TWO articles appearing recently-the one by Dr. Barrs, in the British Medical Journal, dealing more especially with the dire results of pleuritic effusion, the other by Dr. Lindsay, in the Lancet, touching more on the advisability of early interference in such cases-have brought out very suggestive points for us to consider.
It is, however, with some hesitation that I have undertaken to direct the attention of this Society to so familiar and well nigh hackneyed a subject as pleural effusion and empyema. I feel somewhat at case, though, in doing so, because the disease in question, however familiar, possesses and exceptional clinical interest, and because there are many points in its ultimate pathology, perhaps aetiology-and more especially its treatment- around which much controversy has raged and is still raging. It is out of the question to handle exhaustively so vast a subject as pleural effusion and empyema. I will therefore limit my remarks.
There can be no doubt, in my opinion, that there is a strong and growing tendency to employ operative measures by those who see much pleurisy, and who are able to keep track of these sufferers for months or years after their original attack.
It is only in this collective method that we shall be able to speak pro and con for early operative methods.
As the best thinking and scientific minds of the Old and some of the New School are busying themselves most with preventive medicine, and then with curative medicine, it seems to us that a more fitting field for such investigations does not exist than in the one under discussion.
In orthopaedic surgery much has been learned and discovered within the past ten years-recognizing disease early (by experts), by suitable appliances rectifying deformities, and if they already exist, minimizing them to a marked degree.
In pleurisy a similar picture should the presented.
Unrecognized pleurisy, or pleuritis with effusion, maltreated leads to a maiming of the lung, its disability to perform more than one-third of its proper work, phthisis and lateral curvature of the spine, etc.
Curative medicine, then, in such cases must be looked for in two directions: first, as a power to promote recovery from injury of external origin; secondly, as a power to mitigate or remove diseases arising within the body.
And again, we are led in such cases by our old habits of thought to regard life as a thing of the body alone, and to forget that life lies between the body and the medium, and is, as it were, a play of activities between two surfaces, so that the medium needs as much curative vigilance as the body does, and is far more within our power and comprehension.
Therefore the prominent, and often even exclusive, place given to the administration of medicines and the swallowing of drugs is not only questionable, but positively mischievous, in so far as it leads the public, not to mention ourselves, to attach primary importance to measures at best auxiliary, and in so far as it blinds us to the far greater importance of studying the earlier and lesser deviation of function, and of readjusting the conditions under which the individual lives exist.
Those of us who may have made many post-mortems or witnessed them attentively, must have been impressed with the great frequency with which adhesive pleuritis was met.
And it seems to me that it matters little where these adhesions are found, but that they must represent just so much mechanical interference with the act of respiration and interchange of oxygenation during the act of respiration.
To properly understand the gravity of all pleuritic effusion we should appreciate somewhat the pathology of such cases.
The changes which take place in an inflamed pleura are essentially the same as those met in other serous membranes. The earliest stages are indicated by capillary congestion, and sometimes ecchymotic spots in the subserous tissue, with extravasations of blood into the pleura itself; the membrane then loses its smooth, glossy surface, becoming rough, dull and opaque, and is soon covered by a delicate gray deposit, consisting of fibrin, epithelium and young cells, and as this deposit increases apparently layer by layer, it becomes yellowish in color.
These changes are observed both on the parietal and pulmonary pleura.
In the rare cases in which a more or less diffused pleuritis stops here, and is not followed by liquid effusion, the inflammatory products are either entirely absorbed, or-which occurs most frequently-the opposing surfaces become adherent in whole or in part by organized connective tissue, and the sac is obliterated over the adherent areas.
Complete obliteration over the bases is seen chiefly in severe and long standing cases, where absorption has been left to its own judgment, or after empyema.
Mehu and Laboulbene have justly maintained that the ultimate recovery of the patient will proceed more slowly or more rapidly, according as the exudations are more or less fibrinous.
The next step to congestion and fibrinous exudation is the effusion of fluid.
All pleuritic effusions lead naturally to a number of local and general pathological conditions, partly owing to the quantity and quality of the exudations themselves, and partly in consequence of the changes which these exudations gradually undergo. The amount of the exudation will limit the amount of the compression of the subjacent organs, as the mediastinum, the opposite lung, the great venous, arterial, and nervous trunks, the diaphragm, the chest wall, liver, stomach, etc.
In fibrino-effusions-which frequently met with at the onset of all pleurisies-recovery commences in most cases by the gradual concentration of the exudation. In consequence of this the absorption proceeds much more rapidly at the beginning than it does later on. Finally, the fluid portion of the exudation may entirely disappear, and the pleural surfaces, roughened by deposits, come again in contact and often become fused together.
If the process of absorption sets in sufficiently early, the compressed lung again becomes permeable to air and re-expands.
We must still form an accurate idea of the anatomical changes which arise in those chronic cases in which the exudative deposits become organized into connective-tissue masses.
In the course of the pleuritis we not repeated exudations taking place which undergo organization, harden, and finally are found in layers sometimes an inch in thickness.
The serous and sub-serous tissues are often merged into this new formation, and are hard to distinguish from it.
If the pleura pulmonalis is affected, it always appears thicker on section and shrunk on the surface.
This leads to a shrinking and retraction of the subjacent lung tissue, the hilus of the lung forming the centre of the retraction, while the margins of the lung become rounded by this pleuritis deformans.
This retraction leaves a free space in the pleural cavity which becomes filled with fluid, which has little chance of being absorbed the thicker the two pleural surfaces become. The pleura, in such a state, rapidly loses its absorbent power.
Thus the capability of expansion in such a lung is forever last.
Again, if the pleura becomes covered with thick false membranes while there is still considerable effusion in the pleural cavity, and before its absorption has been possible, this circumstance hinders its further absorption, and the remainder of the exudation may thus remain for months or years encapsulated.
The thicker and more fibrous the false membranes, the less vascular are they.
This organized false membrane sometimes assumes a pyogenic character, from which pus is continuously secreted. When the fluid effused in the earlier stages of the disease becomes absorbed and no new liquid (serous or purulent) effusions are poured out between the layers of exudation, the lung must, in such cases of pleuritis deformans, diminish more and more in size.
The adjacent movable organs, as well as the thoracic walls, must contribute to the filling up of this vacuum.
The different character of the effusions, whether serous, sero-fibrinous, purulent or haemorrhagic, all have their important significance.
Anstie and Wagner, from clinical and microscopical work, have found that these false membranes develop more freely at first when the opposing surfaces are kept apart by the effused liquids. The running of the two pleurae together seem to impede the process of organization.
Wagner betones the fact that these newly-organized and vascular tissues often become the starting-points of fresh inflammatory processes and of new products.
The question, then, now which presents itself to us, after digesting the foregoing opinions of the most reliable authors upon the constant tendency for pleuritis with effusion to leave the lung damaged, is, whether we should be satisfied with remedial measures until the patient is nearly in extremis, or shall we, by a timely and simple operative procedure, speedily restore our patient to perfect health by removing in exudation which is seldom able to leave the organ as it found it.
