject a weak
solution of chloride of lime, which he found to have the effect of
diminishing the discharge and correcting its character. Crompton[290]
(1834) had 3 successful cases out of 10.
[Footnote 289: _Cyc. Prac. Med._, vol. ii. p. 43.]
[Footnote 290: _Ibid._, vol. iii. p. 400.]
Robert Law[291] pronounced paracentesis more successful in chronic than
in acute pleurisy. Townsend doubts whether the admission of air was
hurtful; he quotes Nysten and Spies's experiment, showing that air
introduced into healthy pleuræ was invariably absorbed in a few days.
[Footnote 291: _Ibid._, 1834.]
Townsend[292] and Law, as well as C. I. B. Williams,[293] speak of the
different kinds of syringes that have been proposed to draw off the
fluids.[294] Dupuytren proposed (1814) the introduction of a small
canula with a very flexible substance at its outward extremity, such as
the bladder of some domestic animal, which would allow fluid to escape,
and at the same time would oppose the entrance of air into the chest.
Becker (1834) published a work in which he investigated the nature of
the false membranes in pleurisy, and showed that the {591} access of
air did not produce unpleasant results. He reported 2 successful cases
out of 3 of operation.
[Footnote 292: _Ibid._]
[Footnote 293: _Library of Pract. Med._, 1841.]
[Footnote 294: Boyson, _Thèse de Paris_, 1814.]
R. Townsend[295] wrote an elaborate paper in 1833 on empyema, in which
he applied the principles of physical diagnosis. He cites numerous
cases of thoracentesis, and speaks of the operation as easy of
execution, productive of little pain to the patient, generally followed
by immediate relief, and as having been in numerous instances crowned
with complete success. Robert Law[296] (1834) speaks discouragingly of
the operation in consequence of the "unavoidable admission of air into
the inflamed cavity." He considered the operation of tapping the chest
more likely to be successful in chronic than in acute pleurisy.
[Footnote 295: _Cyclop. Prac. Med._, vol. ii., 1833, London.]
[Footnote 296: _Ibid._, vol. iii., 1834.]
In 1835, Faure[297] read his paper on thoracentesis before the Academy
of Medicine of Paris, which attracted a great deal of attention.
Contradictory opinions were given by prominent members as to the value
of the operation. The debate was prolonged, and no definite conclusion
was reached. Laennec, although he had recommended the operation in
excessive effusions and in chronic cases, was yet timid, and his advice
had not the overwhelming influence that it should have had. Becker of
Berlin in 1834 wrote his paper on chronic pleurisy, in which he also
laid down the principles of diagnosis by means of auscultation and
percussion. He detailed 5 cases which he had operated upon. To Thomas
Davies is due the credit of having in 1835 recommended the use of the
exploring-groove needle to ascertain the nature of the pleuritic
effusions, but Powell claims that Sir Benj. Brodie first suggested it.
Ringer first recommended the use of the hypodermic syringe for that
purpose. Stokes[298] insisted upon the evils attending paracentesis,
among which he mentions the converting of serous into purulent
effusions.
[Footnote 297: _Bullétin de l'Académie de Médecine_, 1838, tome i. p.
62.]
[Footnote 298: _Dis. of Chest_, Dublin.]
Watson's lectures on practice, delivered in 1836-37, show that while he
was much interested in the operation, the necessity of which he
discusses with his characteristic ability, yet his conservatism led him
to put prominently forward the dangers and evils connected with it.
According to these two prominent English practitioners, only imminent
peril to life justified the operation. Guérin[299] in 1841 applied his
subcutaneous method of operation to empyema. He drew fluids from the
chest by a suction-pump applied to a canula, using a curved trocar and
canula to prevent injury to the lung.[300]
[Footnote 299: _Essai sur la Méthode Sous-cutanée_, Paris, 1841.]
[Footnote 300: Drawings of the trocar and canula, with the aspirators,
are shown in Jacob and Bongeré, _Med. operatoire_.]
