Medicine. TREATMENT OF PLEURITIC EFFUSION. BY JAS. CUMMING, M.D., Professor of Practice of Medicine, Queen's College, Belfast. The operative treatment of effusion in the pleural cavity has recently been the subject of some important observations. The value of thoracentesis-an operation which dates from the earliest times of medicine- has been very variously estimated by many of the most eminent observers. Laennec seems to have entertained little confidence in its utility Dupuytren performed the operation frequently, and with fatal results in the great majority of his cases, so that in his last illness, when it was proposed to him to allow his chest to be tapped for the relief of a copious pleuritic effusion which existed in it, he is reported to have refused, saying that he preferred to die by the hand of God than by the hand of man. In this country the operation was regarded with little favour, notwithstanding the energetic advocacy of a more extended application of it by Dr. Thomas Davies and Dr. Hamilton Roe. It is to Trousseau probably more than to any other that the more frequent employment of this procedure in recent years is owing. Dr. Bowditch, of Boston, has also performed thoracentesis very frequently, and with great success, and his experience has had much influence in popularising the operation. Nevertheless, there can be no doubt that there is a wide divergence between the practice of physicians in this kingdom and that adopted on the continent with regard to tapping the chest. The opinion prevalent in this country seems to be that thoracentesis is not to be had recourse to during the acute stage of pleurisy, merely in consequence of the effused fluid having reached a large amount, unless other urgent symptoms, such as marked dyspnea, have arisen. On the other hand, Trousseau has laid it down as a rule, that the chest must be at once tapped in all cases in which there is dulness from the base of the lung to the clavicle in front and to the supra-spinous fossa behind, with displacement of the diaphragm, liver, spleen or heart. The danger which he apprehends from this condition and which he regards as rendering the operation imperative, is that of sudden death apparently from syncope. Some doubt has been thrown on the likelihood of this mode of fatal issue being a legitimate result of the disease, and it has been suggested that antiphlogistic measures adopted to combat the malady may have had much to do with the production of syncope. The termination of acute Gairdner, Clinical Medicine, p. 374. pleurisy in sudden death has, however, been too often observed in the abscence of any lowering treatment to render this explanation satisfactory. Quite recently Dr. Sutton* has recorded a case in which death suddenly occurred in acute pleuritis with only a moderate amount of effusion, not exceeding forty ounces. Another case of a similar kind occurred within the cognizance of the writer of this report. Trousseau has suggested that the explanation may be that the displacement of the heart by the pressure of the fluid may cause such a degree of tension of the large vessels that the passage of the blood through the aorta may be materially interfered with, and that as a result of any unusual effort on the part of the patient the circulation may be altogether arrested; or that in some instances it may occur in consequence of the diminished flow of blood through the vessels giving rise to the formation of thrombi in the cavities of the heart. Bartels, who has contributed a paper of great value on the question of the operative treatment of pleuritic effusions, has had several opportu. nities of making post mortem examinations of the changes produced by pressure in the position of the heart and great vessels. He states that the most important effect as regards the circulation is that produced on the intra-thoracic portion of the inferior cava and on the right auricle of the heart, and draws attention to the fact that when effusion takes place into the left pleura it has more influence in producing stoppage of the circulation than when it occurs in the opposite side. In a case of leftsided pleuritic effusion Bartels found that the heart had been pushed to the right side, so that it assumed an almost vertical position with the apex resting on the depressed diaphragm, that the lower wall of the right auricle was folded on itself, and that the inferior cava immediately above its emergence from the foramen quadratum was bent at right angles. This condition of parts must have interfered considerably with the return of blood to the heart, and the effect of any sudden exertion under such circumstances might readily be to altogether cut off the flow of blood through the cava for a short time, and thus bring about a fatal syncope. In many cases of acute pleuritic effusion, it has been found that after tapping the fluid does not again accumulate. Trousseau has recorded. instances of this, and the same fact has been noted by other observers. An interesting caset in which tapping the chest was followed by complete and rapid recovery of the patient, has been quite recently recorded by Dr. Constantine Paul. In this case the enormous amount of above * British Medical Journal, July 17th, 1870. Deutsches Archiv fur Klinische Medicin. Band. iv. Dr. C. Paul. Bulletin Général de Thérapeutique, Dec. 15, 1869. nine pints of fluid were withdrawn from the chest at a single operation. No fresh accumulation took place, and the patient recovered without a single symptom of disturbance from the thoracentesis. Professor Kussmaul reports with great care and fulness the details of sixteen cases in which thoracentesis was performed in his own practice. In six of these, in which the operation was performed under urgent and almost desperate circumstances, permanent recovery followed. Of these six cases five were owing to acute and chronic empyema, and one to acute pyopneumothorax. In a seventh case life was prolonged for a year and a half. In an eighth case, one of acute pleuritis with purulent effusion, the first operation decidedly injured the condition of the patient, probably in consequence of having been too early performed; subsequent operations, however, became necessary, and the patient died phthisical a year after. The ninth case terminated favourably, but not on account of the tapping. The tenth case was an empyema of necessity, with a great amount of pericardial effusion. The eleventh, a similar empyema, with advanced disorganization of the pleura; both these cases ended fatally. The twelfth and thirteenth cases were cases of pyopneumothorax, in which the operation was only performed with the view of paliating the sufferings of the patient, which object was satisfactorily accomplished. The fourteenth case was one of tubercular pleuritis, with hemorrhage at the pleural sac, and was also