1. Early aspiration.
2. If the pneumococcus or bacillus of Koch is found, the puncture is to be repeated if the fluid persists or increases.
3. If the streptococcus is found, resort at once to pleurotomy.
Briefly, as to the technique of the operation already described in our presence by Prof. Biggar:.
The weight of opinion is in favor of the sixth intercostal space in the middle axillary line as the point for puncture.
The instrument, in aspirator, with the special trocar of Potain or Frantzed to avoid wounding the lung.
Use absolute asepsis. Withdraw the fluid very slowly. Do not withdraw more than a quart at one operation. Stop the moment the patient complains of pain, or enough or dyspnoea appear.
JOHN W.D. DOWLING, M.D.: After reading Dr. Schley’s able argument in favor of early operation in cases of pleurisy with effusion, it is difficult to open the discussion when one is in almost complete accord with the views expressed. I have seen too much of the ill effects following delay in these cases, the delay in some cases being due to timidity and in other cases to failure to recognize the actual conditions present.
The disadvantages of delay are many, and by far the most important at these, to my mind, is the fact that every day’s persistence of the fluid in the pleural cavity adds to the chance of that fluid becoming purulent, thus creating an empyema out of a simple serous effusion, or sero-fibrinous perhaps more frequently than simple serous. Every one admits that an empyema is a more grave condition, and it seems negligent to fail to resort to operative measures early, the result being the not unlikely development of the more serious condition, with its consequent dangers to the life of the patient.
As your speaker has said, many are not in favor of operation when moderate effusion remains unabsorbed. It seems clear, that if the consequences of the prolonged presence of this fluid were properly considered, the number of those who hold this opinion would be materially diminished. The presence in the pleural cavity of even a moderate amount of serous fluid necessitates the compression of part of the lung on the affected side, with a retraction of the lung as well. By this compression, air cells are obliterated entirely and portions of the lungs rendered almost impervious to the entrance of air further than the bronchi and larger bronchioles. The circulation is interfered with and slowed.
From what we know of the conditions favorable to the development of tubercular processes in the lung, we see that the conditions required are thus produced, and though the effusion may eventually be absorbed, the chances are, that more serious trouble of the nature to will have had an opportunity to develop. Even failing this, the lung thus for a long time unable to expand will refuse to do so when the opportunity does come, and there will be a permanent coupling of the lung, and not uncommonly a visible deformity of the chest as well.
The shorter the time the lung has been compressed the more as well. The shorter the time the lung has been compressed the more readily then will it expand if the compression be removed, and the earlier the operation is performed, even though necessarily repeated, the greater chance will there be of restoration in perfect function.
I would differ with Dr. Schley in his statement that the operative procedure will speedily restore our patient to perfect health. It is too sweeping a generalization. Many times early removal of the fluid will do this, but in my experience cases not infrequently arise where the removal must be repeated, not once only but several times, the disease lasting over a considerable period. I agree with the practice of early operation, but am not so sanguine as to its inevitable, favorable and speedy cure. Occasional and experience has taught me this.
The presence or absence of orthopnoea I do not consider a reliable indicator by itself for operation or delay. In many cases the accumulation has been so gradual that a considerable degree of toleration is attained, the patient being able to lie down without distress, and even to endure moderately gentle exercise without extreme dyspnoea. If orthopnoea be present, operate at once, but if it be absent, try to see if you cannot find other indications for operating, and if you cannot, operate, anyway, and I believe your results will give you reasons for early operation in succeeding cases.
As to whether the operation should be that of aspiration or free incision should be determined by the character of the fluid. If serous of even sero-fibrinous, aspiration would be indicated. But if purulent, particularly i children, the recovery of a number of cases after free incision has been performed, the immediate improvement consequent upon the complete removal of the pus, an impossibility where aspiration is resorted to, and the case with which further accumulation is prevented by the establishment of free drainage, all speak loudly in favor of this method, and in these cases it would seem to be almost certainly indicated.
A.A. WHIPPLE, M.D.: I want to agree in the main with all that has been said in the first paper and in the discussion. I would like to state a case that happened to me three or four years ago which I left in other care during a brief absence. When I returned I found the boy just ready to die. He was fourteen years of age. The father and three or four brothers or sisters died of consumption and some two or three of his uncles and aunts. He had hectic fever, high temperature, and all the symptoms pointing to empyema. Without any hesitation I made a free incision between the fifth and sixth ribs, removed three quarts of offensive matter, put in a drain-age-tube and syringed as thoroughly as possible, and followed that up for a few days, morning and evening.
The temperature came down considerably, but the case not being satisfactory I put him under chloroform and made another incision between the eighth and ninth rib, put in another drainage-tube, and followed that with free syringing, using peroxide of hydrogen. I used it frequently, throwing it in at the upper tube and letting it run out of the lower. He made a good recovery, and in a not very long time. But the fact was it ought to have been operated earlier. It was on account of my absence from home that this was not done. In several instances I have operated early and have always found it best.
W.H. BURT, M.D.: It seems applicable, while on this subject, that I should show you a new instrument that I have just devised for examination of the lungs. Heretofore our instruments have been made principally of rubber, and rubber is a very poor conductor of sound. I have devised an instrument made wholly of metal, and with the use of the ball and socket joint we get every motion we want, and I am pleased to state that it carries the sound ten-fold better than any other device up to date. I simply want to exhibit it to the members of the Society at this time. The paper that has been read here I can heartily endorse.
E.R. EGGLESTON. M.D.: It seems, ladies and gentlemen, that I am to take up the unpopular side of this question. Is pleurisy to be treated by surgical means exclusively?.
That is the question I would like to have answered. So far neither in the papers nor in the discussions has a single word been said about the Homoeopathic remedy. I claim this: that under the proper use of the proper remedy administered at the proper time and place and under the proper conditions the trocar becomes obsolete. So much for that.
Now, I take exception to the philosophy of the paper. Let us see. An inflammation has been set up in the cavity. Nature, for the express purpose of keeping the surfaces of that cavity apart, has filled it more or less completely with fluid. These gentlemen propose to withdraw that fluid and hinder the operations of nature, let those surfaces come together and become adherent. That is why we get so many cases of fibroid phthisis in the hospitals and so few of them in private practice.
Do they do it in fractures? Isn’t the process precisely the same under different conditions? Here is a broken bone, and what does nature do? Throws out a provisional callus to protect the fractured ends of the bone. In pleurisy, nature throws out a provisional fluid to keep the surfaces apart. The cases are precisely analogous. Do they open the location of the fractured bone and take out this bony deposit? Why, no; they encourage it. What does nature do with the excess? Absorbs it, just exactly as it does in pleurisy. Nature takes care of its own deposits.
The only experience given us, so far as I heard, was that of the Old School. Is there any other? I have my own experience, and I have heard the experience of many others. Now what is it? That at the onset of this inflammatory action, just as in the onset of every other inflammatory action, there is irritation, hyperaemia, exudation always. Well, now what are the remedies that control all these processes? First, Aconite. Aconite controls the irritative stage on a philosophical and physiological basis. As soon as the irritative stage has passed, Bryonia controls the exudation stage on philosophical and physiological grounds, and it will do it, other things being equal, every time.