Reybard in 1837 took up Dupuytren's suggestion, and used gold-beater's
skin as a valvular means of excluding air at the mouth of the canula;
this is now known as Reybard's canula apparatus, and was the one used
and highly recommended by Trousseau. Stanski in 1839 invented an
apparatus for drawing off air from the chest, working on the principle
of aspiration. Bowditch states[301] that while in Paris from 1832 to
1835 he never saw a case of pleurisy in Louis's, Chomel's, Andral's, or
Trousseau's wards where thoracotomy was performed or even suggested.
Medical opinion was either indifferent or in actual opposition at that
time. H. I. Bowditch of Boston relates[302] that he saw 2 cases of
effusion in the pleural cavity in 1839, in which he proposed
thoracentesis, but the surgeons would not operate: both of these
patients died. He was convinced at the time that their lives might have
been saved. Schuh of Vienna published his work on the _Influence of
Auscultation and Percussion on Practical Surgery_, in which he boldly
maintained that paracentesis was a radical cure in cases of chronic
thoracic effusion, no matter how originating. This work had a great
influence in advancing {592} the popularity of the operation of
thoracentesis. Subsequently, Schuh and Skoda, both professors at
Vienna, published[303] a monograph on the treatment of pleurisies,
especially by surgical means, which, as Trousseau acknowledged, has
become a classical work in Germany, and occupies a distinguished place
in the history of paracentesis of the chest. They admitted that when
the effusion is not excessive in quantity, and there are no
complications, recovery generally takes place. When the effusion is
excessive even, it may in time disappear, but it may prove a matter of
months or years. They advised that the operation should be performed
when there was no marked improvement for three weeks. These authors
refuted the arguments urged against the operation, and gave details as
to the mode of operating. The Germans were the first to consider the
puncture as a means of radical cure in pleuritic effusions: Becker,
Schuh, and Skoda gave it a decided impulse. Hope's[304] paper
endeavored to prove that pleuritic effusions did not require surgical
interference, but would yield to general treatment.
[Footnote 301: Unpublished MS., 1883.]
[Footnote 302: _American Journal Med. Sciences_, April, 1852.]
[Footnote 303: _Medicinische Jahrbücher der K. K. Oesterreich Staates_,
1841.]
[Footnote 304: "Notes on the Treatment of Chronic Pleurisy," in
_Medico-Chir. Review_, London, 1841.]
Thus we see that up to 1841 these unsettled controversies over the
dangers and advantages of the operation were still going on. Fred.
Bird's results in 1843 proved the possibility of its successful
employment, doubted up to that time in England. Trousseau's attention
was strongly drawn to the necessity of the operation of thoracentesis
as early as 1832, when he attended a case at the Hôtel Dieu that died
from excessive pleuritic serous effusion. Louis, from the observation
of 150 cases of simple pleurisies that had recovered, had enunciated
the law that pleurisy is never the immediate cause of death. This fact,
together with Récamier's want of success, had so prejudiced the minds
of French practitioners against the operation that it was loudly
condemned in acute cases of effusion and in all cases of hydrothorax.
Having no fears of fatal termination in pleurisy, they saw naturally no
necessity for surgical interference. Trousseau states that it was not
until after he had witnessed three patients die from acute pleurisy
that he ventured to operate (Sept. 11, 1843). He did not summon a
consultation, for fear of being thwarted. It was so successful that he
was emboldened to operate without hesitation. After his third operation
he read his memoir to the Academy of Medicine in 1843. Trousseau in
these memoirs maintained the proposition which extensive observation
has now after forty years fully sustained, that dyspnoea and orthopnoea
may occur when the effusion is in moderate quantity, and that they may
be absent when the effusion is considerable, especially if it has
formed slowly. Furthermore, that the signs that constantly indicate the
gravity and imminent danger of effusions, and which consequently demand
the operation, are the displacement of the heart (whence results
syncope), displacement of the mediastinum, depression of the spleen and
of the liver, acceleration and feebleness of the pulse, and an anxious
countenance.
The next year (1844) Trousseau read another memoir on the same subject.
He used the trocar with Reybard's gold-beater's skin at the orifice.
