This is a fact which we cannot and should not ignore.
It is to be much regretted that we have no satisfactory records to show us what is the normal course of pleuritic effusions-moderate and large-without treatment. The tendency is probably to a spontaneous subsidence-quoad the effusion per se- and the great practical question is whether, by the administration of drugs or operative interference, we can materially hasten the cure. It is now generally admitted that many of the methods of elimination formerly in vogue by the Old School are either useless or injurious.
The testimony of those employing early puncture or advocating early operation gives a far different note of hope to the aggressive element in the profession.
The great question, then, for us in this connection to settle is, not whether aspiration should be performed, but how soon must it be done?.
In certain cases where the effusion is large and the dulness ascends as high as the second rib in front, or if the measurement of the affected side be markedly increased, much dyspnoea, etc., the advantage of aspiration cannot for a moment be disputed.
I maintain that we should not allow our patient to come to such a pass.
Those cases which present the most difficulty of decision are where we have a moderate effusion with or without fever and with or without dyspnoea or other disturbing symptoms. In such cases the inquiries arise: 1. Does aspiration lessen the chance of a speedy or remote fatal issue? and 2. Does aspiration shorten the duration of the disease, with the immediate prospects of restoring the affected parts to a condition of perfect physiological action?.
The first question may be somewhat summarily dismissed as to a sudden fatal issue where the effusion is moderate, but as to a remote fatal issue, where the accumulation has been in existence some time, our judgment must be reserved.
The second inquiry is a very interesting one, but the difficulty of absolutely determining it is very great.
It seems to me that the duration of the malady, in answering the second query, must first be taken into consideration.
In cases of several weeks’ standing I believe the lung-and ergo its pleural surface-never returns to a healthy condition.
We must take cognizance, though, in this discussion, of the literature dealing with it. It must shape the judgment of the inexperienced and give a strong support to the man of large experience either pro or con.
One practitioner inclines to tap early in all cases, and to repeat it, if necessary, and his statistics will show the greatest number of recoveries and the shortest duration of illness. His remote results will be the most satisfactory fro a medical, surgical and prognostic point of view.
Another practitioner reserves operation for serious cases with large effusions, or for chronic or semi-chronic cases. His remote results will be the most unsatisfactory from a medical, surgical and prognostic point of view.
In empyema most writers agree that aspiration is not the method to employ, but that free incision, with drainage, is the recognized operation in American and the results quoad vitam are most gratifying.
In children we should note the marked tendency for pleuritic effusions to becomes purulent.
As a summary we would state:.
I. That aspiration carried out antiseptically in any stage of pleuritic effusion is not a dangerous procedure.
II. More people die from a postponed aspiration than from any operative interference.
III. Anstie and Weber have shown that organization of the fibrinous portion of the effusion can proceed very slowly and imperfectly when the two pleural surfaces are allowed to play on each other. Effusion separating the two surfaces hastens the formation of neo-membranes.
IV. Aspiration shortens the illness to fourteen or eighteen days.
V. Pleuritis without operation and with moderate effusion lasts seldom shorter than three weeks, and from that up to two months.
VI. With aspiration, the lung pleurae in very recent cases return to a physiological state.
VII. In semi-chronic, chronic and purulent effusions portions of the pleura and lung are permanently damaged and lead to one form, perhaps the most frequent, of phthisis.
VIII. Early aspiration is growing in favor, and I have witnessed several brilliant cures in my own practice and that of others.
IX. In three cases of large effusion seen in consultation, the operation being postponed until the following day, the patient has expired suddenly in the night.
DISCUSSION.
OSCAR LESEURE, M.D.: I am heartily in sympathy with the principles advanced in Dr. Schley’s paper, and will refer to them specially from the surgical standpoint.
I have failed to find an authority who does not admit the fact that the sooner a lung oppressed by pleuritic effusion is relieved from compression, the more completely will that lung be restored to its normal anatomical and physiological condition.
The opposition to early, or any, operation for the relief of pleuritic effusions (and in this sense I refer to serous or sero- fibrinous effusion and the operation of aspiration) is based mainly upon the accidents which have accompanied or immediately followed the operation, and which have very unjustly, in many instances, been attributed to it, or on the accidents which might theoretically complicate the process.
It is true that the mortality accompanying the early history of thoracocentesis was discouraging. Boyer and Gendrin lost 100 per cent.; Dupuytren, 96 per cent.; Davis, 33 per cent. (Donaldson). But from the time when Trousseau urged and practiced thoracocentesis with the trocar of Reybard, and Bowditch first used the method of aspiration, down to the present day, the statistics of the operation have so improved that Matas, in 1892, records over one thousand cases without a death.
Of the more important accidents attributed to the operation, we may enumerate the following: Injury to the intercostal vessels and nerves; injury of the liver, peritoneum, heart, or lungs; syncope; cerebral accidents, as paralysis and convulsions; cough and albuminous expectoration; purulent transformation.
We many dismiss the question of injury to the intercostal vessels and nerves by saying that, given a knowledge of their location, the average intercostal space, a proper instrument and reasonable skill, the objection should have no weight.
Injury to the liver, peritoneum, heart, or lungs we cannot dismiss so lightly, for, with the distinguished names of Aran and Claude Bernardo associated with these accidents, we must admit their importance. Still, with the advanced knowledge and improved methods of to-day; with the results of experience in selecting the point of puncture; also the proof from the statistics just quoted, we may consider the importance of this objection to be in its warning to the operator.
Of four cases of syncope occurring at the time or immediately following the operation, analyzed by Vergely, Guyot, Chaillou, and Besnier, one was due to heart clot, one to pulmonary embolus, one to phlebitis and thrombosis, and one to pulmonary gangrene. Bowditch and Donaldson have also attributed the accident to the complications existing at the time of the operation.
This accident might be due, also, to a too rapid evacuation of the fluid, thus suddenly depleting the cerebral vessels. A skilful operation will, therefore, remove the only just part of this objection.
Cerebral accidents are: paralysis, due to an embolus not directly traceable to the operation, or convulsions possibly due to a disturbed intracranial pressure, in turn attributable to a too rapid or complete evacuation of the effused fluid.
Cough, with albuminous expectoration, due to acute oedema of the lung, is justly charged to the operation, but is a dangerous condition only when the operator rashly disregards the warning which is given him, and which was so clearly described in the interesting paper presented to you by Prof. Biggar on Wednesday evening. I refer to the irritating cough, sometimes accompanied by dyspnoea, which may occur during the evacuation of the fluid. That it is an acute oedema of the pulmonary tissue has been demonstrated by Herard, Dieulafoy, Lavaran, Tissier, Moutard- Martin, Dujardin-Beaumetz, and others, and by them ascribed to a too rapid removal of the intra-pleural fluid, which, in turn, produces an extensive congestion of the lung suddenly freed from pressure.
Purulent transformation of the fluid remaining after aspiration is the objections most strenuously advanced by surgeons who oppose the operation. Late microscopical and bacteriological researches promise to prove the predictions of Fraenkel and Netter to be well founded, viz., that an early examination of the fluid effused will determine whether it is to remain a serous fluid or whether it is to become a purulent fluid.
The observations of Dieulafoy allow him to state that when the fluid contains five thousand (5000) or more red blood globules to the cubic millimeter, empyema will be the result. More important, and later, are the researches of Baviere, who has demonstrated the presence of the streptococcus in a certain number of cases, the pneumococcus in others, and the bacillus tuberculosis of Koch in others. In the majority of cases he found no bacilli. His conclusions, based on a large number of cases, are as follows:.