relieved. The fifteenth and sixteenth were cases of acute pleuritis, with extensive serous exudations, and both ended fatally. It becomes accordingly a matter deserving the serious attention of physicians whether the employment of thoracentesis might not be advantageously somewhat extended in cases of acute pleurisy with very copious effusion, even in the absence of symptoms of an urgent character. With regard to chronic effusion, the arguments in favour of the operation are still stronger, In this country it is not considered advisable to tap the chest in consequence of the presence of the fluid, even in considerable quantity and remaining for a long period, if there is reason to believe that it is of a serous and not of a purulent character. There are several considerations possessing weight which are favourable to the adoption of operative interference at a comparatively early period. Certain changes of some prognostic importance have been found to take place in the ribs and their cartilages in cases of chronic pleuritis. A process of ossification of the cartilages is found to take place even in * Deutsches Archiv, Band. iv. † Parise, Archives Générales. 1849. Wintrich, Die Krankheiten der Pleura. Virchow's Handbuch der Spec., Path. 1855. young subjects, and an enlargement frequently to a considerable extent of the ribs themselves. The effect of these changes may, as has been shown by Bartels, be very prejudicial to a complete removal of a chronic effusion. If the lung is bound down by false membranes so as to be unable to expand, or if the pulmonary tissue itself has undergone such changes as to render it no longer capable of expansion, then the only way in which the pleural surfaces can be approximated so as to obliterate the space between them and permit of the absorption of the fluid is by the yielding of the chest walis. It will be easily understood that the possibility of this yielding depends in a great degree on the elasticity of the parietes, and that any change which increases their rigidity offers an ob stacle which may be an insuperable one to this change of shape, without which removal of the fluid is impossible. Other considerations favourable to an early performance of the operation are derived from the changes which a lung which has been subjected to long-continued pressure is liable to undergo. It is remarkable how completely this organ may retain its power of being inflated even after having been compressed for a long time, but it does occasionally happen that changes occur in its texture which render it no longer capable of admitting air. The false membranes also, which bind down the lung, may undergo a process of development which may render their yielding impossible, and in this way the expansion of the lung may be prevented. It has long been known that a tubercular condition of the lung is one of the causes of pleurisy; there is every reason to believe that the converse of this proposition is also true, and that the existence of a chronic pleurisy may be a cause of phthisis. Nor is this difficult to understand by the aid of the additional breadth which our conceptions regarding the nature of pulmonary consumption have recently received. When one lung is compressed, so as to become useless, the needs of the circulation must throw such an additional amount of work on the unaffected lung as to cause a hyperemic condition of it. This tends to the production of a catarrhal condition under slight exciting causes, and it must be remem bered that the free play of the unaffected lung is seriously interfered with, partly owing to pressure through the mediastinum, partly by the pain caused by the respiratory movements, partly to the interference with the diaphragm by the fluid effused. These are precisely the conditions which favour an accumulation of the products of bronchial catarrh within the lung, and the development of those morbid processes which are now regarded as constituting one of the most frequent forms of pulmonary consumption. It is a fact well known to practical physicians that effusions, which AA there is every reason to believe to be merely serous, will for a long time resist all measures adopted for bringing about their absorption. In many instances they cause no apparent injury to the health or strength of the patient; in others they merely diminish his capacity for exertion, and render him unable to rapidly ascend stairs and the like, but otherwise seem to exercise little prejudicial effect. In such cases the question arises how far a physician is justified in leaving matters in statu quo, after rest and tonics and diuretics and iodine have failed in causing absorption. It cannot be a matter of indifference to the future of a patient to have a dislocated heart or a depressed liver, even if he doe- not suffer from the abnormal condition of these important organs at the time. Besides, there is always a risk that under the influence of intercurrent disease the fluid in the chest may become purulent. No physician would hesitate to remove such an effusion if it could be done without exposing the patient to serious risk. In a case recently under the care of the writer effusion was found to exist in the left pleura, displacing the heart to the right side and causing dulness as high as the clavicle. It had accumulated without any marked chest symptoms, and also without any considerable febrile reaction. When the p tient came under observation he had been blistered over the affected side and otherwise treated with a good deal of activity. Iodide of iron, diuretics, rest, and abundant nourishment were prescribed with no perceptible effect upon the amount of fluid or on the measurement of the chest. The question arose how long it was justifiable to proceed with remedies of this kind under the circumstances. The patient was to all intents and purposes well, but unable to work from the dyspnea which exertion caused, and he had a family dependant on his exertions. Thoracentesis was decided upon, a fine tubular needle was introduced between the sixth and seventh ribs, and 20 ounces of serum removed by suction, by means of an instrument to be described. Two days after a similar amount was removed. The little operations were almost painless, no suffering being caused except by the trifling prick of the needle. No cough or other unpleasant concomitant occurred, and absorption proceeded rapidly, so that in a week the patient left hospital, and in another fortnight very little dulness and no displacement of the heart remained. Professor Ziemssen,* of Erlangen, recommends strongly that thoracent tesis be performed even in cases of non-inflammatory hydro-thorax occurring in connection with cardiac or pulmonary disease, with tumours in the chest, or with Bright's disease, when the pressure on the lungs * Ziemssen, Deutsches Archiv, Vol. v, 457. |