While he was popularizing the operation and laying down the indications
which called for its performance, several English observers[305] were
turning their attention in the same direction. The paper by Hughes and
Cock[306] showed that they had been operating in Guy's Hospital for
four or five years, and with great success, using a simple trocar and
canula of the diameter of one-twelfth of an inch. They imputed their
success to the small size of the instrument used, which allowed the
fluid to flow slowly and never permitted air to enter the chest during
respiration. They gave a tabular account of 20 operations. Hamilton
Roe[307] at that time was operating successfully with the trocar. {593}
Roe's paper was replete with information and with practical
suggestions. He tabulated 39 cases where syncope (one great objection
which had been urged against the operation) did not occur even once. He
disproved another popular objection, that there was great danger of the
admission of air into the pleural sac. Owing to the size of his trocar,
a considerable quantity of air entered the pleura during his
operations, and in some of them so freely as to produce all the
physical signs of pneumothorax, but in none of them did it produce any
permanently evil effects. In one instance only was even temporary
inconvenience caused. When the fluid was ascertained by the
exploring-needle to be purulent, he advised the immediate performance
of the operation. In acute cases he recommended a delay of three weeks
as the time for testing nature's powers of absorbing the fluid. He
advised the closing of the orifice after operation. This author gave an
account of his 24 cases. He concluded by stating that the operation is
not more dangerous than any other which is performed upon the human
body, and that the evil consequences supposed to attend it are
imaginary rather than real, inasmuch as it was only fatal in 1 out of
24 cases, and does not produce even temporary inconvenience. Thompson
in the same year justly condemns the practice of leaving the canula in
the orifice--a proceeding he considers as capable of converting a
serous into a purulent fluid. In 1848,[308] at the request of H. I.
Bowditch of Boston, J. M. Warren operated by the usual method
recommended in the works on surgery. Partial relief was obtained, but
the amount of suffering undergone by the patient during the operation,
and the fact that an aperture was usually left open by this method,
decided Bowditch that he would never recommend it unless under very
urgent circumstances. Soon after this, Stone operated with the common
trocar and canula, by the advice, in consultation, of Bowditch. In
1849, Bowditch saw another death resulting from effusion where he had
advised the operation, but the consulting surgeon would not consent.
[Footnote 305: _London Medical Gazette_, 1847.]
[Footnote 306: _Guy's Hospital Reports_, vol. ii., 1844.]
[Footnote 307: _London Lancet_, 1844, copied into _Amer. Journal Med.
Sciences_, Oct., 1845.]
[Footnote 308: Bowditch, _Amer. Journal Med. Sciences_, April, 1852.]
To illustrate the opposition Bowditch found in the United States, he
quotes[309] a remark of W. W. Gerhard, the distinguished auscultator of
Philadelphia, "that he should be as willing to have a bullet shot
through his chest as to have paracentesis performed on one of his
patients."
[Footnote 309: Unpublished MS., 1882.]
About 1850,[310] Bowditch saw the paper published by Hughes and Cock,
and it determined him in future to try the trocar they had used or
something like it.[311] "Fortunately, a few weeks before (April 10,
1850) M. Wyman had a sudden and severe case with large effusion and
intense orthopnoea. Death was threatening, yet Wyman felt called upon
by public opinion, medical and lay, to summon a prominent practitioner
from Boston. They both agreed that the patient was in extreme danger,
and Wyman urged tapping with an exploring-trocar. It was decided to
postpone surgical interference until next day, when another meeting
would be held, the consulting physician returning to Boston to advise
with the ablest men of the faculty and render their decision the
following forenoon. That was done, and it was found that no prominent
practitioner in Boston would consent to the idea of tapping.
Nevertheless, the oppression was so severe, and death so imminent
unless the patient could be relieved by some means, that the country
physician agreed to Wyman's proposal that an exploring-trocar should be
introduced. The fluid flowed out imperfectly, but some relief and no
harm resulted" (Bowditch). Two days after this, Wyman operated again
with the exploring-trocar and a suction-pump. Wyman[312] demonstrated
to John Homans on the 23d of February, 1850, that the chest could be
safely punctured with his instrument and the serum evacuated in acute
pleurisy.
[Footnote 310: _Ibid._]
[Footnote 311: _Ibid._]
[Footnote 312: Private letter to author, 1883.]